Squamous cell carcinoma of the nasal vestibule: a diagnostic and therapeutic challenge.

Nasal vestibule squamous cell carcinoma (NVSCC) is an exceedingly rare malignancy, often misclassified due to its anatomical location and lack of a standardized definition. This review aims to consolidate current evidence on NVSCC, focusing on epidemiology, risk factors, classification, clinical presentation, treatment modalities, and prognostic factors. The NV anatomy is delineated, emphasizing the need for a clear definition to avoid misclassification. Risk factors include smoking, sunlight exposure, and debated associations with chalk exposure or viral factors. Clinical presentation includes symptoms like nasal obstruction, pain, burning, and bleeding, often misdiagnosed as inflammatory conditions. NVSCC exhibits distinct local spread patterns along cartilaginous surfaces, with the facial and submandibular lymph nodes at higher metastatic risk. Current classifications lack consensus, hindering comparison of outcomes. Treatment varies, with surgery or radiotherapy for early-stage tumors and multimodality approaches for advanced cases. The choice between surgery and radiotherapy is debated, with potential advantages and drawbacks for each. Radiotherapy, especially with Interventional RadioTherapy (IRT, previously known as brachytherapy), is gaining prominence, showing promising outcomes in terms of local control and cosmetic results. Prophylactic neck treatment remains controversial, with indications based on tumor characteristics. Prognostic factors include T classification, tumor size, surgical margins, nodal involvement, and histological features. Long-term survival rates range widely, emphasizing the need for further studies to refine management strategies for this rare malignancy. In conclusion, NVSCC poses diagnostic and therapeutic challenges, warranting multidisciplinary approaches and continued research efforts to optimize patient outcomes.

Staphylococcus aureus nasal colonization level and intracellular reservoir: a prospective cohort study.

Staphylococcus aureus is a major pathogen in humans. The nasal vestibule is considered as the main reservoir of S. aureus. However, even though the nasal cavity may also be colonized by S. aureus, the relationships between the two sites are still unclear. We conducted a prospective study in humans to assess the S. aureus colonization profiles in the vestibule and nasal cavity, and to investigate the presence of intracellular S. aureus in the two sites. Patients undergoing ear, nose, and throat surgery were swabbed during endoscopy to determine S. aureus nasal load, genotype, and presence of intracellular S. aureus. Among per-operative samples from 90 patients, the prevalence of S. aureus carriage was 32.2% and 33.3% in the vestibule and the nasal cavity, respectively. The mean S. aureus load was 4.10 and 4.25 log10 CFU/swab for the nasal vestibule and nasal cavity, respectively (P > 0.05). Genotyping of S. aureus revealed that all nasal strains isolated from a given individual belong to the same clonal complex and spa-type. An intracellular carriage was observed in 5.6% of the patients, all of whom exhibited a S. aureus vestibule load higher than 3 log10 CFU/swab. An intracellular niche was observed in the vestibule as well as in the nasal cavity. In conclusion, the nasal cavity was also found to be a major site of S. aureus carriage in humans and should draw attention when studying host-pathogen interactions related to the risk of infection associated with colonization.

Nasal vestibule squamous cell carcinoma: a population-based cohort study from DAHANCA.

BACKGROUND: Cancer of the nasal vestibule is a rare type of malignancy dominated by squamous cell carcinoma (SCC), and with poor survival. The treatment is either radiotherapy, surgery or a combination of both. Previous studies have shown a 5-year disease-specific survival of 74% and overall survival (OS) of 50%.Our objective was to describe the consecutive cohort of patients diagnosed with SCC of the nasal vestibule in Denmark from 2008 until 2018 and evaluate prognostic factors and treatment outcome using locoregional failure (LRF), disease-specific mortality (DSM), and OS as endpoints. METHODS: All patients diagnosed with SCC of the nasal vestibule from 2008 until 2018 were identified in the nationwide clinical database, DAHANCA and were followed for LRF and death (DSM and OS) until March 2021. OS was analysed using Kaplan-Meier estimator, and cumulative incidence of LRF and DSM were analysed using the Aalen-Johansen estimator. Analysis of prognostic factors was performed using Cox proportional hazard models. RESULTS: A total of 162 patients were identified. The median age was 71 years and 54% were male. Disease stage at the time of diagnosis were stage I (70%), II (17%), III (2%) and IV (11%). Curatively intended treatment was performed in 146 patients (90%), of which treatment failure occurred in 42 patients (29%). Most failures occurred at the primary tumour site (64%). Cancer Patient Pathways recommended time to treatment was fulfilled in 71% of patients. The 5-year OS and DSM in patients treated with curative intent were 65% and 11%, respectively. Stage was a significant independent prognostic factor. No difference in LRF, DSM or OS were shown between the applied treatments. CONCLUSIONS: Stage is the main independent prognostic factor, and failure most commonly appear at the primary tumour site.

A single centre's experience of 23 cases of total rhinectomy for the treatment of squamous cell carcinoma involving the nasal vestibule.

PURPOSE: This study aims to analyse the oncological outcomes of total rhinectomy (TR) for squamous cell carcinomas (SCCs) involving the nasal vestibule, and to identify prognostic factors for disease recurrence. METHODS: A retrospective single-centre study was conducted between September 2003 and February 2021 including all patients who underwent a TR for a SCC involving the nasal vestibule. RESULTS: 23 patients were included in the study. Tumours originated from the anterior septum (n = 12), vestibule (n = 8) or skin (n = 3). Six TRs (26.1%) were salvage procedures, after primary radiotherapy or partial rhinectomy. Seven patients had a concurrent neck dissection and 17 patients (73.9%) received adjuvant treatment (14 patients had radiotherapy and 3 had chemoradiotherapy). After a median follow-up of 32 months, six patients (26.1%) presented with tumour recurrence. Three patients (13%) had nodal-only recurrence. The estimated 5-year overall survival, disease-free survival and disease-specific survival were 67.5%, 66.3% and 80.7%, respectively. Positive excision margins were a predictive factor for tumour recurrence (p = 0.0401). CONCLUSION: For SCCs involving the nasal vestibule that are not amenable to limited surgical resection, TR along with adjuvant radiotherapy provide good oncological outcomes and should be considered the main treatment option.

The presence of aberrant p53 pattern is a negative prognostic predictor in squamous cell carcinoma of the nasal vestibule.

The aim of this study was to analyze the role of Ki-67, p53, and the "aberrant p53 pattern" in squamous cell carcinomas of the nasal vestibule. Patients between 1995 and 2014 were included. Baseline characteristics and outcome were analyzed with respect to immunohistochemical staining of Ki-67 and p53. "Aberrant p53 pattern" was represented by a moderate or strong staining of at least 60% of the tumor cells or a complete absence of immunoreactivity. Forty-six patients were included of whom 31 (67.4%) were available for Ki-67 and 32 (69.9%) for p53 immunohistochemistry. The "aberrant pattern" of p53 was present in 50% of the patients. While immunoreactivity for both Ki-67 and p53 was not related to each other or outcome, the "aberrant p53 pattern" was associated with a worse disease-free survival (p = 0.014). The "aberrant p53 pattern" is a negative prognostic factor in squamous cell carcinoma of the nasal vestibule and might enable a patient-tailored treatment.

Infraorbital Neuralgia Attributed to a Foreign Body.

We reported a case of secondary infraorbital neuralgia due to a foreign body involving the nasal ala. As it was a very rare care, we reviewed reported literatures. This case highlights that infraorbital neuralgia could be caused by any tiny problems such as foreign body involving the area innervated by infraorbital nerve.

Radiation therapy for nasal vestibule squamous cell carcinoma: a 40-year experience.

We evaluated the treatment of squamous cell carcinoma (SCC) of the nasal vestibule. Eighty-six patients were treated with radiotherapy (RT) and 13 patients received surgery and RT. The mean follow-up was: 9.7 years (range 4 months-35.9 years). The 5- and 10-year outcomes were: local control (LC), 88 and 82 %; local-regional control (LRC), 78 and 73 %; freedom from distant metastases (FFDM), 96 and 96 %; cause-specific survival (CSS), 91 and 86 %; and overall survival, 75 and 51 %. The 5- and 10-year LC rates for patients treated with RT were 94 and 89 % overall. A multivariate analysis was performed. Tumor size predicted LC, LRC, OS, and CSS. Overall stage predicted LRC. RT cures most patients with T1-T2 and favorable T4 SCCs with acceptable toxicity. RT and surgery result in improved likelihood of cure for patients with advanced T4 lesions.

The nasal vestibular body: anatomy, clinical features, and treatment considerations.

Nasal obstruction is a common presenting complaint, with many possible etiologies. Herein, we provide an introductory anatomic description, clinical relevance, and proposed nomenclature for an underappreciated soft tissue focus in the nasal vestibule-the nasal vestibular body (NVB)-that can contribute to nasal obstruction in a subset of patients. This is a small mound of dynamic soft tissue in the lateral aspect of the internal nasal valve, situated inferior and anterior to the head of the inferior turbinate that can be missed on routine examination for many salient reasons. In well-selected patients, whose symptoms of nasal obstruction may in part be secondary to the presence of this soft tissue focus, directed testing and tissue reduction can be performed.

Analysis of the nasal vestibule mycobiome in patients with allergic rhinitis.

Advances in culture-independent sequencing methods have been utilised in recent studies to understand the phylogenetic composition of the human microbiome of healthy and diseased skin. Allergic rhinitis (AR) is an inflammatory condition of the nasal cavity caused by environmental allergens. Although nasal microbial communities have been considered important contributors in human health, no studies to date have comprehensively compared fungal communities (mycobiome) of the nasal vestibule using the culture-independent pyrosequencing method. This study aimed to investigate how fungal communities of the nasal vestibule skin surface are influenced by AR. The phylogenetic composition of the nasal vestibule mycobiome of patients with AR was analysed by culture-independent pyrosequencing methods and compared with healthy individuals. A total of 69 fungal genera were identified from both AR samples and healthy controls, and the genus Malassezia predominated in the nasal vestibule. Species-level analysis classified eight different Malassezia species including M. pachydermatis and M. cuniculi, which were normally isolated from animals, and revealed M. restricta to be the most abundant species in the nasal vestibule. Although high interpersonal variation was observed, some of the AR samples displayed significantly higher diversities than healthy controls at both the genus and species level.

Impact of Intra-Phenotypic Nasal Vestibular Variation on Local Airflow Dynamics.

OBJECTIVES: Many individuals with healthy normal nasal anatomy and function exhibit a prominent notch indentation at the junction of the ala and sidewall, specifically around the anterior-superior region of the unilateral nasal vestibule up to the internal nasal valve. This study evaluates the influence of various sizes of notched indentations at the anterior nasal airway on local airflow pattern. METHODS: A retrospective study involving 25 healthy individuals, each exhibiting at least one unilateral notched indentation (40 total airways). Each individual's notched indentation was quantified after subject-specific three-dimensional nasal airway reconstruction from radiographic images. Computational fluid dynamics modeling was used to simulate nasal inspiratory airflow in each nasal airway at 15 L/min. Localized airflow distributions passing through the inferior, middle, and superior regions were calculated at 15 cross sections. RESULTS: Notched indentation size ranged 1.75-86.84 mm2 (average = 22.37 mm2). At the anterior airway, notched size significantly correlated with inferior airflow volume (R = 0.32, p = 0.04) but not in the middle (R = 0.21, p = 0.20) or superior (R = 0.06, p = 0.70) regions, whereas middle and superior regional resistance values were significantly correlated with notched size (middle: R = 0.54, p < 0.001; superior: R = 0.41, p = 0.009). Medially, resistance at the middle region significantly correlated with notched size (R = 0.56, p < 0.001). At the posterior airway, airflow distributions through the inferior, middle, and superior regions demonstrated weak correlation with notched size (inferior: R = 0.24, p = 0.14, middle: R = 0.24, p = 0.13; superior:R = 0.03, p = 0.83), whereas resistance was significantly correlated in the middle and inferior regions (middle: R = 0.56, p < 0.001;inferior: R = 0.43, p = 0.006). CONCLUSIONS: Anterior nasal airway notched indentation size had significantly stronger influence on localized airflow volume through the anterior-inferior airway than other regions of the nasal passage. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

A Rare Neurilemmoma of the Nasal Vestibule: A Case With the Review of Literature.

A variety of diseases can affect the nasal vestibule. It might be challenging to diagnose and treat a nasal vestibular tumor due to the anatomical characteristics of the nasal vestibule. Neurilemmoma is a tumor derived from Schwann cells of the nerve sheath. Less than 4% of these tumors invade the nasal cavity and sinuses. Nasal vestibule neurilemmoma is rare, it is often overlooked when a mass discovered. The diagnosis of it is mainly based on clinical symptoms, nasal endoscopy, and imaging, The mainstay of treatment is complete resection surgery. Pathological examination provides the final diagnosis. We present a patient with nasal vestibule neurilemmoma who underwent a successful endoscopic surgery without cosmetic deformity, and discuss the clinical manifestations, histological features, imaging features, differential diagnosis, treatment options, then reviewed relevant literature of this rare benign lesion.

Salvage Strategies for Local Recurrences of Squamous Cell Carcinoma of the Nasal Vestibule: A Single-Center Experience of 22 Years.

Squamous cell carcinomas of the nasal vestibule are an extremely rare neoplastic disease. Although brachytherapy is gaining popularity for primary treatment, surgery remains the best option in case of recurrences. The aim of this paper is to outline our treatment experience of local recurrence of SCCNVs over the past 22 years. We retrospectively reviewed the clinical data of the patients who underwent surgical treatment for local recurrence of SCCNV: data regarding age, sex, primary tumor treatment, recurrence location and time of appearance, surgical resection, type of reconstruction, postoperative complication, surgical revision, and re-recurrence rate were analyzed. Twenty patients were included in the study. The median period for recurrence appearance was 17 months, and the prevalent location of recurrence was the nasal alae. Prevalent reconstructive procedures were the nasolabial flap and paramedian forehead flap. No postoperative complications were observed, and one case of re-recurrence was detected at 12-months of follow-up. Based on our experience, salvage surgical procedures for SCCNV recurrences must be individualized and carefully planned, taking into account the peculiar pattern of tumor spread and the presence of scar and heavily radiotherapy damaged tissue from previous treatment; delayed reconstruction should be considered for all the cases with skeletal involvement.

Squamous cell carcinoma of the nasal vestibule in the Netherlands: A clinical and epidemiological review of 763 cases (2008-2021).

BACKGROUND: Squamous cell carcinoma of the nasal vestibule (SCCNV) is a rare disease, distinctly different in presentation, treatment, and outcome from squamous cell carcinoma (SCC) of the nasal cavity and paranasal sinuses. However, these are often not analyzed separately. METHODS: The Netherlands Cancer Registry (NCR) and pathology reports from the Dutch Nationwide Pathology Databank (PALGA) were used to identify all newly diagnosed SCCNV cases in the Netherlands between 2008 and 2021. RESULTS: A total of 763 patients were included. The yearly incidence rate displayed a significant downward trend with an annual percentage change (APC) of -3.9%. The 5-year overall survival (OS) and disease-free survival were 69.0% and 77.2%, respectively. The 5-year relative survival was 77.9% and improved slightly over the inclusion period. OS for patients who were staged cT3 appeared to be worse than those staged cT4a, calling the applicability of the TNM-classification into question. CONCLUSION: SCC of the nasal vestibule is rare, with declining incidence rates. Introducing a specific topography code for SCCNV is recommended to enhance registration accuracy. The TNM classification seems poorly applicable to SCCNV, suggesting the need to explore alternative staging methods.

Individualized 3D-printed applicators for magnetic resonance imaging-guided brachytherapy in nasal vestibule cancer.

Background and purpose: Brachytherapy is treatment of choice for early stage nasal vestibule cancer. Over the years improvements were achieved by means of image guided target definition, interstitial implant techniques and also individual mold techniques. The aim of this study was to improve the technique of the implant so that the need for interstitial catheters can be limited by making use of patient individualized 3D-printed applicators. Materials and Methods: In 19 patients 3D-printed applicators were used to deliver pulse dose rate (PDR) brachytherapy. All patients underwent computed tomography (CT) and magnetic resonance imaging (MRI). A pre-plan with tumor delineation and manually optimized catheter positions to achieve tumor coverage was made. Based on the pre-plan a 3D-printed applicator was manufactured. Dose was evaluated by several indices: Conformity Index, Healthy Tissues Conformity Index, Dose Homogeneity Index, Dose non-uniformity ratio, Conformal index and high dose (HD) index. Results: A high target coverage was achieved, with a median V100%CTV of 99.1 % (range, 81.8-100 %) and median CI of 0.99 (range, 0.82-1.00), as well as a median V0.7GyGTV of 100 % (range, 93.0-100 %). The median HD was 0.39 (range, 0.20-0.83). Interstitial catheters were needed in 12 patients. None of the patients developed grade ≥ II toxicity within the median follow up of 18 months. Conclusions: This study shows that using 3D-printed applicators limits the need for interstitial catheters and also limits the high doses in normal tissue.

PRO-NOVELTY: Patient-Reported Outcomes in NOse VEstibule interventionaL radioTherapY (brachytherapy).

Background: The aim of this paper is to evaluate the impact on the quality of life of the treatment of nasal vestibule tumors by interventional radiotherapy (IRT-brachytherapy) through a patient reported outcome questionnaire. Methods: We prospectively collected data about patients undergoing IRT according to our institutional schedule of 44 Gy delivered in 14 fractions twice a day. We recorded both acute toxicity data, using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, and quality of life data, using the 22-item Sino-Nasal Outcome Test (SNOT-22) at baseline (T0), at 1 month (T1), at 3 months (T3), and at 6 months (T6). Results: We enrolled 10 consecutive patients treated between February 2023 and October 2023. The decrease in terms of SNOT-22 mean value was statistically significant from T0 and T6 with a p-value < 0.001. A noteworthy clinical finding is that quality of life improved regardless of the occurrence of G1-G2 side effects. Conclusions: Using SNOT-22 on patients with nasal vestibule carcinoma treated with IRT has shown an improvement in quality of life that is not strictly dependent on the occurrence of expected G1-G2 side effects.

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology - Head and Neck Surgery.

Objective: Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality. Methods: A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus. Results: Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation. Conclusions: The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.

Interventional Radiotherapy (Brachytherapy) for Nasal Vestibule: Novel Strategies to Prevent Side Effects.

Interventional radiotherapy (brachytherapy) has become the new therapeutic standard in the management of early stages nasal vestibule tumors; in fact it allows for high local control rates and low toxicity profiles. However, since more and more patients will receive interventional radiotherapy (brachytherapy) as primary treatment, it is desirable to implement novel strategies to reduce the dose to organs at risk with the future aim to result in further lowering long-term side effects. MATERIALS AND METHODS: We were able to identify two different strategies to reduce dose to the treatment volume, including the implantation technique (the implant can be interstitial, endocavitary or mixed and the catheters may be placed either using the Paris system rules or the anatomical approach) and the dose distribution within the implant (the most commonly used parameter to consider is the dose non-uniformity ratio). We subsequently propose two novel strategies to reduce dose to organs at risk, including the use of metal shields for fixed organs as in the case of the eyes and the use of a mouth swab to push away mobile organs, such in the case of the mandible. We used two different algorithms to verify the values namely the TG-43 and the TG-186. RESULTS: We provided an accurate literature review regarding strategies to reduce toxicity to the treatment volume, underlining the pros and cons of all implantation techniques and about the use dose non-uniformity ratio. Regarding the innovative strategies to reduce the dose to organs at risk, we investigated the use of eye shielding and the use of swabs to push away the mandible by performing an innovative calculation using two different algorithms in a series of three consecutive patients. Our results show that the dose reduction, both in the case of the mandible and in the case of eye shielding, was statistically significant. CONCLUSION: Proper knowledge of the best implantation technique and dose non-uniformity ratio as highlighted by existing literature is mandatory in order to reduce toxicity within the treatment volume. With regard to the dose reduction to the organs at risk we have demonstrated that the use of eye shielding and mouth swab could play a pivotal role in clinical practice; in fact, they are effective at lowering the doses to the surrounding organs and do not require any change to the current clinical workflow.

Long-term oncological follow-up after mold-based pulsed dose rate brachytherapy for early stage squamous cell carcinoma of the nasal vestibule: A single center experience of 68 patients over a 17-year period.

PURPOSE: Cancer of the nasal vestibule is a rare type of malignancy constituting less than one percent of all head and neck cancers. These tumors are typically diagnosed at an early stage. Both surgery and radiotherapy provide excellent oncological results, but esthetic results are better after radiotherapy. The aim of this study was to evaluate the long-term oncological follow-up after brachytherapy for early stage squamous cell carcinoma of the nasal vestibule. METHODS AND MATERIALS: Retrospective analysis of patients with carcinoma of the nasal vestibule who were treated with primary brachytherapy in the Utrecht University Medical Center. RESULTS: In this single center experience over a 17-year period 68 patients with early stage squamous cell carcinoma of the nasal vestibule were treated with brachytherapy. Two patients had lymph node metastases at first clinical presentation. Median follow-up duration was 46.5 months. Five-year locoregional recurrence-free survival, disease-specific survival, and overall survival were 91.1%, 96.1%, and 66.2%, respectively. All recurrences occurred within the first 3 years of follow-up. CONCLUSIONS: Brachytherapy offers excellent oncological outcomes and is a safe and effective treatment for early stage carcinoma of the nasal vestibule. Recurrences typically occur within 3 years after treatment.

Evaluation of Staging Systems for Cancer of the Nasal Vestibule.

Squamous cell carcinoma of the nasal vestibule is reported to account for less than one percent of all head and neck malignancies. It lacks a designated WHO ICD-O topography code, and multiple systems are available for the staging of this disease, which results in unwanted variability and the subsequent poor reliability of data. The aim of this study was to evaluate the currently available staging systems for cancer of the nasal vestibule, including the recently introduced classification by Bussu et al., which built on Wang's original concept but with clearer anatomical cutoffs. Different staging systems for cancer of the nasal vestibule (UICC nasal cavity, UICC skin cancer of the head and neck, Wang and Bussu et al.) were evaluated via a retrospective analysis of 148 patients. The staging system, per Bussu et al., had the most balanced allocation of patients among the stages. When using the Wang classification as a reference, stage migration occurred less frequently with the Bussu classification. The widespread adoption of a single staging system, as well as the introduction of a designated topography code for cancer of the nasal vestibule, could lead to more uniformity in data reporting and improve an understanding of the incidence and disease outcome. The newly proposed carcinoma of the nasal vestibule classification by Bussu et al. has the potential to improve the staging and allocation among stages. Further analysis of survival data is needed to assess which classification system is best suited for nasal vestibule carcinoma.

Exploring the influence of nasal vestibule structure on nasal obstruction using CFD and Machine Learning method.

Motivated by clinical findings about the nasal vestibule, this study analyzes the aerodynamic characteristics of the nasal vestibule and attempt to determine anatomical features which have a large influence on airflow through a combination of Computational Fluid Dynamics (CFD) and machine learning method. Firstly, the aerodynamic characteristics of the nasal vestibule are detailedly analyzed using the CFD method. Based on CFD simulation results, we divide the nasal vestibule into two types with distinctly different airflow patterns, which is consistent with clinical findings. Secondly, we explore the relationship between anatomical features and aerodynamic characteristics by developing a novel machine learning model which could predict airflow patterns based on several anatomical features. Feature mining is performed to determine the anatomical feature which has the greatest impact on respiratory function. The method is developed and validated on 41 unilateral nasal vestibules from 26 patients with nasal obstruction. The correctness of the CFD analysis and the developed model is verified by comparing them with clinical findings.