Propel Stents for Congenital Pyriform Aperture Stenosis
Propel stents (mometasone furoate-eluting sinus stents) can be used as an alternative stenting option for congenital pyriform aperture stenosis (CNPAS) following surgical correction, and may offer advantages over traditional nasal stents by potentially reducing restenosis, stent plugging, and nasal alar necrosis. 1
Understanding the Condition and Treatment Context
Congenital nasal pyriform aperture stenosis is a rare but potentially life-threatening cause of neonatal airway obstruction that presents with cyclic cyanosis, apneic episodes, feeding difficulties, and inability to pass a small catheter through the anterior nasal valve. 2, 3 Immediate recognition is mandatory to prevent potentially deadly outcomes. 2
Treatment Decision Algorithm
Severity-based approach:
Mild cases: Conservative management with nasal saline, topical decongestants, and oral airway establishment may be sufficient, with long-term expectant management showing success in select patients 4
Moderate cases: Nasal dilation using Hegar cervical dilators (to at least 4mm) without bone removal or stenting has shown success in avoiding more invasive surgery 5
Severe or refractory cases: Surgical correction via sublabial approach with pyriform aperture drill-out followed by nasal stenting is indicated 2, 1, 3
Role of Propel (Mometasone Furoate) Stents
When surgical intervention is required, mometasone furoate stents represent a novel alternative to traditional nasal stents. 1 A case report demonstrated successful use of Propel stents in a 9-day-old infant undergoing surgical correction of CNPAS, with the theoretical advantage of avoiding complications typically associated with conventional stenting. 1
Advantages Over Traditional Stents
- Reduced restenosis risk: The steroid-eluting properties may minimize inflammatory scarring 1
- Prevention of stent plugging: Unlike traditional stents that can become obstructed with secretions 1
- Avoidance of nasal alar necrosis: A significant complication of prolonged traditional stent placement 1
Critical Caveats and Pitfalls
Important limitations to consider:
- The evidence for Propel stents in CNPAS is limited to case reports, not comparative studies 1
- Traditional stenting data shows concerning failure rates—in choanal atresia (a related condition), stented patients had a 35% restenosis rate compared to only 11% in non-stented patients managed with serial dilations 6
- Stenting duration varies widely (1-12 weeks) and optimal duration for Propel stents in CNPAS is undefined 6, 1
- Associated anomalies (holoprosencephaly, hypopituitarism, cardiac malformations) must be evaluated before any intervention 3
Practical Implementation
If choosing Propel stents for CNPAS:
- Use following sublabial drill-out of the stenotic pyriform aperture 2, 1
- Consider as first-line stent choice given potential advantages over traditional stents 1
- Maintain close postoperative endoscopic surveillance regardless of stent type 6
- Be prepared for potential repeat dilation procedures (typically on postoperative days 18-23 if needed) 5
- Consider adjunctive mitomycin C application (0.4 mg/ml for 10 minutes) intraoperatively to further reduce restenosis risk 6
Alternative approach to avoid stenting entirely: Serial nasal dilations with Hegar dilators performed initially by the surgeon daily, then reduced to weekly intervals, and eventually taught to parents for outpatient continuation up to one year has shown success in severe cases. 5 This approach had a mean hospital stay of only 4 days post-treatment. 5