Total nasopharyngeal stenosis: treatment with laser excision, nasopharyngeal obturators, and topical mitomycin-c

Oropharyngeal Stenosis Caused by Significant Scar Hyperplasia Following Tonsillectomy: A Case Report

Oropharyngeal stenosis (OPS) is a relatively rare long-term complication of tonsillectomy in children, resulting from the narrowing of the upper aerodigestive tract between the soft palate, pharyngeal sidewalls, and base of the tongue. This is the first reported case of OPS due to significant scar hyperplasia; however, whether it is as prone to recurrence as skin scar hypertrophy remains unknown. In this article, we present the case of a 5-year-old girl who presented to our otolaryngology clinic with sleep snoring and suffocation. Her medical history included tonsillectomy and adenoidectomy, performed 3 years prior to presentation. The patient underwent a combination of surgery and administration of triamcinolone injections, resulting in significant symptomatic improvement. To date, no signs of recurrence have been reported.

Post-Operative Sleep Endoscopy with Target-Controlled Infusion After Palatopharyngoplasty for Obstructive Sleep Apnea: Anatomical and Polysomnographic Outcomes

INTRODUCTION

The findings of drug-induced sleep endoscopy (DISE) are not always correlated with the outcome of upper airway surgery for obstructive sleep apnea (OSA), and whether multilevel surgery is truly required in treating multilevel obstruction identified in preoperative DISE remains an issue. We attempted to compare DISE findings before and after palatopharyngoplasty in patients with OSA because changes in DISE may be beneficial to better understand polysomnographic and anatomical outcomes.

METHODS

This was a prospective cohort study for 34 patients with moderate to severe OSA who underwent palatopharyngoplasty at a tertiary care center from 2016 to 2018. We recorded the patients' demographic characteristics, procedures, and surgical outcomes and compared the preoperative and postoperative DISE staging patterns.

RESULTS

The apnea-hypopnea index (AHI) values of 34 adults improved significantly after surgery (40.6 ± 23.3 versus 25.6 ± 20.6, P < 0.001). The majority of patients, 26/34, had preoperative complete concentric collapse at the velum, and for most (20/26, 77%) there was a change of the collapse pattern into anteroposterior collapse postoperatively. Patients with postoperative velar collapse had higher follow-up AHI values than those who without (27.8 ± 21.9 versus 15.2 ± 7.7, P = 0.023). Patients with preoperative complete tongue base collapse had higher follow-up AHI values than did those with no or partial collapse (40.6 ± 21.0 versus 21.0 ± 18.6, P = 0.017). Patients with postoperative complete tongue base collapse also had higher follow-up AHI values than the others (42.7 ± 22.1 versus 18.5 ± 15.4, P = 0.001).

CONCLUSION

Palatopharyngoplasty could change the collapse pattern at the velum in most patients. Preoperative and postoperative complete tongue base collapse and postoperative velar collapse identified in TCI-DISE were associated with relatively poor outcomes.

Use of Purastat, a novel haemostatic matrix based on self-assembling peptides in the prevention of nasopharyngeal adhesion formation

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Purastat is a novel haemostatic agent used effectively in nasal procedures in the prevention of epistaxis and adhesions.

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This study describes the use of PuraStat following division of nasopharyngeal stenosis to reduce the risk of restenosis.

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On last follow-up the patient experienced excellent resolution of symptoms with no evidence of readhesion.

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The authors propose that PuraStat may be used in other surgical interventions to prevent mucosal adhesion formation.

Introduction

Purastat is a novel haemostatic agent that has recently been used effectively in nasal procedures, specifically in functional endoscopic endonasal surgery in the prevention of post-operative epistaxis while minimising adhesion formation. This study presents a case of successful application of Purastat following division of a nasopharyngeal/palatal stenosis following radiotherapy.

Presentation of case

A 49-year-old male developed severe nasopharyngeal stenosis following concurrent chemoradiotherapy with curative intent a HPV positive base of tongue squamous cell carcinoma. Following treatment, while the patient experienced excellent metabolic response, he began to progressive nasal obstruction which he reported to be significantly affecting his quality of life. Following multidisciplinary team discussion, division of the stenosis was considered appropriate.

Under general anaesthesia, the patient was positioned lying supine with the neck extended. A Boyle-Davis gag with lip and teeth protection was placed and a Y-suction catheter inserted to lift the palate from the posterior pharyngeal wall. Coblation using a PDW wand was used to divide the area of fibrosis bilaterally toward the superior tonsillar pillar until palatopharyngeus musculature was visible. Injection of 4 mg of Dexamethasone with a hypodermic needle was then performed followed by application of 4 ml of topical Purastat onto the raw surfaces after haemostasis was confirmed.

The patient was discharged the same day on simple analgesia and instructions to avoid exertion for two weeks. He attended follow-up in the outpatient department two months later and reported persisting resolution of his nasal obstructive symptoms. No evidence of recurrence or residual adhesion tissue was noted.

Acquired Nasopharyngeal Stenosis Correction Using a Modified Palatal Flaps Technique in Obstructive Sleep Apnea (OSA) Patients

Background: Acquired nasopharyngeal stenosis is a rare and heterogeneous pathological condition that has different causes, generally resulting as a complication of a pharyngeal surgery, especially in patients affected by obstructive sleep apnea (OSA). Different approaches have been proposed for the treatment of nasopharyngeal stenosis but a unique and standardized management has not yet been presented. The aim of our paper is to evaluate the efficacy of our surgical technique, describing its steps and results with the aim to consider it as a possible solution for the treatment of this condition. Methods: This is a retrospective cohort study. Eight patients (mean age 27.25 years old (yo), range 8–67 yo; Male/Female ratio 4/4; mean body mass index (BMI) 26.1) affected by OSA (mean apnea hypopnea index (AHI) before OSA surgery was 22.1) and acquired nasopharyngeal stenosis as a consequence of different pharyngeal surgeries were treated with our modified approach in the Department of Otolaryngology, Morgagni Pierantoni Hospital, Forlì, Italy. Resolution of stenosis and complication rate were the main outcome measures. Results: Complete resolution of the stenosis was achieved in all cases and no complications were recorded at three weeks, six months, and 2 years follow-up. Conclusions: Our technique appears to be a promising method for the management of nasopharyngeal stenosis in OSA patients. However, further studies comparing different techniques and reporting on larger series and longer follow up time are needed to prove the efficacy of the proposed technique.

Treatment of post-adenotonsillectomy velopharyngeal stenosis with bivalved uvular flaps

OBJECTIVE

Velopharyngeal stenosis (VS) is a rare devastating complication of adenotonsillectomy that causes obstructive sleep apnea (OSA). Its treatment is challenging and has a high recurrence rate. The aim of this study was to assess the efficacy of a bivalved uvular flap technique with topical application of mitomycin C for treatment of this problem.

STUDY DESIGN

Case series.

METHODS

Fourteen children with VS after adenotonsillectomy were treated with a bivalved uvular flap technique with application of mitomycin C after release of the adhesions and removal of scar tissue. Preoperative and postoperative evaluation of patients were performed. Flexible nasopharyngoscopy was used to assess the patency of the velopharynx, and apnea/hypopnea (A/H) index and minimum O₂ saturation were measured before and after surgery.

RESULTS

Adequate patent airway was obtained in all patients as seen by oropharyngeal examination and flexible nasopharyngoscopy. Additionally, significant improvement in A/H index and minimum O₂ saturation were achieved postoperatively.

CONCLUSION

The bivalved uvular flap technique with topical application of mitomycin C after removal of scar tissue is an effective treatment for VS that may follow adenotonsillectomy in children.

The ancient practice of sutra neti leading to velopharyngeal stenosis: case report

BACKGROUND

An ancient yoga technique called sutra neti, which is extensively used in India to keep the sinuses healthy, led to complete velopharyngeal stenosis in a 67-year-old male patient who presented with bilateral nasal obstruction, mouth breathing, anosmia and a change in voice.

METHOD

The patient was diagnosed by nasal endoscopy using a zero-degree Hopkins rod endoscope, and adhesions were released using coblation.

RESULTS

The patient had post-operative alleviation of symptoms and a patent velopharyngeal inlet on examination.

CONCLUSION

Vigorous sutra neti can lead to velopharyngeal stenosis. Release of the stenosis is then required to cure the nasal blockade.

Oropharyngeal Stenosis Leading to an Unanticipated Difficult Airway in a Patient After Uvulopalatopharyngoplasty: A Case Report and Review of the Literature

Oropharyngeal stenosis can manifest as a rare complication after surgery for obstructive sleep apnea or tonsillectomy. Scar tissue formation from oropharyngeal stenosis may impede tracheal intubation or laryngeal mask airway insertion. We report the case of an asymptomatic adult woman found to have oropharyngeal stenosis after induction of anesthesia and discuss the management of this challenging scenario. We also contrast oropharyngeal stenosis with nasopharyngeal stenosis, another rare complication of uvulopalatopharyngoplasty.

Repair of Oropharyngeal Stenosis With Bilateral Buccal Myomucosal Flaps

Oropharyngeal stenosis (OPS) is a rare postoperative complication of adenotonsillectomy that can be a source of considerable patient distress and morbidity. Circumferential scarring of the soft palate and tonsillar pillars leads to narrowing of the oropharyngeal aperture. This case report describes the novel use of bilateral buccal myomucosal flaps for the repair of postoperative OPS in a 20-year-old woman presenting with dysphagia, odynophagia, dyspnea, and intermittent hypernasal speech. Postoperatively, the patient noted immediate improvement of her symptoms. At 1-month follow-up, she noted complete resolution of her symptoms with no dysphagia, nasal regurgitation, speaking difficulty, dyspnea, or gagging. The buccal flaps were well healed and completely intact, maintaining appropriate height of the tonsillar pillars. The buccal myomucosal flap is an effective tool for numerous palatal and oropharyngeal abnormalities and, as described in this case study, is a reliable, safe, and effective technique that can be considered for the reconstruction of postsurgical OPS.

Nasopharyngeal Stenosis: A Rare Radiotherapy Complication

Introduction

Acquired nasopharyngeal stenosis after radiotherapy for NPC is rare. We report a case of bilateral choanal stenosis and nasopharygeal stenosis in patient treated with chemo radiotherapy for undifferentieted nasopharnygeal carcinoma.

Case Report

A 68 years old man treated for undifferentiated nasopharyngeal carcinoma with chemo-radiotherapy 10 years before. He complained of complete nasal obstruction, rhinorrhea, anosmia, snoring and hearing loss. Clinical examination and imaging revealed bilateral choanal stenosis and nasopharyngeal stenosis. Patient underwent a transnasal endoscopic resection for scar tissue with stenting of posterior choanae. Restenosis was noted just after stent removal. Second endoscopic resection of stenosis was done, followed by application of mitomycin-C without stenting. Several months later, the patient has good airflow, a patent nasopharynx without reccurence of stenosis.

Discussion

The use of topical mitomycin-C may prove useful in the treatment and prevention of subsequent restenosis and scar formation in larynx and tracheal. Mitomycin-C application has being shown useful in treating nasopharyngeal stenosis. It is safely used topically in various surgical sites without major side effect.

Conclusion

Nasopharyngeal stenosis is an unusual complication of radiotherapy that can be successfully treated with combine two modalities: surgical and mitomycin-C as an adjunct.

FAMM Flap in Reconstructing Postsurgical Nasopharyngeal Airway Stenosis

Introduction. Postsurgical nasopharyngeal airway stenosis can be a challenge to manage. The stenosis could be as a result of any surgical procedure in the nasopharyngeal region that heals extensive scarring and fibrosis. Objective. To evaluate patients with nasopharyngeal stenosis managed with FAMM flap. Study Design. Prospective study of patients with nasopharyngeal stenosis at the Kenyatta National Hospital between 2010 and 2013 managed with FAMM flap. Materials and Methods. Patients with severe nasopharyngeal airway stenosis were reviewed and managed with FAMM flaps at the Kenyatta National Hospital. Postoperatively they were assessed for symptomatic improvement in respiratory distress, patency of the nasopharyngeal airway, and donor site morbidity. Results. A total of 8 patients were managed by the authors in a duration of 4 years with nasopharyngeal stenosis. Five patients were managed with unilateral FAMM flaps in a two-staged surgical procedure. Four patients had complete relieve of the airway obstruction with a patent airway created. One patient had a patent airway created though with only mild improvement in airway obstruction. Conclusion. FAMM flap provides an alternative in the management of postsurgical severe nasopharyngeal stenosis. It is a reliable flap that is easy to raise and could provide adequate epithelium for the stenosed pharynx.

Transoral robotic surgery for pharyngeal stenosis

BACKGROUND

Pharyngeal stenosis is a complication of head and neck cancer and sleep apnea treatment that results in functional impairment. Due to the location of the stenosis and tendency to recur, surgical management is challenging. Robotic surgery may allow these areas to be treated with surgical technique that would be difficult using traditional approaches.

METHODS

A retrospective chart review was performed to identify patients who underwent transoral robotic surgery (TORS) for pharyngeal stenosis at a tertiary hospital system.

RESULTS

Five patients were identified, ages 8-75 years. Length of follow-up ranged from 1-12 months. There was one failure, a 74 year old male with a history of chemoradiation to the area who has required additional procedures.

CONCLUSION

TORS may offer improved surgical access to the pharynx in patients who require complex reconstruction that would otherwise be very difficult. Appropriate patient selection is necessary and long-term follow-up is warranted for the selected cases.

Complete nasopharyngeal stenosis: presentation of a rare case

A sixty-eight years old female patient with complete nasopharyngeal stenosis without any determined etiology is presented. She had complete nasal obstruction as well as obstructive sleep apnea syndrome. She was operated and dense, thick, avascular fibrotic tissues were excised and reconstructed with local flaps and skin graft. Only partial opening was achieved in the long term follow-up.

Acquired nasopharyngeal stenosis in a patient with sarcoidosis

INTRODUCTION

Acquired nasopharyngeal stenosis typically occurs as a result of surgery or irradiation of the nasopharynx. Sarcoidosis has numerous manifestations in the head and neck region, although an association with nasopharyngeal stenosis has not previously been reported.

CASE REPORT

A 40-year-old man with sarcoidosis developed severe acquired nasopharyngeal stenosis. This was successfully managed with balloon dilatation, followed by pharyngoplasty with local pharyngeal flap reconstruction.

CONCLUSION

This report is intended to prompt consideration of nasopharyngeal stenosis as a potential cause of nasal obstruction in patients with sarcoidosis, and to draw attention to the need to consider sarcoidosis in the differential diagnosis of patients with acquired nasopharyngeal stenosis. We also demonstrate the viability of pharyngoplasty in the management of nasopharyngeal stenosis in the setting of sarcoidosis.

Palatal eversion: a new technique in treatment of nasopharyngeal stenosis

OBJECTIVE

The treatment of nasopharyngeal stenosis is challenging because of a high incidence of recurrence after surgical correction. Therefore, many treatment modalities are being tried to cure this problem. The aim of this study is to assess the efficacy of palatal eversion as a new technique for treatment of nasopharyngeal stenosis after adenotonsillectomy.

STUDY DESIGN

Case series.

METHODS

This study was conducted on 12 patients with nasopharyngeal stenosis after adenotonsillectomy were subjected to treatment by palatal eversion by dividing the soft palate in the midline and removal of the fibrous tissue causing stenosis followed by evertion and fixation of the two palatal division on either side for six weeks to allow complete epithelialization of the stenotic area followed by another operation to reunion the soft palate in the midline. Post-operative follow up was done for one year by flexible nasopharyngoscopy, perceptual speech analysis and polysomnography.

RESULTS

Flexible nasopharyngosopic examination of the 12 patients at the end of post-operative period revealed a freely mobile soft palate with no nasopharyngeal stenosis or palatal fistula. Velopharyngeal function and speech assessment by perceptual speech analysis was normal in all 12 cases. No obstructive episodes were recorded in polysomnograms.

CONCLUSIONS

Palatal eversion is a promising technique in treatment of post-adenotonsillectomy nasopharyngeal stenosis and it is recommended to be used in a wider scale of patients and other indications as nasopharyngeal stenosis following uvulopalatoplasty and post nasopharyngeal radiotherapy.

LEVEL OF EVIDENCE

4 (case series).

Stenting the nasopharyngeal isthmus by nasopharyngeal airway after correction of acquired total nasopharyngeal obstruction: surgical procedure and results

The objective of this study is to describe a simple surgical procedure for management of acquired total nasopharyngeal obstruction in adults. Five patients were diagnosed as having complete nasopharyngeal obstruction over a 3-year period. Three patients previously underwent uvulopalatoplasty, while for the remaining two it was due to pharyngoscleroma. In all the patients, nasopharyngeal obstruction was at the level of the inferior edge of the soft palate. Two of the post-uvulopalatoplasty patients had recurrent obstruction after scar excision and topical application of mitomycin-C without stenting. All the patients were treated surgically by creation of a new anatomical nasopharyngeal isthmus and stenting it by nasopharyngeal airway for 6 months. All the patients experienced satisfactory results and good tolerability to airway placement. The nasopharyngeal airway can counteract the inevitable scar contraction of the new nasopharyngeal isthmus after surgical correction and maintain its patency.

'A good shepherd, but with obstructive sleep apnoea syndrome': traditional uvulectomy case series and literature review

BACKGROUND

In the West, removal of the uvula is predominantly undertaken as part of palatal surgery, in cases of obstructive sleep apnoea. In the developing world, such as the Middle East and Africa, uvulectomy is a more common practice. The uvula is removed for curative or preventive purposes, or as part of ritual practice. Due to immigration from developing to developed world countries, and to Western doctors working abroad, such doctors are increasingly being confronted with unfamiliar traditional healing practices, within a medical context.

METHODS

The Medline and Embase online databases were systematically searched for literature on traditional uvulectomy. We present a review of this literature. We also present the first report, to our best knowledge, of obstructive sleep apnoea as a late complication of traditional uvulectomy.

DISCUSSION

Traditional uvulectomy may be complicated by post-operative haemorrhage and local infections, among many other problems. We report cases of obstructive sleep apnoea and snoring caused by palatal stenosis resulting from traditional uvulectomy during childhood.

CO₂ laser ablation and balloon dilation for acquired nasopharyngeal stenosis: a novel technique

OBJECTIVES/HYPOTHESIS

Although acquired nasopharyngeal stenosis (NPS) is frequently attributed to infectious and granulomatous processes, it can also occur secondary to external beam radiation therapy for head and neck cancer. NPS can be treated with local flaps, laser excision, nasal stenting, and combinations thereof. Unfortunately, the postoperative course is frequently complicated by scarring and restenosis that often necessitates multiple revision surgeries. The objective of this study is to report a novel endoscopic approach, employing the use of a flexible CO(2) laser in combination with balloon dilation and mitomycin-C application, allowing for the successful treatment of acquired NPS with lasting results.

STUDY DESIGN

Retrospective review of case series.

METHODS

An endoscope with a working channel is passed transnasally to the location of nasopharyngeal stenosis. A flexible CO(2) laser fiber is then inserted via the working channel of the scope. Precise radial incisions are made on the stenosis using the laser under direct visualization. The laser is removed, and a controlled radial expansion balloon dilation device is inserted, advanced to span the segment of stenosis, and inflated to achieve adequate dilation. Mitomycin-C is then applied topically to the area of dilation.

RESULTS

Three patients with severe NPS were treated using this novel technique. All patients had successful long-lasting dilation of NPS without complications over a follow-up period ranging from 12 to 18 months.

CONCLUSIONS

Acquired NPS can be successfully treated with durable results with radial laser incisions and controlled radial expansion balloon dilation.

Amelioration of acquired nasopharyngeal stenosis, with bilateral Z-pharyngoplasty

Nasopharyngeal stenosis as a postoperative complication following pharyngeal surgery (tonsillectomy/adenoidectomy) is rare and may be difficult to treat. All patients with severe nasopharyngeal stenosis treated at UCLA with a bilateral Z-pharyngoplasty procedure from 1999 to 2006 were studied (n = 6). Degree of pharyngeal stenosis preoperatively and following a bilateral Z-pharyngoplasty was graded 0-4 based on (1) symptomatology (snoring, hyponasal speech, difficulty with nasal breathing, difficulty breathing during exercise, obstructive sleep apnea, daytime fatigue, anosmia, rhinorrea, dysphagia, or difficulty in blowing nose) and (2) measurement of stricture at the time of direct nasolaryngoscopy. Nasopharyngeal stenosis after pharyngeal surgery (adenotonsillectomy--67%, uvuloplasty--17%, pharyngoplasty--17%) failed to be alleviated by a mean of 2.3 procedures (kenalog injection or scar excision) and required corrective bilateral Z-pharyngoplasty a mean of 9.2 months after the original surgery. Symptomatic grading of the nasopharyngeal stenosis improved from a mean score of 3.3 (severe stenosis) preoperatively to a score of 0.2 (minimal to no stenosis) in follow-up. Endoscopic stricture measurement improved from 6.1 x 6.3 mm preoperatively to 28.1 x 39.3 mm in follow-up. Bilateral Z-pharyngoplasty was effective in alleviating severe postsurgical nasopharyngeal stenosis.

Velopharyngeal stenosis, a late complication of radiotherapy

Choanal stenosis has recently been recognized as a late complication of radiation therapy for nasopharyngeal carcinoma. The management of velopharyngeal stenosis is challenging with high risk of restenosis. We report a case of velopharyngeal stenosis post-radiotherapy and illustrated the use of mitomycin-C to prevent restenosis. Mitomycin-C application has being shown useful adjunct to surgical technique in managing nasopharyngeal stenosis for surgeons.

Study of Wound Healing in Rats Treated with Topical and Injected Mitomycin C

Objectives:

Mitomycin C, a widely used chemotherapeutic drug, has been proposed as a potential adjuvant for the control of scar tissue in surgical wounds because of its capacity to inhibit fibroblast proliferation. The current study used a combination of topical and injected mitomycin C to slow the healing process of surgical wounds in rats.

Methods:

An experimental model of surgical wounding at the dorsum of rats was used. A total of 43 animals were subdivided into 3 groups: Control, topical mitomycin C, and a combination of topical treatment and intradermal injections of the drug at 30 and 60 days after the initial topical treatment. After 3 months, the animals were painlessly sacrificed and the surgical scars were removed for microscopic analysis.

Results:

The group that received only topical mitomycin C presented milder inflammatory signs and consequently had a less intense healing process than the control group. The group treated with a combination of both topical and injected mitomycin C presented results comparable to those of the control group.

Conclusions:

The toxic characteristics of mitomycin C were most likely responsible for the greater tissue damage that occurred when it was used in the injected form, causing increased scar tissue formation. Mitomycin C slows the healing process of surgical wounds when used topically, but causes enhanced scar tissue formation when injected.