Acquired nasopharyngeal stenosis: surgical treatment for this unusual complication after chemoradiation for nasopharyngeal carcinoma

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.

'Nasal flossing': A case report of nasopharyngeal stenosis due to severe erosive lichen planus and a novel therapeutic intervention

INTRODUCTION

We describe a case of severe erosive oral lichen planus that led to nasopharyngeal stenosis. This is a rare clinical presentation that was ultimately, successfully treated by surgery combined with post-operative 'nasal flossing': a novel therapeutic intervention.

PRESENTATION OF CASE

A 76-year-old male suffering from a rare case of severe oral lichen planus that was resistant to conservative measures is described. Initial surgery was complicated by recurrence of nasopharyngeal stenosis. Definitive surgery required revision of nasopharyngeal stenosis release combined with a course of post- operative 'nasal flossing'. The technique for 'nasal flossing' is described and demonstrated in photographs. The patient remained asymptomatic at 3 years using this combined approach, with restoration of olfaction, taste perception and voice quality, significantly enhancing quality of life.

DISCUSSION

Erosive oral lichen planus is a rare but important presentation in oral medicine. We found 'nasal flossing' to be a successful treatment to maintain nasopharyngeal patency following surgical repair of this uncommon condition. We are not aware that this combined approach has previously been described in the published literature.

CONCLUSIONS

Severe erosive oral lichen planus can lead to nasopharyngeal stenosis. Nasopharyngeal stenosis in these patients may be refractive to conventional surgical approaches. 'Nasal flossing' is demonstrated to be both practical and acceptable as a surgical adjunct in these difficult to treat cases of recurrent nasopharyngeal stenosis. This report has relevance for all those practicing oral and maxillofacial surgery, ear nose and throat surgery and oral medicine.