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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com


CASE REPORT
Acquired nasopharyngeal stenosis: Case report and
review of surgical techniques

Villarreal I. MD
1
, Pinilla Urraca M. MDPhD
2
, Arellano B. MDPhD
3
,
Brea B. MD
4
, Lpez-Cortijo C. MDPhD
5
.

Otorhinolaringology
1,2,3,5
and Neuroradiology
4
Departments Puerta de Hierro Majadahonda
University Hospital, Universidad Autnoma Madrid, Spain


ABSTRACT:
Acquired nasopharingeal stenosis (NSP) is a rare cause, but to be considered, of
nasal breathing insufficiency. Its diagnosis is made initially by nasofibroendoscopy
with consequent radiological confirmation. The most common cause is iatrogenia,
followed by inflammatory diseases. In extremely rare cases the cause is uncertain.
The main treatment involves surgery followed by classical postoperative stenting
during a variable time. We present a case of an adult patient with stenotic choanas
without an apparent cause who underwent an endoscopic surgical procedure with
microdebrider and bilateral nasal packing with Merocel for seven days. After five
years of follow-up, the functional results are good. In addition, we perform a
review of possible surgical techniques which we can be used in this type of
pathology, and their postoperative care according to different authors.

Keywords: Acquired nasopharyngeal stenosis, endoscopic procedure, surgical
techniques


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Cite this Article: Villarreal I, Pinilla Urraca M, Arellano B, Brea B, Lpez-Cortijo C:
Acquired nasopharyngeal stenosis: Case report and review of surgical techniques, Journal
of Head & Neck physicians and surgeons Vol 2 Issue 1 2014 : Pg 102-111




INTRODUCTION:

Nasopharyngeal stenosis (NPS) is defined as a lack of communication between the
nasal cavity and the aerodigestive tract. The area with higher tendency of stenosis
is the palatal-maxillary union in front of the posterior edge of the vomer and the
palatine bone. Its ethiology is usually congenital. Acquired cases are attributed
usually to surgical procedures, radiotherapy and granulomatous diseases [1]. In
extremely rare cases no cause is found and its origin becomes indeterminate and
uncertain.

CASE REPORT:

We report a case of a 43 year old patient, natural from Ecuador, who presented in
2009 with a 20 year long history of nasal voice, bilateral nasal obstruction,
anosmia, frequent seromucous otitis and obstructive sleep apnea. She underwent a
septoplasty procedure almost 20 years ago in her hometown. She had no history of
other surgical procedures, known infectious or chronic inflammatory diseases or
needing to use a nasogastric tube. Physical examination revealed an obstruction of
more than 95% of the nasopharynx with a fibrotic, scarred tissue. (Figure 1) A
sinonasal CT scan was performed. A clear reduction of size in the posterior nasal
cavities due to thick soft tissue material that extends from palate to nasopharynx
was observed. (Figure 2)
Based on the clinical history and physical/radiological findings an endoscopic
surgical approach was suggested and accepted by the patient. A complete
resection of the posterior nasal septum including the vomer and the scarring tissue
found in the nasopharynx, being especially careful when approaching the tubaric
areas bilaterally, was done using a microdebrider followed by bilateral 10 cm

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Merocel (oxidized cellulose) packing during 7 days. The anatomopathological
result showed a collagen fibrous scarring tissue with no inflammatory process
associated. A thorough immunological blood testing was performed having
negative results (Anti-smooth muscle antibodies, anticentromere antibodies, anti-
nuclear antibodies, c-ANCAs and p-ANCAs, and others)
During follow-up, she continued with the same otologic symptoms regarding
seromucous otitis requiring pressure equalization tubes positioning associated with
nasal steroid treatment. The resected area showed a correct scarring and
permeability. Today she is symptom free and with no signs of restenosis. (Figure
3)



Figure 1: Endoscopical image of a scarring tissue causing a nasopharyngeal stenosis of
more than 95%.

Figure 2: (A), CT Axial soft tissue, (B), Coronal and (C) Sagital bone algorithms.
Narrowing of posterior nasal cavities due to thick soft tissue component (arrow head)

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extending from palate (dashed line) to nasopharynx (continuous line). Stenosis of the
choana (black arrows)



Figure 3: Endoscopical image of a permeable nasopharynx after a 5-year follow-up

DISCUSSION:

Acquired nasopharyngeal stenosis is almost always an iatrogenic problem caused
by surgical trauma after adenotonsillectomy or uvulopalatopharyngoplasty (UPPP)
[1, 2]. Furthermore, laser-assisted uvulopalatopharyngoplasty for the treatment of
sleep apnea and severe roncopathy may lead to the development of cicatricial
scarring and stenosis especially at the level of the velopharynx. In light of the
pivotal role of radiotherapy in the management of head and neck cancer, its
prevalence is increasing due to this cause as well [3, 4].

Other causes to be taken into consideration are granulomatous diseases such as
sarcoidosis [1] and lupus, severe infection such as syphilis, rhinoscleroma,
diphtheria, tuberculosis and scarlet fever [5]. Factors that increase the incidence
of postsurgical NPS include severe mucosal reaction, patient history of keloid
formation, postoperative bleeding, infection, use of KTP laser, over-resection or
excessive undermining of lateral pillars, and combination of adenoidectomy with
UPPP [4].


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The relatively circular anatomic structure of the posterior choanae and its close
proximity to the posterior end of middle turbinates, inferior turbinates, nasal
septum, and floor of the nose could have induced the enhanced scarring after
radiotherapy [4] and ENT procedures resulting in stenosis.
Krespi et al suggested a grading system that divides NPS into 3 different types
based on severity [4, 5]. Mild cases were treated in the outpatient setting, but
moderate and severe cases were treated in the operating room. (Table 1)
Table 1
Type Characteristics
I (mild) Lateral aspects of the palate adhere to the posterior pharyngeal
wall.
II (moderate) Circumferential scarring with a small central opening (1-2 cm).
III (severe) Residual opening less than 1 cm.


Clinical symptoms generally relate to altered nasal breathing, olfaction and voice
quality disturbances, hyponasality, rhinorrea, dysphagia, and obstructive sleep
apnea [4, 5], may be found and are often poorly tolerated. Our patient presented all
of these symptoms and also intermittent conductive hearing loss due to seromucous
otitis.Most of the studies have indicated that the only curative treatments for NPS
are surgical. However, most of them are complicated and result in inconsistent
outcomes. The ideal method should be whichever one achieves the highest rate of
permanent success in restoring communication between the nasal fossae and the
nasopharynx, while causing as little morbidity as possible [6, 7].

Various methods for repairing NPS have been described (Table 2), but none has
shown clearly superior results in treating this difficult problem [3, 4, 6].

Table 2
Possible treatments for NPS repairing
1. Steroid injections 2. Scar Lysis

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3. Skin grafts 4. Z-plasty repair
5. Local mucosal flaps 6. Laser excision
7. Cold knife/ motorized excision 7. Balloon endoscopic dilation

The transeptal, transnasal, transpalatine, transoral and sublabial techniques are
possible surgical approaches described in the literature. [7-9]

A detailed preoperative evaluation of the extent and degree of stenosis is
indispensable if the best surgical result is the goal on the first attempt at correction;
furthermore, individualizing treatment is essential to avoid geometric worsening of
the disease process [3,7].

High resolution CT is the key radiological study to confirming diagnosis. We
believe that it is an indispensable study to identify possible anatomical variations
and osseous vs membranous components. CT scans can accurately characterize the
nature and thickness of the atresia, the narrowing of the posterior nasal cavity and
the thickening of the vomer [7].

The transoral route to perform a bivalved palatal transposition flap is also to be
mentioned. [7].This technique performed by Toh E et. al had also positive results.
[2] Another type of flap that might be used is the lateral pharyngeal flap closure
which is a very good option but this approach is not possible if there is a
significant depth and extent of scarring. Endoscopic balloon dilatation and
transoral pharyngoplasty may be considered as first-line treatments for acquired
nasopharyngeal stenosis, particularly in patients with rheumatologic diseases such
as sarcoidosis [2].

The transpalatine approach has been the most widely used throughout history.
Defendants of this via report that it provides them with a large surgical field and,
therefore, high success rates. Nevertheless, this approach is associated with a
higher rate of postoperative complications (palatine necrosis, palatine fissures,
hemorrhaging) and greater morbidity[7-9]. This approach is usually performed

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when there is a lack of landmarks and extreme density of the scarring in the
nasopharynx providing a better access to the choanae and a facilitated opening of
the associated scarring of the soft palate to the posterior nasopharyngeal wall
[7].This approach would basically be reserved for after failures of prior surgery.
This technique was the first surgical option in our institution years ago having
positive results [10].

Since 1990 the endoscopic route has been the most widely used because of its
safety, the lack of external scars and its scant postoperative morbidity. The
technique permits a direct approach to the atretic area, with the advantage of an
angled view, good illumination and magnification of the stenosis [7, 9]. It has the
advantage of a reduction in surgery time and less intra-operative bleeding which
leads to a shorter hospitalization time and a rapid recovery. In children it is
known that it doesnt alter the growth centers of the bony palate and pyramid of the
nose and reduces the risk of palatal fistulae [4].Lorente et. al point out two
fundamental steps in this kind of surgery: increasing the surface of the choanal
frame by eliminating the posterior part of the vomer and the creation of the
mucosal flaps that will cover the exposed bony surfaces on the edge of the
choanae. Taking them into consideration reduces the risk of restenosis [7]. The
endoscopic technique was the surgical procedure we chose which included a
posterior septectomy and a resection of the stenotic tissue with microdebrider.

Some authors proposed a technique using the plasma radiofrequency-based
(coblation) Plasma Hook (ArthroCare Corp., Sunnyvale, CA) [3]. The excision of
scar tissue was quick and easy to perform, and it was not necessary to place
sutures, cut flaps, or place grafts. They suggested that plasma radiofrequency-
based excision incurred significantly less epithelial damage and produced a smaller
area of collagen denaturation than conventional electrosurgery [3].

Excision with CO2 laser and nasal endoscopeguided positioning of a silastic
stent, which is worn postoperatively for 6 months to guide reepithelization and
avoid restenosis, appears to be effective in the treatment of NPS especially after
chemoradiation for nasopharyngeal carcinoma [4, 5]. Disadvantages of using the
CO2 laser include increased cost and an obligatory zone of thermal injury, which
may predispose to restenosis. [3]

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Modalities for preventing recurrence have included the placement of stents and
obturators, the endoscopic application of mitomycin C [2, 7], and local flap
reconstruction. In cases with mild scarring, some success has been observed with
triamcinolone acetonide injections. So usually authors suggest that all of the
patients with moderate or severe stenosis treated with laser have to receive a
nasopharyngeal obturator or stent to be worn for 2 to 6 months as a measure to
prevent recurrent stenosis. [5] Ku, et al as well as Llorente et al, modified
traditional stenting with silastic tubes during 6 weeks by using Merocel epistaxis
packing [6, 7]. This was better tolerated by the patients because it caused less
discomfort and was less conspicuous [7]. We made the same modification with
our patient using them for seven days having very good results. Several
publications and a review of the Cochrane database conducted by Cedin et al. have
concluded that there are no differences in the use of stents with respect to the rate
of restenosis [7].

Adjunctive treatment would include pressure equalization tubes, especially in those
patients with obliterated torus tubarius, and aggressive treatment of rhinitis. In our
case the patient, referred all her symptoms were gone except for intermittent
seromucous otitis that even required transtympanic pressure equalization tubes.
The best treatment for NPS, however, remains to avoid any possible treatment
iatrogenia.
Conclusion

Acquired nasopharyngeal stenosis is a possible but not common complication of
numerous procedures and diseases. We present a case in which no clear cause was
established, but regardless this situation, an endoscopic approach to remove the
posterior nasal septum and with microdebrider the stenotic area, followed by
Merocel packing has an outstanding result with no major consequences. The
endoscopic technique allows us to perform a completely adequate safe procedure
with less morbimortality and a higher cost-effectiveness.



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sarcoidosis. J Laryngol Otol. 2012 Nov; 126(11):1182-5.
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correction of acquired nasopharyngeal stenosis. Am J Rhinol. 2000 May-Jun;14(3):199-204
[3] Madgy DN, Belenky W, Dunkley B et al. A simple surgical technique using the plasma
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[8] Giannoni C, Sulek M, Friedman EM, et al. Acquired nasopharyngeal stenosis: a warning
and review. Arch Otolaryngol Head Neck Surg. 1998 Feb;124(2):163-7
[9] Wang QY, Wang SQ, Lin S, et al. Transnasal endoscopic repair of acquired posterior
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[10] Pinilla M, Ramrez-Camacho R, Garca Berrocal JR et al. Acquired stenosis of the
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Acknowledgement- None

Source of Funding- Nil

Conflict of Interest- None Declared

Ethical Approval- Not Required

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Correspondence Addresses :
Mayte Pinilla Urraca
ENT Department Hospital Universitario Puerta de Hierro-Majadahonda
Calle Joaquin Rodrigo 228222 Madrid SPAIN
Tel +34 629810134
Fax +34 911917884
Email: pinillamayte@gmail.com



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