Management of pharyngeal stenosis following tonsillectomy with local injection of steroids: Case report and literature review

Summary 

Objective: Tonsillectomy is a common surgical procedure in pediatric ENT. Pharyngeal stenosis is a late complication with an insidious onset and seems to occur largely in cases with suboptimal surgical technique or in a particular clinical scenario.

We report the case of a 9-year-old child which presented a severe pharyngeal stenosis 4 months after a tonsillectomy for obstructive sleep apnea syndrome (OSAS).

Method: Case report and literature review.

Results: The boy presented with a severe recurrence of OSAS, dysphagia, and recent weight loss. The parents reported frequent vomiting after the initial procedure.

Sleep monitoring showed numerous episodes of apnea and desaturation. Examination and endoscopy under general anesthesia confirmed the presence of a large, fibrous stenosis of the pharyngeal isthmus. Due to the pharyngeal stenosis, the control of the airway was difficult and required an uneasy fiberoptic intubation.

The management of the lesions required several endoscopies and surgical procedures: LASER, stenting, pharyngeal flaps, use of mitomycine. Only repeated injections of corticosteroids in the fibrous area eventually allowed healing of the scarring.

Pharyngeal stenosis is an unusual complication after tonsillectomy. We report a detailed review of the literature dealing with this complication and its management. There are only limited series and the exact incidence is unknown.

Conclusion: Nasopharyngeal stenosis post-tonsillectomy is a rare but serious complication. Early detection of recurrence of the obstructive syndrome several weeks after the surgery is essential. A minimum follow-up of 10 months is required after surgery.

Local triamcinolone acetonide injections can be used as first line therapy. Prevention of this complication can be achieved by surgical expertise and by preserving the anatomical structures, avoiding the use of a LASER and excessive electro coagulation. In cases with an associated significant gastro-esophageal reflux, systematic post-operative treatment with a proton pump inhibitor is recommended.

Keywords: Pharyngeal stenosis, Tonsillectomy, Children, Triamcinolone acetonide, Laser