Volume 5, Issue 1 , Pages 23-27, January 2010
Management of pharyngeal stenosis following tonsillectomy with local injection of steroids: Case report and literature review
Article Outline
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
1. Introduction
Tonsillectomy is a common surgical procedure in pediatric ENT. The various techniques, as well as the early and late complications, are well established. However, there remains controversy as how best to avoid the complications. For example, hemorrhage occurs in the immediate post-operative period or during the 2 weeks post-surgery. Much less frequent is pharyngeal stenosis, which has a more insidious onset, and seems to occur largely in cases with suboptimal surgical technique or in a particular clinical scenario. We report here a case of very severe pharyngeal stenosis developing 4 months post-tonsillectomy in a child with severe gastro-esophageal reflux. Furthermore, we discuss the therapeutic options for this clinical scenario—namely, repeated injections of corticosteroids (triamcinolone acetonide), which allowed control of the scarring and to avoid both tracheotomy and gastrostomy.
2. Case report
A 9-year-old child was referred to the department because of a change in the child's overall state of health, as well as snoring. The patient had been operated on at another institution 4 months earlier by an experienced surgeon and undergone a tonsillectomy for obstructive sleep apnea syndrome (OSAS). Post-operatively, analgesics and a short course of antibiotics were required. The complications were marked by frequent vomiting – several times a day – over a period of several days. The parents indicated that their child tended to vomit quite easily. The snoring, which had initially resolved, reoccurred and became worse, with breaks in respiration at night noted by the parents. The child had dysphagia and had experienced recent weight loss.
Examination revealed a very large horizontal scarring between the two posterior tonsils pillars, with a stenosis of the oropharyngeal isthmus posteriorly extended on the pharyngeal wall. Sleep monitoring showed numerous episodes of apnea and desaturation. Treatment with a proton pump inhibitor (PPI; omeprazole 20
mg daily) was begun.
An endoscopy under general anesthesia confirmed the presence of a large, fibrous stenosis of the pharyngeal isthmus (Fig. 1).
Fig. 1.
Endoscopic view of the oropharynx. Large horizontal scarring between the two posterior tonsils pillars extended on the posterior pharyngeal wall.
The larynx could not be exposed, and we experienced great ventilation difficulties. An emergency fiberoptic intubation was performed, uneasy because of the severe stenosis of both nasopharynx and oropharynx. The endoscopic examination resumed once the endotracheal tube in place. There was no obstruction to the opening of the esophagus.
The scarring was cut using a laser and a pharyngeal stent created using reinforced Silastic® sutured to the soft palate. The child was fed via a naso-gastric tube and the stent was removed 7 days later under general anesthesia.
The follow-up endoscopy on the fifteenth day showed the early signs of recurrent scarring. The lesions were sectioned once again using a laser and, in addition, mitomycin was applied to the fibrous area. A further follow-up at 1 month showed minimal recurrence, however the clinical condition of the patient was much improved. This time, the scars were cut using surgical scissors and mitomycin reapplied using the same protocol as before. The 2-month check-up showed a major recurrence of the scarring and feeding was once more problematic. On this occasion, the lesions were cut and the pharynx freed using cold instrumentation only. Then a flap was created for the posterior pharyngeal wall – using a graft taken from a healthy area of the posterior pharyngeal wall – and split into two hemi-flaps, sutured on both sides to the posterior pillars.
At 4 months, another recurrence was detected and the child remained symptomatic. The lesions were cut again using cold instrumentation and on this occasion an injection of Kenacort® Retard (triamcinolone acetonide 40mg/1ml) was given in divided doses throughout the fibrotic area. Following this intervention, the scarring finally stabilized, feeding recommenced and the child's height and weight increased. Two further endoscopies were performed, at 6 and 10 months, with injection of triamcinolone acetonide on each occasion.
There has been no relapse of the OSAS with more than a 2-year follow-up. The fibrotic areas have flattened and the size of the pharyngeal isthmus is satisfactory. Long-term treatment with the PPI has been continued.
3. Discussion
The most frequent complications post-tonsillectomy are hemorrhage, either immediate or delayed, nausea and post-operative infection. Velopharyngeal incompetence due to a defect in the palate can occur if the posterior pillars are cut during surgery, in particular if an adenoidectomy was performed at the same time [1], [2]. Nasopharyngeal stenosis is a much rarer entity, but is characterized by recurrence of the nasal obstruction, rhinorrhea, nasal speech, dysphagia or recurrence of the clinical signs of sleep apnea several weeks after surgery. Such stenosis is more likely to occur if there are adjacent areas of bleeding and if the there has been excessive mucosal destruction.
There are only limited series reported in the literature dealing with this complication and the exact incidence is unknown. Prior to 1940, about 40% of cases of pharyngeal stenosis were attributable to pharyngeal syphilis; thereafter, most cases are due to surgery for tonsillectomy and adenoidectomy.
The two most recent series [3], [4] report on a total of 15 children who presented with nasopharyngeal stenosis, which was treated with a variety of approaches: LASER treatment, cutting of the scarring, creation of mucosal flaps, local injection of steroids and even micro-anastomosis with a jejunum flap. These reports comment on the increased risk of stenosis associated with excessive use of electro coagulation and LASER treatment, as well as if the surgical incision extends to underlying muscle or the healthy adjacent mucosa.
Several different approaches have been used for the management of these stenoses. The most frequent approach has been to excise the scar tissue and repair the lesion with different types of mucosal flaps. Mac Kenty [5], in 1927, was the first to describe a mucosal flap of the soft palate with upper pedicle. Kazanjian and Holmes [6], in 1945, described the use of rotational flaps to cover the bleeding surfaces. In 1949, Vaughn [7] described lateral mucosal flaps for nasopharyngeal stenoses. Woolf and Broadbent [8], in 1970, and then Bennhoff [9] in 1979, reported good results with Z plasty. In 1985, Cotton [10] described a large lateral mucosal flap of the posterior pharyngeal wall. Finally, in the case of major stenosis, micro-anastomotic flaps have been proposed: from the jejunum, as described by Mc Laughlin et al. [3] in 1997; while Stepnick [11] used forearm free flap in 1993.
LASER treatment of the lesions cannot be recommended. Two authors have reported a strong association between use of the KTP laser for adenotonsillectomy and the subsequent occurrence of nasopharyngeal stenosis [2], [3]. LASER therapy produces vaporization or coagulation of tissue when the light energy is absorbed, which leads to different to thermal effects at different tissue depths. The resultant scarring is delayed by several weeks, as compared to the scarring following the use of cold instrumentation only, because the tissue damage is deeper and hence favors retractile scars.
The topical application of mitomycin is mainly used in ENT in endolaryngeal or endonasal surgery in order to reduce and limit hypertrophic scarring. Mitomycin is a drug which inhibits DNA synthesis and the proliferation of fibroblasts. Therefore, this approach is justified after cutting of the lesions by LASER, but the poor results seen here are probably due to the LASER-induced tissue damage [14], [15].
There are few reports of stenting in the literature: fixation of the stent is difficult, it must be extremely reliable in order to avoid an obstructive catastrophe, and both its insertion and removal require a general anesthesia.
The intra-lesional injection of corticosteroids has been shown to reduce the secretion of collagen as well as leading to its solubilization, significantly reducing the occurrence of keloids [12]. The first report of the use of steroids, triamcinolone acetonide, for oropharyngeal stenosis was by Santos in 1977 [13] with good results. In 1997, Mc Laughlin used the same approach for two cases of severe oropharyngeal stenosis and reported good outcomes with a follow-up of 14 and 18 months.
The local injection of triamcinolone acetonide has resulted in good outcomes in every case, with the effects seen rapidly and without later recurrences [3]. However, this approach has been used in the literature, as well as in the case presented here, only as a measure of last resort following the failure of multiple surgical interventions. There are no specific contra-indications, although there is a risk of inducing Cushing's syndrome in cases where the cumulative total dose is high [16], [17]. A solitary case of treatment-induced Cushing's syndrome secondary to a single injection has been reported, but this was in an adult [18]. The dose that is usually recommended is an injection of 1–2ml (40–80mg) once a month and repeated to a maximum of three times. However, there is no consensus on this subject.
Furthermore, it should be kept in mind that corticosteroids are known to increase the delay of wounds healing, and may induce a poor local cicatrization if another surgical procedure is needed [3], [19], [20].
In the present case, it is probable that the repeated emesis during the post-operative period predisposed to the occurrence of pathological scaring. While gastro-esophageal reflux is very frequent in the pediatric population (estimated to be 31% in one series of adenoidectomy in children) [21], it is not always clinically evident and does not systematically lead to scaring complications. Nevertheless, it would seem prudent to recommend systematic treatment with a PPI in symptomatic cases, which might have limited the degree of fibrotic scaring in this case.
The criteria for response are essentially clinical, with an increase in height and weight, and the resolution of the clinical signs of OSAS. If there is any doubt, a polysomnography can be performed. A minimum follow-up of 10 months is required, as recurrence may occur a long time after a successful initial surgical intervention.
4. Conclusion
Nasopharyngeal or oropharyngeal stenosis post-tonsillectomy remains a rare but serious complication of a surgical procedure that is frequent in ENT. Early detection of recurrence of the obstructive syndrome several weeks after the surgery, which may or may not be associated with growth retardation, is essential. Examination of the nasopharynx and the oropharynx must be performed to make a complete assessment of the lesions and to plan the most appropriate management. Local triamcinolone acetonide injections can be used as first line therapy. If this is not successful, then more invasive surgical intervention can be performed. The response should not be judged solely by anatomical results, but also using clinical criteria with resolution of the OSAS and an increase in height and weight.
Prevention of this rare complication can be achieved by surgical expertise when performing adenotonsillectomy and 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 PPI is recommended.
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PII: S1871-4048(09)00006-9
doi:10.1016/j.pedex.2009.01.002
© 2009 Elsevier Ireland Ltd. All rights reserved.
Volume 5, Issue 1 , Pages 23-27, January 2010
