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Treatment of Post-Adenotonsillectomy Velopharyngeal Stenosis With

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Treatment of Post-Adenotonsillectomy Velopharyngeal Stenosis With International Journal of Pediatric Otorhinolaryngology 126 (2019) 109600 Contents lists available at ScienceDirect International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl Treatment of post-adenotonsillectomy velopharyngeal stenosis with ☆ T bivalved uvular flaps Mosaad Abdel-Aziza,*, Abdel-Rahman El-Tahanb, Mahmoud El-Foulya, Ahmed Kamelc, Assem Abdel-Wahidd a Department of Otolaryngology, Faculty of Medicine, Cairo University, Egypt b Department of Otolaryngology, Aswan University, Egypt c Department of Otolaryngology, Faculty of Medicine, Beni-Suef University, Egypt d Department of Otolaryngology, Faculty of Medicine, Fayoum University, Egypt ARTICLE INFO ABSTRACT Keywords: Objective: Velopharyngeal stenosis (VS) is a rare devastating complication of adenotonsillectomy that causes Velopharyngeal stenosis obstructive sleep apnea (OSA). Its treatment is challenging and has a high recurrence rate. The aim of this study Nasopharyngeal stenosis was to assess the efficacy of a bivalved uvular flap technique with topical application of mitomycin Cfor Adenotonsillectomy treatment of this problem. Bivalved flap Study design: Case series. Obstructive sleep apnea 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 ofscar tissue is an effective treatment for VS that may follow adenotonsillectomy in children. 1. Introduction sleep apnea. Additionally, it may decrease speech resonance and lead to hyponasality. It may be caused by surgical trauma as after tonsil- The velopharyngeal port is the passage between the nasopharynx lectomy, adenoidectomy, and uvulopalatoplasty or radiotherapy for and oropharynx. It is a mechanical sphincter that opens on breathing treatment of nasopharyngeal carcinoma [4,5]. Because of the high in- and shuts during swallowing to prevent regurgitation of food and fluids cidence of recurrence, treatment of this condition is challenging. Pa- and during articulation of oral phonemes to control speech resonance tients with VS may require repeated surgical interventions to obtain [1,2]. It is controlled by the action of the palatal muscles together with satisfactory results. Therefore, many treatment modalities are being superior constrictors and is lined by a mucous membrane that is re- tried to cure this problem [6]. The aim of this study was to assess the spiratory epithelium in the nasopharynx and nonkeratinized squamous efficacy of a bivalved uvular flap technique with topical application of epithelium in the oropharynx [3]. The area is closely related to the mitomycin C for treatment of VS following adenotonsillectomy in pe- adenotonsillar tissues; the adenoid is located in the supero-posterior diatric patients. wall of the nasopharynx, and the tonsils are located between the pillars of fauces in the oropharynx below the soft palate [4]. Velopharyngeal stenosis (VS) may lead to snoring and obstructive ☆ This multicenter study was conducted on the Departments of Otolaryngology of Cairo University, Aswan University, Beni Suef University and Fayoum University (Egypt). * Corresponding author. 2 el-salam st., King Faisal, above el-baraka bank, Giza, Cairo, Egypt. E-mail addresses: [email protected], [email protected] (M. Abdel-Aziz). https://doi.org/10.1016/j.ijporl.2019.109600 Received 22 April 2019; Received in revised form 12 July 2019; Accepted 19 July 2019 Available online 23 July 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved. M. Abdel-Aziz, et al. International Journal of Pediatric Otorhinolaryngology 126 (2019) 109600 2. Methods into oral and nasal halves. The cotton pieces were removed, and the lateral parts of the pharyngeal mucosal flap were used to cover the This study was conducted on 14 patients who presented with ve- lateral pharyngeal walls and the central part was used to cover the lopharyngeal stenosis after adenotonsillectomy. The patients were re- posterior pharyngeal wall. The uvular flaps were rotated to cover the ferred to our institutes from February 2013 to July 2017; their ages open raw areas on the posterior edge of the soft palate, the oral flap for ranged between 4 and 8.5 years with a mean of 6.3 ± 1.4 years, and the right side and the nasal flap for the left side (Fig. 1). We obtained a there were 9 girls and 5 boys. Patients who underwent surgery for VS, posterior border for the soft palate that was completely covered with who presented with any obstructive airway disease, or who presented uvular mucosa without raw areas. Avoiding overstretch of the mucosal with craniofacial anomalies were excluded. Informed consent was ob- flaps and narrowing of the velopharynx is of paramount importance. All tained from the parents that were informed that repetition of the same flaps were sutured in place, using 4-0 Vicryl as a simple interrupted surgical procedure may be needed in cases of restenosis, and the prin- suture technique. Upon awakening, patients were extubated and placed ciples outlined in the Declaration of Helsinki were followed. In addi- in a lateral position and then transferred to the postanesthesia care unit. tion, the research protocol was approved by the ethics committee of our institute. Written consents were obtained from the parents of the pa- 2.3. Postoperative care and follow-up tient presented in the video files. Patients underwent extensive pre- and postoperative assessment as All patients received oral amoxicillin (50 mg/kg/day) and para- described below: cetamol for 10 days. Patients were discharged from the hospital on the third postoperative day, and they were instructed to consume semisolid 2.1. Preoperative assessment food for one week. Children were seen weekly till wound healing was achieved then monthly for at least one year. Flexible nasopharyngo- Medical history was obtained from the parents of the patients, with scopy, PSG and measurement of BMI were performed one year post- emphasis on symptoms suggestive of obstructive sleep apnea (OSA) [7]. operatively. Only patients with a positive history were included in the study. The type of operative procedure and the duration elapsed until symptoms 2.4. Statistical methods appeared after adenotonsillectomy were recorded. Otolaryngologic examination was performed for assessment of the degree of VS and to Data were coded and summarized using the Statistical Package for exclude any associated airway disorders and/or middle ear effusion. VS Social Sciences for Windows, version 20.0 (SPSS Inc., Chicago, IL). was graded as mild when the lateral aspects of the palate adhered to the Quantitative variables are presented as the mean ± standard deviation posterior pharyngeal wall, moderate when there was circumferential as well as median ± interquartile range. Comparison of preoperative scarring with a small central opening that was 1–2 cm in diameter, and and postoperative results of both the A/H index and minimum O2 sa- severe when the entire palate fused with the posterior and lateral turation was performed using Wilcoxon matched-pair signed-rank test pharyngeal wall leaving a residual opening less than 1 cm [8]. Flexible and paired samples t-test respectively. P < 0.05 was considered sta- nasopharyngoscopic examination was performed to assess the thickness tistically significant. and extent of stenosis and to determine if there was scar tissue within the nasopharynx. The nasopharyngeal airway was also assessed by 3. Results computed tomography (CT) for all patients. All patients were assessed by overnight polysomnography (PSG) for at least 6 h (lab-based study) Fourteen children with VS and OSA were enrolled in the study. The in a quiet, dark room. The Apnea/hypopnea (A/H) index and minimum symptoms appeared between 2 and 5 months with a mean of 2.4 O2 saturation were measured, and the A/H index was categorized as months after adenotonsillectomy. The operation was performed with follows: < 1.0, normal; 1–4.99, mild; 5 to < 9.99, moderate; and monopolar diathermy in 9 patients, bipolar diathermy in 3 patients, and ≥10.0, severe [9]. As the Body mass index (BMI) could affect the PSG coblation radiofrequency in 2 patients. Oropharyngeal examination data, we measured the BMI for all patients dividing their weight in (Fig. 2) showed adhesions between the pillars and the lateral and kilograms by their height in meters squared, and that was done at the posterior pharyngeal walls in all patients, and the VS was severe in 11 day of PSG study. According to BMI-for-age percentile growth charts, it and moderate in 3 patients. No patients presented with middle ear ef- was considered that underweight (≤5th percentile), normal weight fusion. Flexible nasopharyngoscopy showed cicatricial stenosis at the (> 5th and < 85th), overweight (≥85th and < 95th), obese (≥95th level of the velopharyngeal port extending to the oropharynx, neither and
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