conditjon 1 Andrs Alvoa, 2 Cecilia Sedanob, 1 Christjan Olavarraa 1 - - PDF document

ISSN: 2250-0359 Volume 5 Issue 2 2015 Drtbalu’s otolaryngology online

Bilateral massive nasal synechiae: a rare presentatjon of a common conditjon

1Andrés Alvoa, 2Cecilia Sedanob, 1Christjan Olavarríaa 1Servicio de Otorrinolaringología, Hospital Clínico Universidad de Chile. Santjago, Chile. 2Facultad de Medicina, Universidad de los Andes. Santjago, Chile.

Abstract Intranasal synechiae are a relatjvely common fjnding in an otolaryngology practjce. Fre- quently, the scar is focal and due to mucosal

• trauma. We present an unusual case of mas-

sive bilateral intranasal scarring, with nega- tjve etjologic studies except for the anteced- ent of an old nasal fracture. Difgerentjal diag- noses are discussed, as well as its manage- ment. A 41-year-old male consulted with a long- term history of rhinorrhea, facial pain and nasal congestjon. Physical examinatjon re- vealed complete bilateral obstructjon of the nasal fossae with fjbrous synechiae. We performed an endoscopic microdebrider- assisted resectjon of the synechiae connectjng the septum to the lateral nasal wall, up to the choanae and sofu palate. The posterior margin

• f the bony septum was resected to increase

the transversal area at the choanae. Silicone stents were placed postoperatjvely to minimize the formatjon of new synechiae. Massive bilateral scarring is infrequent and sev- eral difgerentjal diagnoses must be considered. Its management is diffjcult and not well stand-

• ardized. Microdebrider-assisted resectjon may

be considered in these cases.

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Introductjon There are several conditjons afgectjng the nasal mucosa that may lead to granulatjon, ulceratjon and eventually scarring with formatjon of synechi- ae between structures of the lateral wall and the septum, including infectjous (1,2), autoimmune/ granulomatous (3-5) and traumatjc (6-8) etjologies (Table 1). Table 1. Conditjons afgectjng the nasal mucosa that may lead to granulatjon, ulceratjon, masses and eventually synechiae formatjon Among these, the most frequent are probably secondary to iatrogenic trauma to the muco- sa, which can occur in various otorhinolaryn- gologic procedures such as functjonal endo- scopic sinus surgery (FESS), septoplasty, turbi- noplasty, fracture reductjon or nasal pack- ings. Although usually traumatjc synechiae for- matjon is limited to a few scars that can be managed conservatjvely or with in-offjce re- sectjon, they can produce chronic rhinosi- nusal symptoms and tend to recidivate afuer

• treatment. In infmammatory synechiae, symp-

toms can be more severe and progressive, and extend outside the mucosa causing nasal deformity. Eventually, this scar tjssue may occupy almost completely the nasal cavity and choanae, ob- structjng airfmow and effjcient mucous drain-

• age. In our experience, this situatjon is very

uncommon, and not well reported in the lit-

• erature. Consequently, its diagnosis and man-

agement is not standardized.

Infectious Rhinoscleroma Rhinosporidiosis Leishmaniasis Other: Mycobacteria (M. tuberculosis,

• M. leprae), Syphilis, Histoplasmosis

Autoim- mune and Non- infectious granuloma- tous Wegener’s granulomatosis Cicatricial pemphigoid Epidermolysis bullosa acquisita Sarcoidosis Traumatic Accidental Iatrogenic (surgery, intranasal catheters, packing, etc.) Others Cocaine abuse Physical and chemical burns Radiotherapy Natural Killer/T cell lymphoma-nasal type Intranasal eosinophilic angiocentric fibrosis

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Case report A 41-year-old Peruvian male presented at our oto- rhinolaryngology service with a long-term history

• f mucous rhinorrhea, facial pain and nasal con-
• gestjon. He worked in ecotourism, had no history
• f exposure to chemicals, drug abuse, nor medical

illnesses and was otherwise asymptomatjc. The

• nly relevant antecedent was a nasal fracture that

was managed with closed reductjon and nasal packing, at the age of 16. Physical examinatjon revealed complete bilateral

• bstructjon of the nasal fossae with fjbrous syn-

echiae, which did not allow passage for the nasal endoscope (Fig. 1). Sinonasal computerized tomog- raphy (CT) showed sofu tjssue adhesions occupying both nasal cavitjes and inferior meatus, plus bilat- eral maxillary retentjon cysts (Fig. 2). Figure 1. Endoscopic view of the right inferior mea- tus, with fjbrous tjssue occluding passage posteri-

• rly

Figure 2. Coronal paranasal CT showing mul- tjple sofu tjssue bands between the inferior meatus to the septum and lateral nasal wall, and bilateral maxillary retentjon cysts Autoimmune, microbiologic and histopatho- logic tests were performed, considering the probable etjologies previously mentjoned. The only positjve fjndings were a culture for coagulase-negatjve Staphylococci, and antj- nuclear antjbodies in a 1:80 dilutjon. Antj- neutrophil cytoplasmic antjbodies were also

• negatjve. The biopsy only showed non-

specifjc infmammatjon and fjbrosis, without evidence of fungi, mycobacteria, granulomas, vasculitjdes or malignancies. Treatment alternatjves were discussed with the patjent, who was warned that there was no etjologic diagnosis, and that synechiae could recidivate afuer surgery.

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Finally, endoscopic surgery was performed to re- store nasal airway patency. We chose to leave si- nus surgery for a second instance, as the retentjon cysts had no peremptory surgical indicatjon and

• stjomeatal obstructjon by post-surgical synechiae

could worsen the symptoms. Intraoperatjvely, under general anesthesia, the nasal mucosa was infjltrated with 1:200,000 epi- nephrine and 2% lidocaine. Then, nasal synechiae between the inferior turbinate and the anterior septum were incised with a #15 blade. Then, the turbinate was lateralized with a Freer elevator and synechiae extending posteriorly were removed us- ing a microdebrider (Fig. 3a). This part was espe- cially diffjcult as the anatomy was distorted and the airway was completely obstructed, but using the nasal fmoor, septum and the already liberated portjons of the inferior turbinate as guidelines al- lowed us to securely follow a proper directjon. Intraoperatjvely, under general anesthesia, the nasal mucosa was infjltrated with 1:200,000 epi- nephrine and 2% lidocaine. Then, nasal synechiae between the inferior turbinate and the anterior septum were incised with a #15 blade. Then, the turbinate was lateralized with a Freer elevator and synechiae extending posteriorly were removed us- ing a microdebrider (Fig. 3a). This part was espe- cially diffjcult as the anatomy was distorted and the airway was completely obstructed, but using the nasal fmoor, septum and the already liberated portjons of the inferior turbinate as guidelines al- lowed us to securely follow a proper directjon. Bleeding was moderate, probably due to the re- placement of the normal mucosa with fjbrosis. Up-

• n reaching the choanae, we realized that was also
• bstructed by a fjbrous membrane (Fig. 3b), which

was carefully debrided taking care to avoid dam- age to the Eustachian tube and sofu palate. To improve results, the posterior margin of the bony septum was resected with Kerrison rongeurs (Fig. 3c), to further enhance the cross-sectjonal area of the choanal opening into the nasopharinx. Adequate hemostasis was achieved with gauzes soaked in a vaso- constrictor solutjon. Finally, we stented the recanalized nasal fos- sae with silicone tubes that extended up to the choanae and silicone plaques applied to the septum, that were removed at 6 and 10 days, respectjvely. He was discharged on oral antjbiotjcs while the stents were in place, and later was instructed to use nasal lavages as needed. The patjent evolved favorably, and 45 days later he had permeable airways with no signs

• f atrophic rhinitjs (Fig. 3d). His quality of life

improved considerably, with betuer breathing and less snoring than prior to surgery. Nasal patency was stjll conserved at 18-month fol- low-up, but a slightly hyponasal voice devel-

• ped due to partjal synechiae and stenosis

between the sofu palate and the torus tubar- ius (Fig. 3e-f), without any other symptoms.

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. Figure 3. a) Microdebrider-assisted resectjon of nasal synechiae on the lefu nasal fossa; b) Initjal

• pening of the fjbrous obstructjon of the lefu choana; c) Partjal resectjon of the posterior margin of

the bony septum using a Kerrison rongeur; d) Nasofjbroscopic appearance of the lefu nasal fossa 45 days afuer surgery; e) Patent lefu nasal cavity at 18-month follow-up; f) Recurrent synechiae between the torus tubarius and the sofu palate at 18-month follow-up

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Discussion Nasal synechiae is not an uncommon problem in rhinology, but informatjon in the literature is difguse and usually addressing preventjon afuer FESS or other procedures. A systematjc approach to the patjent with signifj- cant intranasal scarring can enhance the diagnostjc precision, and rule out potentjally treatable condi-

• tjons. When there is no traumatjc explanatjon, an-
• ther etjologies should be considered and studied.

In most of these cases damage is not limited to mucosal scarring, and other signs like tumoral growth, cartjlage destructjon or external compro- mise can be found, so synechiae are not the only

• r most prominent feature, as opposed to our
• case. Besides infectjous, autoimmune and trau-

matjc causes, adhesions secondary to radiothera- py, drug abuse, burns, neoplastjc and idiopathic (9- 10) etjologies should be considered when clinically appropriated. As our laboratory and pathological studies where mostly negatjve, and the only positjve results were not diagnostjc for any specifjc conditjon, we pro- ceeded assuming a stable, non-progressive nasal

• bstructjon by synechiae, probably secondary to

nasal trauma. The isolated fjnding of positjve antj- nuclear antjbodies were interpreted as a non- specifjc result by us and the rheumatologist, but nonetheless prompts us to keep an actjve observa- tjon for the eventual apparitjon of autoimmune symptomatology in the future. Most of the infec- tjous diseases associated with intranasal synechiae are uncommon in Chile, but relatjvely more fre- quent in other South American countries including Perú, where our patjent was born and lived untjl the age of 16, so special care was taken to try to rule out these etjologies. If a medically treatable cause is not found or has been already treated, and the patjent sufgers signifjcant sinonasal symptoms atuributable to synechiae, a surgical solutjon should be ofgered, warning the patjent about the tendency of synechiae to reappear afuer

• excision. We have not found a similar case of

complete bilateral nasal obstructjon by syn- echiae reported in the literature, and micro- debrider-assisted resectjon proved to be an efgectjve solutjon to the problem. Several strategies have been reported to avoid formatjon of scars afuer endoscopic si- nonasal surgery, including silastjc sheets (6) and topical mitomycin (7). We chose to use silicon stentjng of the nasal airway, in a simi- lar fashion than afuer surgery for choanal atresia. Conclusion Intranasal scarring can be explained by sever- al conditjons afgectjng the mucosa, and prob- ably iatrogenic trauma is nowadays the most frequent cause. In massive synechiae, a surgi- cal solutjon for the nasal obstructjon should be ofgered afuer discarding specifjc etjologies difgerent than trauma. Microdebrider- assisted endoscopic resectjon is a good ap- proach, which yielded satjsfactory long-term results in our patjent.

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