Cicatricial stenosis of the pharynx: causes, symptoms, diagnosis, treatment

Cicatricial pharyngeal stenosis, which lead to progressive stenoses, can occur at all three levels. The stenosis of the upper pharynx (nasopharynx) is due, for the most part, to the scar fusion of the soft palate and posterior pharyngeal wall. The cause of stenosis or obliteration of the middle part of the pharynx (oropharynx) is the fusion of the free edges of the palatine arch or soft palate with the root of the tongue. Finally, the stenosis of the lower pharynx (larynx) is caused by the appearance of fibrous adhesions, which extend from the epiglottis or the root of the tongue to the posterior wall of the pharynx. However, these cicatricial changes in the pharynx are represented in this list as if in a "pure" or isolated form. In reality, as a rule, they capture adjacent parts of the pharynx and can spread to great depths, damaging the muscle layers, cartilage and bone tissues, completely deforming the entire pharynx architecture, causing very significant violations of its functions, until their complete deactivation.

Causes of cicatricial pharyngeal stenosis. Cicatricial pharyngeal stenosis is rarely congenital, but if this is observed, then the cause is congenital syphilis. Most often, cicatricial pharyngeal stenosis occurs as a complication of traumatic injuries of the lesion, fractures of the hyoid bone with penetration of fragments into the pharynx cavity, and burns of the third degree. The most common injuries of the pharynx occur in children holding a pencil, pen, plug or some sharp oblong object in the mouth when they suddenly fall on it. As a result of such a trauma, the soft palate, the area of the tonsils, the posterior wall of the pharynx can be damaged, followed by infection of the wound and subsequent healing through scarring.

Chemical burns of the pharynx often lead to the formation of cicatricial cords, deforming the soft palate, palatine arch through adhesions, scars, and shvart, stenosing the entrance to the laryngopharynx.

Postoperative cicatricial pharyngeal stenosis can occur in children after adenotomy and tonsillectomy. Accidental amputation of the posterior arch and injury of the mucous membrane of the posterior pharyngeal wall in the process of adenotomy lead to the formation of three wound surfaces, the fusion between which by formation of scarring leads to stenosis of the oropharynx.

Post-inflammatory cicatricial pharyngeal stenoses occur after severe forms of pharyngeal diphtheria and other purulent inflammatory processes in this area (phlegmon, abscess, etc.). Thus, acquired syphilis in stage III, early or late congenital syphilis is most often complicated by cicatricial pharyngeal stenosis. To the same consequences leads and chronic ulcerative-caseous tuberculosis of the pharynx, lupus, leprosy and rhinoscleroma.

Pathological anatomy. Stenoses of the pharynx can arise as a result of congenital narrowing of the nasopharynx, an anomalous lordosis of the cervical spine, atresia of the hoan, etc. Acquired stenoses are most often observed in the space between the choana and the oropharynx. Cicatricial changes at the level of the nasopharyngeal openings of the auditory tube lead to disturbances in their ventilation function. Adhesions between the soft palate, the arches and the back wall of the pharynx or the root of the tongue and the epiglottis, as well as in the nasopharynx, consist of a strong scar tissue easily recurring after excision.

Symptoms of cicatricial pharyngeal stenosis vary depending on the localization and severity of the scar process. Stenoses in the nasopharynx lead to disturbances in nasal breathing, voice formation (closed nasal), ventilation and drainage functions of the auditory tube (eustachyte, tubo-otitis, and hearing loss). With cicatrical changes of the soft palate and deprivation of its blocking function, a symptom of nasal fluid reflux is observed when trying to swallow. Objectively, when examining the nasopharynx, its scar changes are revealed.

Cicatricial changes in the oropharynx lead to more pronounced impairment of functions, especially swallowing and voice-forming. These cicatricial changes are easily detected with average pharyngoscopy and are whitish very strong and dense formations that connect the soft palate and the posterior pharyngeal wall, leaving only a small slit-like course in the nasopharynx. Sometimes these scars have the appearance of massive shvarts, completely obturating the entrance to the nasopharynx.

Stenoses of the laryngopharynx can be manifested by terrible symptoms: increasing difficulties in breathing and swallowing, to the complete impossibility of the latter, even for liquid food. Such patients with delayed treatment gradually lose weight, they develop a syndrome of chronic hypoxia (cyanosis of the lips, frequent shallow breathing and pulse, general weakness, severe shortness of breath with little physical exertion, etc.).

Evolution of cicatricial pharyngeal stenosis is characterized by a slow progression of the degree of stenosis, the treatment itself is a long, difficult and often not completely satisfactory result due to a tendency to postoperative recurrence of cicatricial pharyngeal stenosis.

Treatment of cicatricial pharyngeal stenosis is based on the following principles: excision of scar tissue, release from it of the elements of the pharynx deformed by it (soft palate, palatine arches), plastic methods of covering the wound surfaces mobilized from neighboring areas of the mucosa and recalibration of the stenosed lumen by temporary implantation of a tubular prosthesis . Based on these principles, a number of methods have been proposed for the plasticization of stenotic pharyngeal sections, depending on the level of stenosis with the use of free flaps or flaps on the feeding legs. The main rule of success for such surgical interventions is the most careful removal of scar tissue and complete coverage of the wound surface of the viable mucosa in the form of its plastic flap. As an example of one of such surgical interventions in the presence of complete overlapping of the entrance to the nasopharynx from the side of the oropharynx by cicatricial tissue, we present the method proposed by the American authors Kazanjian and Holmes, consisting in the formation of the nasopharynx entrance with the help of two grafts from the posterior pharyngeal wall.

The outer flap of the mucous membrane on the upper leg is cut from the posterior pharyngeal wall at a level slightly higher than the root of the tongue and folded anteriorly. Then a cut is made, penetrating through the fusion into the nasopharynx, by means of which a second flap is formed. After that, the front flap is bent backward and upward so as to connect with its posterior surface of its half - the lower and upper, thus forming a two-layered formation, covered on both sides by the mucous membrane, as if imitating the soft palate. The second flap is somewhat mobilized and enlarged, then lowered downwards and stacked in a bed formed after the first flap was cut. As a result, a new hole is formed, which communicates the oropharynx with the nasopharynx. Both flaps, after stacking, are sewn together with the surrounding tissues in a given position. In the postoperative period, the patient is given parenteral nutrition on the 1st day, then for 5-7 days a liquid diet with gradual introduction into normal nutrition.

[1], [2], [3], [4], [5], [6], [7]