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

Cicatricial stenosis of the pharynx, which leads to progressive stenosis, can occur at all three of its levels. Stenosis of the upper pharynx (nasopharynx) is caused mostly by cicatricial adhesion of the soft palate and the posterior wall of the pharynx. Stenosis or obliteration of the middle pharynx (oropharynx) is caused by adhesions of the free edges of the palatine arches or soft palate with the root of the tongue. Finally, stenosis of the lower pharynx (larynx) is caused by the formation of fibrous adhesions that extend from the epiglottis or root of the tongue to the posterior wall of the pharynx. However, these cicatricial changes in the pharynx are presented in this list as if in a “pure” or isolated form. In reality, they usually affect adjacent parts of the pharynx and can spread to a greater depth, affecting muscle layers, cartilage and bone tissue, completely deforming the entire architecture of the pharynx, causing very significant disruptions to its functions, up to their complete shutdown.

Cause of cicatricial pharyngeal stenosis. Cicatricial pharyngeal stenosis is rarely congenital, but if it is observed, the cause is congenital syphilis. Most often, cicatricial pharyngeal stenosis occurs as a complication of traumatic injuries to the pharynx (wounds, fractures of the hyoid bone with fragments penetrating the pharyngeal cavity, third-degree burns). Most often, pharyngeal injuries occur in children holding a pencil, pen, fork or any sharp oblong object in their mouth when they suddenly fall on it. As a result of such trauma, the soft palate, the area of the palatine tonsils, the back wall of the pharynx can be damaged, followed by infection of the wound and its subsequent healing through scarring.

Chemical burns of the pharynx often lead to the formation of scar tissue that deforms the soft palate and palatine arches through adhesions, scars, and adhesions that stenose the entrance to the laryngopharynx.

Postoperative cicatricial pharyngeal stenosis may occur in children after adenotomy and tonsillectomy. Accidental amputation of the posterior arches and injury to the mucous membrane of the posterior pharyngeal wall during adenotomy lead to the formation of three wound surfaces, the adhesion between which through the formation of cicatricial strands leads to stenosis of the oropharynx.

Post-inflammatory cicatricial stenosis of the pharynx occurs after severe forms of diphtheria of the pharynx and other purulent-inflammatory processes in this area (phlegmon, abscesses, etc.). Thus, acquired syphilis in stage III, early or late congenital syphilis are most often complicated by cicatricial stenosis of the pharynx. Chronic ulcerative-caseous tuberculosis of the pharynx, lupus, leprosy and rhinoscleroma lead to the same consequences.

Pathological anatomy. Stenosis of the pharynx may occur as a result of congenital narrowing of the nasopharynx, abnormal lordosis of the cervical spine, atresia of the choanae, etc. Acquired stenosis is most often observed in the space between the choanae 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, 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 strong cicatricial tissue that easily recurs after excision.

Symptoms of cicatricial pharyngeal stenosis vary depending on the location and severity of the cicatricial process. Stenosis in the nasopharynx leads to disturbances in nasal breathing, voice formation (closed nasal voice), ventilation and drainage functions of the auditory tube (eustachitis, tubootitis, hearing loss). With cicatricial changes in the soft palate and deprivation of its locking function, a symptom of nasal reflux of fluid is observed when trying to swallow it. Objectively, cicatricial changes are detected in the nasopharynx during examination.

Cicatricial changes in the oropharynx lead to more pronounced dysfunctions, especially swallowing and voice-forming. These cicatricial changes are easily detected by mid-pharyngoscopy and are whitish, very strong and dense formations that connect the soft palate and the back wall of the pharynx, leaving only a small slit-like passage into the nasopharynx. Sometimes these scars look like massive adhesions that completely obstruct the entrance to the nasopharynx.

Stenosis of the laryngopharynx can manifest itself with formidable symptoms: increasing difficulty in breathing and swallowing, to the point of complete impossibility of the latter even for liquid food. Such patients, if not treated in a timely manner, gradually lose weight, they develop a syndrome of chronic hypoxia (blue lips, frequent shallow breathing and pulse, general weakness, pronounced shortness of breath with little physical exertion, etc.).

The evolution of cicatricial stenosis of the pharynx is characterized by a slow progression of the degree of stenosis; the treatment itself is long, difficult and often with not entirely satisfactory results, due to the tendency to postoperative relapses of cicatricial stenosis of the pharynx.

Treatment of cicatricial pharyngeal stenosis is based on the following principles: excision of cicatricial tissue, release of the pharyngeal elements deformed by it (soft palate, palatine arches), plastic techniques for covering wound surfaces with mucous membrane mobilized from adjacent areas and recalibration of the stenotic lumen by temporary implantation of a tubular prosthesis into it. Based on these principles, many methods of plastic surgery of stenotic parts of the pharynx have been proposed depending on the level of stenosis using free flaps or flaps on feeding legs. The basic rule for achieving success in such surgical interventions is the most thorough removal of cicatricial tissue and complete coverage of the wound surface with viable mucous membrane in the form of its plastic flap. As an example of one of these surgical interventions in the presence of complete blockage of the entrance to the nasopharynx from the oropharynx by scar tissue, we present a method proposed by American authors Kazanjian and Holmes, which consists of forming an entrance to the nasopharynx using two flaps cut from the back wall of the pharynx.

The outer flap of mucous membrane on the upper pedicle is cut out of the back wall of the pharynx at the level and slightly above the root of the tongue and folded forward. Then an incision is made penetrating through the adhesion into the nasopharynx, by means of which the second flap is formed. After this, the anterior flap is folded back and up so that its halves - the lower and upper - are connected by their back surfaces, thus forming a two-layer formation covered on both sides by mucous membrane, as if imitating the soft palate. The second flap is somewhat mobilized and enlarged, after which it is lowered down and placed in the bed formed after cutting out the first flap. As a result, a new opening is formed, connecting the oropharynx with the nasopharynx. After their placement, both flaps are sutured with the surrounding tissues in the given position. In the postoperative period, the patient is prescribed parenteral nutrition on the 1st day, then a liquid diet for 5-7 days with a gradual transition to a normal diet.

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