ISSN: 2250 - 0359 Volume 5 Issue 2 2015 Bilateral massive nasal synechiae: a rare presentatjon of a common conditjon 1 Andrés Alvoa, 2 Cecilia Sedanob, 1 Christjan Olavarríaa 1 Servicio de Otorrinolaringología, Hospital Clínico Universidad de Chile. Santjago, Chile. 2 Facultad de Medicina, Universidad de los Andes. Santjago, Chile. Abstract We performed an endoscopic microdebrider - assisted resectjon of the synechiae connectjng Intranasal synechiae are a relatjvely common the septum to the lateral nasal wall, up to the fjnding in an otolaryngology practjce. Fre- choanae and sofu palate. The posterior margin quently, the scar is focal and due to mucosal of the bony septum was resected to increase trauma. We present an unusual case of mas- the transversal area at the choanae. Silicone sive bilateral intranasal scarring, with nega- stents were placed postoperatjvely to minimize tjve etjologic studies except for the anteced- the formatjon of new synechiae. ent of an old nasal fracture. Difgerentjal diag- noses are discussed, as well as its manage- Massive bilateral scarring is infrequent and sev- ment. eral difgerentjal diagnoses must be considered. Its management is diffjcult and not well stand- A 41 - year - old male consulted with a long - ardized. Microdebrider - assisted resectjon may term history of rhinorrhea, facial pain and be considered in these cases. nasal congestjon. Physical examinatjon re- vealed complete bilateral obstructjon of the nasal fossae with fjbrous synechiae. Drtbalu ’ s otolaryngology online
Among these, the most frequent are probably secondary to iatrogenic trauma to the muco- Introductjon sa, which can occur in various otorhinolaryn- There are several conditjons afgectjng the nasal gologic procedures such as functjonal endo- mucosa that may lead to granulatjon, ulceratjon scopic sinus surgery (FESS), septoplasty, turbi- and eventually scarring with formatjon of synechi- noplasty, fracture reductjon or nasal pack- ae between structures of the lateral wall and the ings. septum, including infectjous (1,2), autoimmune/ granulomatous (3 - 5) and traumatjc (6 - 8) etjologies Although usually traumatjc synechiae for- (Table 1). 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 Infectious Rhinoscleroma treatment. In infmammatory synechiae, symp- Rhinosporidiosis toms can be more severe and progressive, Leishmaniasis and extend outside the mucosa causing nasal Other: Mycobacteria ( M. tuberculosis , deformity. M. leprae ), Syphilis, Histoplasmosis Autoim- Wegener ’ s granulomatosis mune and Eventually, this scar tjssue may occupy almost Cicatricial pemphigoid Non - completely the nasal cavity and choanae, ob- infectious Epidermolysis bullosa acquisita granuloma- structjng airfmow and effjcient mucous drain- Sarcoidosis tous age. In our experience, this situatjon is very Traumatic Accidental uncommon, and not well reported in the lit- Iatrogenic ( surgery, intranasal catheters, packing, etc. ) erature. Consequently, its diagnosis and man- Others Cocaine abuse agement is not standardized. Physical and chemical burns Radiotherapy Natural Killer/T cell lymphoma - nasal type Intranasal eosinophilic angiocentric fibrosis Table 1. Conditjons afgectjng the nasal mucosa that may lead to granulatjon, ulceratjon, masses and eventually synechiae formatjon Drtbalu ’ s Otolaryngology online
Case report A 41 - year - old Peruvian male presented at our oto- rhinolaryngology service with a long - term history of mucous rhinorrhea, facial pain and nasal con- gestjon. He worked in ecotourism, had no history of exposure to chemicals, drug abuse, nor medical illnesses and was otherwise asymptomatjc. The only 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 obstructjon 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 Figure 2. Coronal paranasal CT showing mul- both nasal cavitjes and inferior meatus, plus bilat- tjple sofu tjssue bands between the inferior eral maxillary retentjon cysts (Fig. 2). 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 Figure 1. Endoscopic view of the right inferior mea- the patjent, who was warned that there was tus, with fjbrous tjssue occluding passage posteri- no etjologic diagnosis, and that synechiae orly could recidivate afuer surgery. Drtbalu ’ s Otolaryngology online
Finally, endoscopic surgery was performed to re- To improve results, the posterior margin of store nasal airway patency. We chose to leave si- the bony septum was resected with Kerrison nus surgery for a second instance, as the retentjon rongeurs (Fig. 3c), to further enhance the cysts had no peremptory surgical indicatjon and cross - sectjonal area of the choanal opening ostjomeatal obstructjon by post - surgical synechiae into the nasopharinx. Adequate hemostasis could worsen the symptoms. was achieved with gauzes soaked in a vaso- Intraoperatjvely, under general anesthesia, the constrictor solutjon. nasal mucosa was infjltrated with 1:200,000 epi- Finally, we stented the recanalized nasal fos- nephrine and 2% lidocaine. Then, nasal synechiae sae with silicone tubes that extended up to between the inferior turbinate and the anterior septum were incised with a #15 blade. Then, the the choanae and silicone plaques applied to turbinate was lateralized with a Freer elevator and the septum, that were removed at 6 and 10 synechiae extending posteriorly were removed us- days, respectjvely. He was discharged on oral ing a microdebrider (Fig. 3a). This part was espe- antjbiotjcs while the stents were in place, and cially diffjcult as the anatomy was distorted and later was instructed to use nasal lavages as the airway was completely obstructed, but using needed. the nasal fmoor, septum and the already liberated portjons of the inferior turbinate as guidelines al- The patjent evolved favorably, and 45 days lowed us to securely follow a proper directjon. later he had permeable airways with no signs of atrophic rhinitjs (Fig. 3d). His quality of life Intraoperatjvely, under general anesthesia, the improved considerably, with betuer breathing nasal mucosa was infjltrated with 1:200,000 epi- nephrine and 2% lidocaine. Then, nasal synechiae and less snoring than prior to surgery. Nasal between the inferior turbinate and the anterior patency was stjll conserved at 18 - month fol- septum were incised with a #15 blade. Then, the low - up, but a slightly hyponasal voice devel- turbinate was lateralized with a Freer elevator and oped due to partjal synechiae and stenosis synechiae extending posteriorly were removed us- between the sofu palate and the torus tubar- ing a microdebrider (Fig. 3a). This part was espe- ius (Fig. 3e - f), without any other symptoms. 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- on reaching the choanae, we realized that was also obstructed by a fjbrous membrane (Fig. 3b), which was carefully debrided taking care to avoid dam- age to the Eustachian tube and sofu palate. Drtbalu ’ s Otolaryngology online
. Figure 3. a) Microdebrider - assisted resectjon of nasal synechiae on the lefu nasal fossa; b) Initjal opening 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 Drtbalu ’ s Otolaryngology online
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