Original article | Volume 34, Article 111, 25 Oct 2019 | 10.11604/pamj.2019.34.111.18968

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management

Youssef Lakhdar, Sara Rochd, Mohamed Elbouderkaoui, Youssef Rochdi, Hassan Nouri, Abdelaziz Raji

Corresponding author: Youssef Lakhdar, ENT-HNS Department, Mohammed VI University Hospital Center, Marrakech, Morocco

Received: 28 Apr 2019 - Accepted: 20 Sep 2019 - Published: 25 Oct 2019

Domain: Oncology,Otolaryngology (ENT)

Keywords: Choanal stenosis, nasopharyngeal cancer, radiotherapy, endoscopic surgery

©Youssef Lakhdar et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Youssef Lakhdar et al. Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management. Pan African Medical Journal. 2019;34:111. [doi: 10.11604/pamj.2019.34.111.18968]

Available online at: https://www.panafrican-med-journal.com/content/article/34/111/full

Home | Volume 34 | Article number 111

Original article

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management

Youssef Lakhdar1,&, Sara Rochd1, Mohamed Elbouderkaoui1, Youssef Rochdi1, Hassan Nouri1, Abdelaziz Raji1

 

1ENT-HNS Department, Mohammed VI University Hospital Center, Marrakech, Morocco

 

 

&Corresponding author
Youssef Lakhdar, ENT-HNS Department, Mohammed VI University Hospital Center, Marrakech, Morocco

 

 

Abstract

Choanal atresia is a rare complication of radiation for nasopharyngeal carcinoma, which has to be early detected. Its treatment is based on endoscopic endonasale surgery. We report a rare case of choanal stenosis observed in a 54-year-old patient, Ho presented 4 years after the end of radiotherapy for nasopharyngeal carcinoma, a progressive bilateral nasal obstruction, anosmia, and rhinorrhea without bleeding. The diagnostic of fibrous stenosis was confirmed by endonasal endoscopic examination coupled to CT scan of nasopharynx. The recanalization via endoscopic endonasal surgery with tube calibration gave a great functional result with the improvement of nasal symptoms. Even after 6 months of follow-up, there were no signs of restenosis.

 

 

Introduction    Down

Choanal atresia is a common congenital malformity in newborns; it is characterized by a blocked choanae, the opening between the nose and the nasopharynx. Acquired choanal stenosis is rarely seen and those complicating radiotherapy is even rarer in the literature. Through this observation we describe the clinical presentation, the diagnostic means and the therapeutic value of endoscopic recanalization surgery.

 

 

Patient and observation Up    Down

A 54 years old Moroccan man presented to our otolaryngology (ENT) department with a 5 months history of worsening bilateral nasal obstruction, anosmia and rhinorrhea from both nostrils without epistaxis, associated with progressive bilateral hearing loss. His past medical history included undifferentiated carcinoma of the nasopharynx (UNCT) diagnosed on 2001, American Joint Committee for Cancer TNM staging of T1N0M0. He received a course of radiotherapy (65 Grays). The patient had no other significant past medical history. On examination, patient was breathing with mouth open. A cold spatula test showed absence of air flow on left nostril and minimal air flow on the right side. Rigid endoscopic nasal examination revealed a complete choanal stenosis in the left side and incomplete in the right side. There were no signs of tumor recurrence (Figure 1). Otoscopic examination showed signs of fibro-adhesive otitis and tonal audiometry showed mixed deafness. The computed tomography (CT) scan of the nose and paranasal sinuses was done, and showed a stenosis of the light of the two choanae by tissue density lesion in both choanae of 7.30mm (Figure 2). The patient underwent endoscopic surgery under general anesthesia, where the fibrous obstacle was resected and widening of the posterior choanal stenosis. A 5mm diameter tube was placed in both nasal cavities and kept for 3 weeks to ensure a good calibration and prevent the recurrence of the stenosis. The anatomopathological study did not show signs of tumor recurrence or specific inflammation. Deafness has been treated by bilateral hearing aids. The evolution was marked by the improvement of the clinical symptomatology with restitution of the nasal ventilation and the smell. An endoscopic control after 6 months of the surgical procedure did not find any sign of restenosis with a rather satisfactory choanal light.

 

 

Discussion Up    Down

Nasopharyngeal cancer is a public health problem in South-east Asia and in the Maghreb countries [1], its incidence varies between 30-80/100000/year in areas of high endemicity, including North Africa [2]. These nasopharyngeal cancers are treated mainly by radiotherapy, and their follow-up is based on clinical, endoscopic and radiological monitoring, which is often lacking in our context. This radiation therapy at curative doses can cause several sequels related to its local toxicity, choanal stenosis, although if it's rare, is part of it [3]. Only a few cases of choanal stenosis after radiotherapy have been reported in the literature, this may be explained by a lack of follow-up in these patients. A study carried out in 2014, studying the incidence of various late nasal-sinus post radiation complications, showed that 15% of patients developed choanal stenosis [4]. The clinical profile of our patient is similar to data reported in the literature: The average age found was 40 years [5-7] with a revealing symptomatology with most found signs were: nasal obstruction, anterior rhinorrhea and anosmia [5,6]. Rigid endoscopy allows early diagnosis at the clinical stage and CT allows confirming and quantifying the degree of stenosis [5-8]. In the literature this stenosis was bilateral complete or not in 84% of cases [4-8], and unilateral in 16% [8,9]. the treatment of choice for this complication is video-assisted endonasal surgical permeabilization with nasal cavity calibration, maintained for 2 to 6 weeks [5-8]. However surgery by micro endoscopic debridement without postoperative calibration can give satisfactory results without signs of restenosis [9,10]. In our case, the endoscopic surgery, with a calibration for 3 weeks, allowed us a functional improvement of the patient and a complete regression of the symptomatology, without signs of restenosis to endoscopic control at 6 months.

 

 

Conclusion Up    Down

Post radiation choanal stenosis is an exceptional complication. Its treatment is based on endonasal video surgery associated with a calibration. Endoscopic surveillance is mandatory, in addition to imaging, in irradiated nasopharyngeal cancers, to ensure proper monitoring and early detection of this complication.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors’ contributions Up    Down

Y Lakhdar, the corresponding author, diagnosed the patient. Y Rochdi and A Raji treated the patient. S Rochd obtained consent. Y Lakhdar wrote the majority of the manuscript. S Rochd and M Elbouderkaoui contributed to case report writing and iconography. AR and H Nouri critically reviewed the manuscript. All the authors have read and agreed to the final manuscript.

 

 

Figures Up    Down

Figure 1: endoscopic examination showing an obstructive stenosis of the choanae

Figure 2: facial CT scan in the axial section showing a stenosis of both choanae

 

 

References Up    Down

  1. Taghzout H, Hafidi K, Alami Z, Elmazghi A, Bouhafa T, Hassouni K. Cancer du cavum chez l'adulte (à propos de 391 cas): aspects épidémiologiques, cliniques et thérapeutiques. Cancer/Radiothérapie. 2017;21(6):694. Google Scholar

  2. Fleury B, Biston MC, Montbarbon X, Pommier P. Cancers du cavum de l'adulte. Cancer/Radiotherapie. 2010;14(Suppl 1):S23-33. Google Scholar

  3. Jardel P, Thariat J, Blanchard P, Elloumi F, Toumi N, Bensadoun RJ et al. Prise en charge des cancers du cavum (rhinopharynx). Bull Cancer. 2014;101(5):445-54. Google Scholar

  4. Alon EE, Lipschitz N, Bedrin L, Gluck I, Talmi Y, Wolf M et al. Delayed sino-nasal complications of radiotherapy for nasopharyngeal carcinoma. Otolaryngol-Head Neck Surg (United States). 2014;151(2):354-8. PubMed | Google Scholar

  5. Bonfils P, de Preobrajenski N, Florent A, Bensimon JL. Sténose choanale post-radique: une complication rare de la radiothérapie des carcinomes nasopharyngés. Cancer/Radiotherapie. 2007;11(3):143-5. Google Scholar

  6. Haddad H, Sellal N, Bourhaleb Z, benchakroun N, Jouhadi H, Tawfiq N et al. Sténose choanale post-radique. Ann d'Oto-Laryngologie Chir Cervico-Faciale. 2009;126(1):22-4.

  7. Shepard PM, Houser SM. Choanal stenosis: an unusual late complication of radiation therapy for nasopharyngeal carcinoma. Am J Rhinol. 2005;19(1):105-8. PubMed | Google Scholar

  8. Ku PKM, Tong MCF, Tsang SS, Van Hasselt A. Acquired posterior choanal stenosis and atresia: management of this unusual complication after radiotherapy for nasopharyngeal carcinoma. Am J Otolaryngol-Head Neck Med Surg. 2001;22(4):225-9. PubMed | Google Scholar

  9. Marina MB, Gendeh BS. Acquired nasal posterior choanal atresia: postradiotherapy. Med J Malaysia. 2006;61(1):94-6. PubMed | Google Scholar

  10. Shemesh R, Alon EE, Gluck I, Yakirevitch A. Endoscopic surgery for delayed sinonasal complications of radiation therapy for nasopharyngeal carcinoma: a subjective outcome. Int J Radiat Oncol Biol Phys. 2018 Apr 1;100(5):1222-1227. PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Original article

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management

Original article

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management

Original article

Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management