Introduction
Although squamous papillomas may occur in any mucosal site within the upper aerodigestive tract,Reference Carneiro, Marinho, Verli, Mesquita, Lima and Miranda1 isolated squamous papillomas involving the nasopharyngeal surface of the soft palate are very rare. To our knowledge, only two cases of nasopharyngeal squamous papillomas has been treated via a transoral approach, with uvulopalatopharyngoplasty (UPPP).Reference Briskin, Kerner and Calcaterra2 However, this technique is associated with significant complications, including velopharyngeal insufficiency, dysphagia, persistent dryness and nasopharyngeal stenosis.Reference Won, Li and Guilleminault3
The transnasal endoscopic approach has been used by others to treat nasopharyngeal lesions, including adenoidectomy and nasopharyngeal cysts. However, the use of this approach with powered instrumentation for removal of a squamous papilloma in the nasopharyngeal surface of the soft palate has not previously been reported.
This study was approved by the institutional review board of the Pusan National University Hospital, South Korea.
Case report
A 62-year-old man was referred to our hospital with a recurrent squamous papilloma in the nasopharyngeal surface of the soft palate. The multiple papillomatous lesions on the nasopharyngeal surface of the uvula and soft palate had twice been treated over a six-month period at another hospital using a transoral approach. However, the lesion recurred following UPPP; fibre-optic endoscopy showed an exophytic, solitary papillomatous lesion on the superior nasopharyngeal surface of the remnant soft palate (Figure 1). The patient also suffered from nasal regurgitation when drinking water.
Fig. 1 Endoscopic photograph showing an exophytic, solitary papillomatous lesion on the superior nasopharyngeal surface of the remnant soft palate following uvulopalatopharyngoplasty.
Surgery was performed under general anaesthesia using a transnasal endoscopic approach with powered instrumentation (Figure 2). After proper decongestion of both nasal cavities was achieved, we operated through both nostrils using a two-handed technique. The endoscope was inserted into the right nostril, and the curved blade of a microdebrider (Medtronic Xomed, Jacksonville, Florida, USA) was inserted through the left nostril. The papillomatous lesion was removed with a 30-degree angle, 4-mm microdebrider in oscillating mode, at speeds between 100 and 1500 rpm, under direct visualisation using a 30-degree nasal endoscope. Haemostasis was achieved with the intermittent application of pledgets soaked with adrenaline hydrochloride.
Fig. 2 Endoscopic photograph showing the papillomatous lesion being removed via a transnasal endoscopic approach.
There were no post-operative complaints, and the post-operative course was uneventful except that nasal regurgitation remained unchanged. An endoscopic examination performed 15 months post-operation showed no evidence of recurrence (Figure 3).
Fig. 3 Endoscopic photograph showing no evidence of tumour recurrence, with well healed mucosa of the soft palate at three months post-operation.
Discussion
The transoral approach is a commonly chosen approach to the soft palate and nasopharynx because it allows the most direct route to pathology of the soft palate and posterior wall of the nasopharynx.
Briskin et al. reported two cases of squamous papilloma in the same area as in our case that were treated with a UPPP approach.Reference Briskin, Kerner and Calcaterra2 Uvulopalatopharyngoplasty, introduced in the early 1980s, is usually used to treat obstructive sleep apnoea.Reference Maisel, Antonelli, Iber, Mahowald, Wilson and Fiedler4 However, it is associated with significant complications.Reference Maisel, Antonelli, Iber, Mahowald, Wilson and Fiedler4, Reference Rombaux, Hamoir, Bertrand, Aubert, Liistro and Rodenstein5 Typical early complications include pain, post-operative bleeding, nasal reflux, local infection, hypernasality and middle-ear cleft dysfunction. The most common late complication is velopharyngeal insufficiency, with varying degrees of nasal regurgitation.
The treatment of squamous papillomas in the nasopharynx using a transoral approach such as UPPP is considered a safe and effective method for complete resection.Reference Briskin, Kerner and Calcaterra2 However, our patient, who suffered from velopharyngeal insufficiency, experienced two episodes of recurrence following a transoral approach. A squamous papilloma may recur with any treatment modality,Reference Pasquale, Wiatrak, Woolley and Lewis6 although most recurrences are related to incomplete excision. A squamous papilloma in the nasopharyngeal surface of the soft palate is difficult to access, which makes complete surgical excision challenging.
The physical and optical features of an endoscope, such as ease of use in narrow surgical anatomy, a wide panoramic view and an angled view of anatomical corners, prompted us to explore the nasopharyngeal surface of the soft palate via a transnasal endoscopic approach.Reference Alfieri, Jho and Tschabitscher7 During an operation, when manipulation of a microdebrider or other larger surgical instruments is impeded by the presence of an endoscope in the same nostril, the surgical instruments can be introduced via the other nostril or through two nostrils.Reference Alfieri, Jho and Tschabitscher7, Reference Zimmer, Hirsch, Kassam, Horowitz and Snyderman8 This can be done without any significant additional damage to the nasal structures because each nasal air passage is directly connected to the nasopharynx via the choana.
During the past decade, the use of powered instrumentation has become widespread in rhinology.Reference Christmas and Krouse9 Recent reports have described the use of the microdebrider for adenoidectomy,Reference Pagella, Matti, Colombo, Giourgos and Mira10 and the removal of lesions in the larynx and trachea.Reference Parsons and Bothwell11, Reference El-Bitar and Zalzal12
• A transoral approach such as uvulopalatopharyngoplasty (UPPP) has been used to treat squamous papillomas in the nasopharyngeal surface of the soft palate
• This technique is associated with significant complications
• A transnasal endoscopic approach can also be used for excision of squamous papilloma in this difficult-to-access region
• This alternative approach has the potential to be safer, faster, easier and less invasive than UPPP
The microdebrider offers precise resection and rapid debulking, and it may reduce surgical bleeding and post-operative pain. In addition, the microdebrider blade incorporates a suction device that enables the operator to pull the papilloma away from underlying tissue, making it easier to remove the diseased mucosa.Reference Pasquale, Wiatrak, Woolley and Lewis6 However, there may be potential complications such as nasal bleeding, nasal synechia and injury of palatal muscle due to surgical trauma. A transnasal endoscopic approach using powered instrumentation should be conducted with caution, under direct visualisation.
Conclusion
Compared with a transoral approach such as UPPP, a transnasal endoscopic approach with powered instrumentation could provide a safer, faster, easier and less invasive means to treat squamous papilloma in the nasopharyngeal surface of the soft palate, especially a lesion that recurs following treatment using a transoral approach.
