Discussion
NPS is a challenging problem that can complicate palatal surgeries.
Diversesurgical interventions have been used to correct NPS; but, most
are complicated and result in inconsistent outcomes4.
Theend-goal of repair remains the expansion of the
nasopharyngeal-oropharyngeal communication through removal/release of
the scar and mucosal coverage of denuded surfaces to limit recurrence.
MacKenty described the first use of superiorly based pharyngeal mucosal
flaps folded on themselves in 19272. This was
subsequently modified by Kazanjian et al7 to include
local oropharyngeal mucosal flaps. In more severe NPS cases, aggressive
strategies included use of radial forearm and jejunal free flaps to
treat recurrent stenosis after conventional flaps failure. Due to
technical challenges of free tissue transfer, other local approaches
developed; bilateral Z-plasty8andbivalved palatal
transposition flap9.
The NPS repair is difficult because it is rare clinical entity. Clinical
series are usually limited to just a few patients and comparative
studies are non-existent. Few reports in the literature described the
usage of anyone specific technique for its surgical correction with
lacking follow-up beyond 6 months in most series. In addition, there are
no standardized outcome measures yet to detect the effectiveness of each
surgical method. The success has been based mostly on subjective relief
of symptoms9. But, we used the subjective VAS of
symptoms, grading of stenosis and objective evaluation by AHI.
Most acquired NPS arise after UPPP. In the current study, UPPP was the
cause in 88.9%of cases and males were more affected than females.
Similarly, the two studied cases by Toh et al9and the
three repaired by Magdy et al4 were males.
Successful NPS correction relies on adequate scar tissue removal and/or
lysis, and coverage of the raw mucosal surfaces9. So,
we ensured complete scar tissue removal with mucosa preservation to use
it to cover the raw area and avoid the presence of two raw areas on the
nasopharynx and palate.
In our study, there was no necessity for postoperative obturationthat
appears very difficult to fit for a long time into this irregular, very
mobile and sensitive mucosal area and may be difficult to be tolerated
by the patients beside its foreign body effect and reaction.
The current procedure was performed through the transoral rout without
extra tool or suture material and so no financial implications.
Avoidanceof excess palatal dissection reduced postoperative edema and
soavoided ICU admission. Our follow-up period (12 months at least)
exceeds these of past studies and thus the results appear promising.
Recently, Cammaroto et al10 published a technique for
grade ΙΙΙ NPS correction that represents a modification of bivalved
palatal transposition flaps originally described by Toh et
al9. However, our technique which represents a
modified form of ZPP originally described by Friedman et al dedicated
mainly for grade Ι and ΙΙ NPS.
Thus, our technique for NPS repair showed satisfactory outcome and easy
applicability. However, further studies on larger number of patients and
in comparison to other techniques are recommended.