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.