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Transpalatal Approach to Nasopharynx

last modified on: Thu, 03/07/2024 - 10:23

Transpalatal Approach to Nasopharynx

(Without Palatal Split)

return to: Paranasal Sinus Surgery Protocols

GENERAL CONSIDERATIONS

  1. Indications
    1. Juvenile nasopharyngeal angiofibroma (JNA), stage I
    2. Small nasopharyngeal tumors
  2. Contraindications
    1. Tumors extending lateral to nasopharyngeal sidewalls

PREOPERATIVE PREPARATION

  1. Additional Preoperative Evaluations
    1. Preoperative embolization for JNA or other vascular lesions
    2. A preformed acrylic palate splint may aid in closure of the palate
    3. Consider neck flexion/extension films in patients with possible neck instability
  2. Consent Inclusions
    1. Explain procedure and general risks including bleeding, infection, and reaction to anesthesia
    2. Risk of palate mucosal loss
    3. Required palate bolster, splint, and nasal packing
    4. Recurrence with need for further surgery or adjuvant therapy based on tumor type
    5. Tooth injury
    6. Velopharyngeal insufficiency with secondary change in voice and swallow

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Palate-Pharyngeal Tray
      3. Sinus Tray
      4. Woodruff Screw Implant - Instrument Tray (used to secure palatal prosthesis)
      5. Zimmer hand drill
    2. Special
      1. Beaver blade cleft palate #69B
      2. DeBakey thoracic forceps, 1 x 2 in
      3. Potts-Smith vessel scissors, angle 45°, 7.5 x 2 in
      4. Suction coagulator, 10 Fr, 6 in
      5. Cautery electrode ENT/IMA or guarded needle tip
  3. Medications (specific to nursing)
    1. 1% lidocaine with 1:100,000 epinephrine
  4. Prep and Drape
    1. Intraoral prep
    2. Head drape
      1. Square off face with towels
      2. Split sheet
  5. Drains and Dressings
    1. None
  6. Special Considerations
    1. Position high on the table so when headrest is dropped the head is hyperextended

ANESTHESIA CONSIDERATIONS

  1. General Anesthesia
    1. Tube position: midline oral RAE tube
    2. Paralysis: will aid in exposure
  2. Systemic Medication
    1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
    2. Steroids: Decadron 8 mg IV
  3. Positioning
    1. Supine
    2. Neck in extension

OPERATIVE PROCEDURE

  1. Pertinent Anatomy
    1. Neurovascular supply to the palate mucosa is primarily from the greater palatine pedicles, which reach the palate via the greater palatine foramen bilaterally at the posterior edge of the hard palate
  2. Nasal and Oral Preparation
    1. Inject local anesthesia (1% lidocaine with 1:100,000 epinephrine) along upper the dental alveolar ridge of hard palate
    2. Throat pack placed
  3. Opening
    1. Make a lingual pericoronal incision.
    2. Elevate palate mucoperichondrium.
    3. Place retention sutures of 4-0 silk along palate.
    4. To gain added length, remove posterior wall of greater palatine foramen and mobilize greater palatine vessels.
    5. Remove posterior hard palate with rongeurs.
    6. Make transverse incision through nasal mucosa of posterior floor of the nose.
    7. Isolate and remove lesion.
    8. Control bleeding with packing/cautery/bone wax.
  4. Closure
    1. Pack nose with Xeroform gauze.
    2. Close palate with interdental vertical mattress sutures (3-0 or 4-0 vicryl).
    3. Place two layers of Xeroform gauze and position and secure palate splint with four to six circumdental silk sutures or Woodruff screw technique.
    4. If no custom-made splint is available, utilize reinforced silastic sheeting cut to cover entire hard palate and secure with four to six circumdental silk sutures.
  5. Nasal Packing
    1. Xeroform gauze roll cut into long 1-in-wide strips is packed transnasally into the defect; to include the sphenoid sinuses if opened during the surgery.
  6. Drains
    1. None
  7. Dressing
    1. Nasal drip pad

POSTOPERATIVE CARE

  1. General Considerations
    1. Continue antibiotics until packing removed
    2. Bedside humidification
  2. Dressings
    1. Change as needed
  3. Monitoring
    1. Palate viability
    2. PO intake
  4. Packing and Splint Removal
    1. Packing removal postoperative day 3 to 5
    2. Splint removal postoperative day 5 to 7
    3. Remove packing and splint in the operating room in young children
  5. Follow-Up
    1. Weekly follow-up until healing complete and then follow-up based on tumor type

REFERENCES

Maran AGD. Surgical approaches to the nasopharynx. Clin Otolaryngol. 1983;8:417-429.