by Larry M. Wolford DMD, Eber Luis de Lima Stevao DDS, PhD
Dr. larry Woldord describes the Transnasal Approach for Nasopharyngeal Adenoidectomy technique as a relatively simple and direct approach to performing the nasopharyngeal adenoidectomy when a maxillary Le Fort I osteotomy is also indicated for the correction of a coincident dentofacial deformity.
Statement of the Problem
The nasopharyngeal adenoid tissues (NPAT) are part of the circumferential ring of lymphoid tissues in the oro-nasopharyngeal area called Waldeyer’s ring; an immunological defense mechanism for the head and neck. The NPAT are located in a space limited by the walls of the lateral pharyngeal recess and the roof of the nasal pharynx. The NPAT can extend inferiorly toward the oropharynx, laterally around the torus tubarius and the associated ostium, and antero-superiorly into the posterior choanae, creating functional obstructions. The NPAT are present during childhood, but usually spontaneously atrophy by the age of 12 to 14 years. However, some late adolescent and adult patients have hypertrophied NPAT that can cause dysfunction of the Eustachian tubes and nasal airway, affect speech, and alter facial growth.
Transnasal Approach for Nasopharyngeal Adenoidectomy Technique Description
When the NPAT causes functional and/or growth aberrations, then nasopharyngeal adenoidectomy may be indicated. In patients requiring orthognathic surgery, the adenoidectomy can be preformed through a transnasal approach in conjunction with the maxillary Le Fort I osteotomy, eliminating the necessity for a separate surgical procedure.
Prior to mobilization of the maxilla, the nasal mucoperiosteum is reflected off the nasal floor, and the maxilla mobilized. Retracting the maxilla inferiorly, an incision is made through the mucoperiosteum of the nasal floor at its junction with the posterior hard palate. The nasal mucoperiosteum is retracted anteriorly exposing the posterior pharyngeal wall and the nasopharyngeal adenoid tissue. A nasopharyngeal adenoid curette is used to gently remove the NPAT from the posterior pharyngeal wall, starting inferiorly and moving superiorly. Care is taken not to damage the torus tubarius or other soft tissue structures. The access incision does not require suturing. The rest of the orthognathic surgical procedures are carried to completion.
The transnasal adenoidectomy approach provides direct visualization and access to the area that cannot be achieved by the traditional intraoral approach. Specific indications for adenoidectomy include the following conditions caused by hypertrophied NPAT: 1) Chronic recurrent pharyngeal infections; 2) Dysfunction of the Eustachian tubes including recurrent serous otitis infections; 3) Nasal airway or nasopharyngeal airway obstruction; and 4) Hyponasal speech. Contraindications to the procedure include: 1) Bleeding disorders; 2) Total adenoidectomy would cause worsening of speech (i.e. cleft palate patients, preexisting hypernasality); and 3) Pre-existing velopharyngeal insufficiency.
Summary of Dr. Wolford's Personal Experience
This technique is a relatively simple and direct approach to performing the nasopharyngeal adenoidectomy when a maxillary Le Fort I osteotomy is also indicated for the correction of a coincident dentofacial deformity. To date, we have not encountered complications.