Transcript Pharyngeal Flap: Maximizing Outcomes, Minimizing Complications
Is surgical treatment of hypernasal speech in VCFS special?
Sherard A. Tatum, MD, FAAP, FACS Associate Professor of Otolaryngology Associate Professor of Pediatrics Upstate Medical University Syracuse, NY, USA
Velopharyngeal insufficiency (VPI)
Failure of the velar and pharyngeal musculature to close the portion of the throat that separates the oral cavity from the nasal cavity during speech.
Treatment goal
Block sound and air from coming out of the nose without causing respiratory problems, sleep apnea, and excessive stuffiness.
Surgical Options
There are many available surgical procedures available to treat VPI, and all of them will work in some cases. However, VCFS is a special case. Many strategies that work in other patients have consistently poor outcomes in VCFS.
Special Factors in VCFS
• Hypotonia of the palate and pharynx • A very deep, large pharynx • Structural and functional asymmetry of the palate and pharynx • Abnormal placement of the internal carotid arteries • Abnormal articulation patterns • Higher frequency of airway obstruction • Speech and language delay
Hypotonia
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Hypotonia
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Deep, large pharynx
Posterior rotation of the skull base is a common VCFS feature
Internal carotid arteries
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Asymmetry
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Asymmetry
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Causes of airway/apnea problems
Research has shown the following factors contribute to airway/apnea problems: • Tonsils • Narrowing of the pharynx caused by side-to side closure of the flap donor site • Flaps that are too low, increasing negative pressure in the hypopharynx
Solution
Upstate Protocol
• • • • Modified superiorly based pharyngeal flap Adenotonsillectomy before flap • Adenoidectomy allows the nasopharyngeal mucosa to be available for high flap • Tonsillectomy to prevent lateral port and oropharyngeal obstruction Flap raised at or above above the velum to make it as high as possible Donor site closed by elevation of posterior pharyngeal wall rather than side-to-side
Short, High, Wide Flap
Lateral ports flap velum flap velum
VPI Rating Scale
International Working Group, 1990 (Golding-Kushner et al., 1990, CPJ, 20:337-347 )
Based on: videofluoroscopy and nasopharyngoscopy
Palate and pharyngeal wall motion rated using a ratio scale
Studies done immediately before surgery
Multiview Videofluoroscopy
MVF Frontal View
0.0
0.5
Rest: 0.0
Side wall function: 0.0 - 1.0
Typical: 0.3 - 0.5
0.3
0.3
0.0
MVF Lateral View REST SPEECH 0.0
1.0
MVF Base View Side Wall Movement: 0.0 - 1.0
typical: 0.3 - 0.5
Palate Movement: 0.0 - 1.0
typical: 0.5 - 1.0
Posterior Wall Movement: 0.0 - 1.0
typical: 0.0 - 0.5
0.0
1.0
0.4
0.4
Nasopharyngoscopy
What We See What Patient Sees
Nasopharyngoscopy
• • • Rating scale • 0.0 - 1.0
• • • Palate Posterior wall Lateral walls (ML 0.5) Tonsils and adenoids SMCP
At Rest 1.0
0.0
0.0
0.5
1.0
0.0
Partial Closure
1.0
0.2
0.3
0.0
1.0
LW 0.5
Complete Closure
LW 0.5
Surgical Technique
Conventional Flap Technique Short Flap
Soft Palate Soft Palate Donor Site
C L O S U R E D O N O R S I T E Traditional Modified
Donor Site Closure
Modified Traditional
Closure of Donor Site Lateral Closure Vertical Closure
Lateral pharyngeal wall
Measures and Follow-up
• • Immediately post-op • • Cardiac/apnea monitors Continuous oximetry Follow up at 1 week, 3 - 6 months, annually • Clinical screening for OSA • • • Polysomnogram if symptoms and signs of obstruction Nasopharyngoscopy Speech assessment
• • • • •
Obstructive Symptoms
Snoring • Exercise intolerance Restlessness • Sinusitis Nasal dyspnea • Otitis media Chronic rhinorrhea • Denasality Mouth breathing • Sleep disordered breathing
•
Results
94 pharyngeal flaps • 12 had previous operations elsewhere • 9 had 1 previous operation • 5 Sphincter pharyngoplasties • 2 previous secondary palatoplasties, one combined with a sphincter pharyngoplasty • 2 pharyngeal flaps • 3 had multiple operations • 1 had sphincter pharyngoplasty with 2 revisions • 1 had 2 palatoplasties and fat injections • 1 had 5 previous palatoplasties
Flap design based on diagnostic information
• 94 pharyngeal flaps • 71 very wide • 14 moderately wide • 1 narrow • 8 skewed to one side
Complications
• 94 pharyngeal flaps • 3 returns to OR for bleeding • 3 surgical revisions for partial dehiscence • 1 port dilation • 5 with moderate hyponasality • 2 with persistent obstructive symptoms • negative PSGs - RDI < 5
Outcomes
• 94 pharyngeal flaps • 88/94 with elimination of hypernasality (93.6%) • 5 with hypernasality, 3 revised, 2 would benefit from additional treatment and are pending treatment depending on outcome of speech therapy
Summary
• • • Small gap VPI can be managed successfully multiple ways, but such cases are rare with VCFS Large gaps, asymmetric gaps are common in VCFS and are best managed with wide pharyngeal flaps Preoperative adenotonsillectomy and short flaps with vertical donor site closure reduce the obstructive symptoms associated with wide flaps
Example: before and after
Example: speech before and after
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