Management of the Black Hole in Velopharyngeal Incompetence: Combined Use of a Furlow Palatoplasty and Sphincter Pharyngoplasty

Abstract

Patients with velopharyngeal incompetence may have a combination of a large velopharyngeal gap and poor lateral wall motion on phonation, simulating a "black hole" on nasendoscopy. Pharyngeal flaps for treatment of velopharyngeal incompetence in these patients are of questionable efficacy, because poor lateral wall motion necessitates such a wide flap that nasal airway obstruction is likely. Thirteen patients with velopharyngeal incompetence were managed between 1994 and 2003 with a combined Furlow palatoplasty and sphincter pharyngoplasty by a single surgeon. A diagnosis of velopharyngeal incompetence was established by means of perceptual speech evaluation performed by a trained speech pathologist using a standardized speech/voice rating scale (0 to 13); scores of 4 or higher indicated an incompetent velopharyngeal valving mechanism. Surgical inclusion criteria were a large velopharyngeal gap (> or =7 mm) and poor lateral wall motion (1 or 2 of 5, with 3 being rated as average) measured by multiview videofluoroscopy and nasendoscopy. The mean preoperative score on the speech and voice rating scale was 10.5 (range, 4 to 13), with a mean postoperative score of 1.9 (range, 0 to 8) following Furlow palatoplasty and sphincter pharyngoplasty in 13 patients. Two patients required an additional surgical procedure to achieve complete correction of velopharyngeal incompetence without nasal airway obstruction, to achieve a final mean score of 0.8 (range, 0 to 2) among the 12 patients who completed surgical management, achieving a highly significant reduction in nasality (p < 0.0001). Patients with velopharyngeal incompetence who have a black hole on nasendoscopy consisting of a large velopharyngeal gap and poor lateral wall motion are at high risk for recurrent velopharyngeal incompetence or nasal airway obstruction following surgical management. Initial treatment with a Furlow palatoplasty and sphincter pharyngoplasty has a high rate of success in these patients and does not preclude further surgical correction if needed, with minimal risk of nasal airway compromise.