Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence.

Michael Carr,Arun K Gosain,Michaela Skarlicki,Jeffrey Bone,Jugpal S Arneja,Sheryl Palm,Marija Bucevska

doi:10.1177/10556656211021738

Abstract

Objective:To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication.Design:Retrospective review.Setting:Tertiary care center.Patients:Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded.Intervention:Modified pharyngeal flap with through-and-through dissection of the soft palate.Main Outcome Measure(s):Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale.Results:The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours.Conclusions:This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Highlights

Velopharyngeal incompetence (VPI) is a condition in which the velopharyngeal sphincter (VPS) fails to create a functional seal between the oral and nasal cavities during phonation
A retrospective review was conducted of patients with severe VPI who underwent modified pharyngeal flap with throughand-through dissection of the soft palate, as described previously (Arneja et al, 2008)
Inclusion criteria were a diagnosis of severe VPI based on perceptual speech assessment, with confirmation by nasoendoscopy or videofluoroscopy; surgical management of VPI by modified pharyngeal flap with through-and-through dissection of the soft palate; and a minimum follow-up of 6 months with a complete postoperative speech assessment

Summary

Introduction

Velopharyngeal incompetence (VPI) is a condition in which the velopharyngeal sphincter (VPS) fails to create a functional seal between the oral and nasal cavities during phonation. Incomplete closure during speech leads to air escape causing hypernasality, increased nasal resonance, and decreased intelligibility (Ruda et al, 2012). Surgery is the only effective intervention for severe VPI related to anatomical deficiencies and works by creating a functional seal between the oropharynx and nasopharynx during phonation. The pharyngeal flap is the most described surgical technique for the management of VPI, designed to create an incomplete central velopharyngeal obstruction that permits peripheral airflow between the oral and nasal cavities during phonation (Setabutr et al, 2015; de Blacam et al, 2018). The technique has been revised many times, by the likes of Rosenthal (1924), Padgett (1930), Sanvenero-Roselli (1935), and Conway (1951), leading to the description of the lateral port control flap by Hogan (1973)—a technique that is considered by many as a first-line technique for VPI management for its consistent speech outcomes and relatively low complication rates (Boutros & Cutting, 2013)

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