Pharyngeal Flap Research Articles

Results of speech improvement following simultaneous push-back together with velopharyngeal flap surgery in cleft palate patients

ObjectiveVelopharyngeal insufficiency (VPI) can be caused by a variety of disorders. The most common cause of VPI is the association with cleft palate. The aim of this study was to evaluate the effectiveness of different surgical techniques for cleft palate patients with VPI: 1) velopharyngoplasty with an inferiorly based posterior pharyngeal flap (VPP posterior, Schönborn–Rosenthal), and 2) combination of VPP posterior and push-back operation (Dorrance). Patients and methods41 subjects (26 females, 15 males) with VPI were analysed. Hypernasality was judged subjectively and nasalance data were assessed objectively using the NasalView® system preoperative and 6 months postoperative. ResultsSubjective analysis showed improved speech results regarding hypernasality for all OP-techniques with good results for VPP posterior and VPP posterior combined with push-back with success rates of 94.4% and 87.7%, respectively. Objective analysis showed a statistically significant reduction of nasalance for both VPP posterior and VPP posterior combined with push-back (p < 0.01). However, there were no statistically significant differences concerning measured nasalance values postoperatively between the VPP posterior and VPP posterior combined with push-back. ConclusionBased on our findings, both VPP posterior and VPP posterior combined with push-back showed good results in correction of hypernasality in cleft patients with velopharyngeal insufficiency.

A Delphi survey on diagnosis and management of stress velopharyngeal insufficiency in wind musicians

The aim of this study was to identify current trends in clinical assessment and management of stress velopharyngeal insufficiency (VPI) in wind musicians. This was an online two-round Delphi survey of health practitioners familiar with assessing and treating musicians with stress VPI. Fourteen specialists (seven otolaryngologists and seven speech-language pathologists) from four countries participated in the Delphi survey. From the first round questionnaire, 32 items were identified as being causes, assessment tools, diagnostic indicators, and treatment methods for stress VPI. The second round questionnaire revealed that prolonged exposure to high intra-oral pressures was important in determining the cause of stress VPI. The most important assessment tools for stress VPI were case history and nasendoscopy. The most important indicator for stress VPI was self-reported symptoms. There was no clear agreement identified on the management methods for stress VPI for musicians. However, the trend followed by most of the survey participants was a combination of conservative management approaches (including rest or watch and wait, speech-language pathology intervention, velopharyngeal muscle training, and changes to the instrument or reed), and then, if symptoms persist, to use injection pharyngoplasty or pharyngeal flap. This survey demonstrates that no standard management protocol currently exists for musicians diagnosed with stress VPI, but provides current trends in the assessment and management which can be used in future guidelines for health professionals who treat wind musicians.

Outcomes of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency

Objectives: Compare surgical outcomes between pharyngeal flap, sphincter pharyngoplasty, and concomitant Furlow palatoplasty and sphincter pharyngoplasty in the management of pediatric velopharyngeal insufficiency. Methods: Retrospective review of 96 patients with velopharyngeal insufficiency, who underwent surgical intervention at a tertiary pediatric care center between 2008 and 2012. Patients with velocardiofacial syndrome were excluded from the study. Surgical interventions were categorized as pharyngeal flap, sphincter pharyngoplasty, and concomitant Furlow palatoplasty and sphincter pharyngoplasty. Main outcome measures included perceptual speech analyses, complications, and surgical revision rates. Results: Of the 96 reviewed patients, 38 (39.6%) underwent pharyngeal flap, 20 (20.8%) sphincter pharyngoplasty, and 38 (39.6%) concomitant Furlow palatoplasty and sphincter pharyngoplasty. The mean improvement in postoperative perceptual speech analysis scores was significantly higher in both the combined procedure and pharyngeal flap when compared to sphincter pharyngoplasty alone ( P = .013, P = .031). No statistically significant difference in speech improvement was observed between the combined procedure and pharyngeal flap. There were no differences in complications among the three surgical interventions. However, the combined procedure required significantly less surgical revisions than the pharyngeal flap ( P = .019). Conclusions: Concomitant Furlow palatoplasty and sphincter pharyngoplasty is an effective procedure for the management of pediatric velopharyngeal insufficiency and may result in superior speech outcomes and lower revision rates than sphincter pharyngoplasty and pharyngeal flap, respectively.

Hogan’s modification of the Sanvenero-Rosselli velopharyngoplasty

A competent velopharyngeal mechanism is essential for the production of intelligible speech and the secondary procedure of the posterior pharyngeal flap may be necessary in some patients to achieve this goal. The purpose of this study was to examine short and long-term results between the Sanvenero-Rosselli and Hogan's modification of the cranially based velopharyngoplasty. During a 20-year period, 17 patients underwent secondarily a posterior pharyngeal flap to treat velopharyngeal incompetence. All the patients were treated in the same institution and under the supervision of the same stuff surgeon. Nine patients were operated on according to the Sanvenero-Rosselli method and eight according to Hogan's modification, which consists of the preparation of two mucosal flaps on the dorsal side of the soft palate. Both mucosal flaps are sutured at the base of the pharyngeal flap and cover its raw surface. Comparing the post-operative condition of the patients in two groups to their pre-operative state, it was observed that speech and comprehensibility were significantly improved, but Hogan's technique produced better speech results. According to our limited experience, additional surgical effort to create mucosal flaps on the nasal surface of the soft palate in Hogan's technique is compensated for by the reliable and substantial advantages that this technique holds, compared to Sanvenero-Rosselli's original proposition.

Cerclage and sphincter pharyngoplasty techniques for management of velopharyngeal insufficiency: How I do it?

AbstractThe activities of swallowing and speaking depend upon the ability to achieve adequate closure of the velopharyngeal (VP) port. Swallowing and speaking are complex motor skills that involve the coordination of diverse groups of muscles between the nasopharynx and oropharynx. Various conditions can affect VP closure function including an adenoidectomy operation. Defects in the VP sphincter can affect the patient’s speech in many ways–for example, induction of hypernasality, decreased speech intelligibility, and nasal emissions. Three main surgical approaches to VP corrective surgery can be used–namely, pharyngoplasty, pharyngeal flap, and posterior pharyngeal wall augmentation. The author of this study designed a new procedure called cerclage sphincter pharyngoplasty to be added for correction of VP insufficiency. Maximum benefit can be achieved when the surgical technique takes advantage of the remaining native VP closure. As pharyngeal flaps are not functional and have multiple drawbacks and because posterior pharyngeal wall augmentation is successful only in case of minor defects, the author focuses on functional techniques used for correction of different closure patterns and grades–namely, cerclage and sphincter pharyngoplasty.

A speech nasoendoscopy-based surgeon’s decision for correction of velopharyngeal insufficiency following adenotonsillectomy

Both sphincter pharyngoplasty (SP) and pharyngeal flap (PF) procedures have gained popularity among surgeons as effective surgical management for velopharyngeal insufficiency (VPI). Different centers prefer either SP or PF and have published their results to support this preference. But is one technique superior to the other? To answer this question, we have adopted the concept of differential therapeutic management, based on detailed assessment of velopharyngeal function. According to this assessment either SP or PF was performed for management of VPI (secondary to adenotonsillectomy). The aim of this work is to evaluate and compare the surgical results after SP and PF (based on the preoperative nasoendoscopy and phoniatrics' evaluation). This study was conducted on 31 patients with persistent hypernasality after adenotonsillectomy. All patients were subjected to perceptual speech evaluation and nasoendoscopic examination. According to this evaluation and data analysis, 18 patients were operated by SP and 13 patients underwent PF. Statistically, highly significant improvements were found when comparing pre- versus postoperative perceptual speech evaluation following both SP and PF (P < 0.001). When comparing the postoperative perceptual speech evaluation following both techniques, statistically non-significant differences were reported (P > 0.05). Preoperative differential diagnosis of VPI using perceptual speech assessment and nasoendoscopy of the velopharynx allows for tailored surgical management with either SP or PF. Both SP and PF procedures could yield good surgical outcomes, when patients are properly selected and the technique is chosen according to preoperative assessment.

Dimensões nasofaríngeas e sintomas respiratórios após a cirurgia de retalho faríngeo em crianças e adultos

OBJETIVO: Verificar a influência da idade sobre as dimensões nasofaríngeas e os sintomas respiratórios em pacientes submetidos à cirurgia para a correção da insuficiência velofaríngea pela técnica de retalho faríngeo. MÉTODOS: Amostra formada por 103 indivíduos distribuídos em três grupos: crianças (6 a 12 anos), adultos jovens (18 a 30 anos) e adultos de meia-idade (≥40 anos). Trata-se de estudo retrospectivo que analisou os valores da área nasofaríngea (técnica fluxo-pressão, valor de referência 0,570 cm²) e os sintomas de respiração oral, ronco e dificuldade respiratória durante sono, obtidos, em média, 12 meses após a cirurgia. A área nasofaríngea foi comparada entre os grupos por análise de variância e os sintomas respiratórios pelo teste Qui-quadrado (p&lt;0,05). RESULTADOS: Os valores médios da área nasofaríngea após a cirurgia foram 0,527±0,215 cm², 0,599±0,213 cm² e 0,488±0,276 cm², respectivamente para crianças, adultos jovens e adultos de meia-idade, não havendo diferença entre os grupos. As proporções de respiração oral, ronco e dificuldade respiratória durante o sono foram, respectivamente, 66%, 69% e 9% nas crianças, 51%, 49% e 7% nos adultos jovens e 75%, 75% e 19% nos adultos de meia-idade, com maior frequência de ronco nos adultos de meia-idade. CONCLUSÃO: A idade não interferiu nas dimensões nasofaríngeas na presença de retalho faríngeo, mas foi um fator agravante de sintomas respiratórios, principalmente nos indivíduos mais velhos.

A 25-year review of cases with submucous cleft palate

ObjectivesTo evaluate the effect of diagnostic and operative time on velopharyngeal closure in submucosal cleft palate (SMCP). MethodsSMCP patients treated at the Keio University School of Medicine from 1986 to 2011 were enrolled as subjects. Clinical data were obtained, including patient sex, age at diagnosis, and operative age, occasion of diagnosis, accompanying deformities, speech test results before and 6 months after palatoplasty, and pharyngeal flap usage after palatoplasty. ResultsData were available for 16 patients, with a mean diagnostic age of 51.1 months (range: 0−132 months). The clinical presentations were bifid uvula in 4 patients and speech dysfunction in 11. The cases suspected from bifid uvula were diagnosed significantly earlier than those with speech dysfunction (19.5 versus 56.8 months, p<0.01). Velopharyngeal closure was improved in 6 cases, and the average age of these patients at surgery was significantly lower than that of the other patients (46.7 versus 79.8 months, p<0.05). A pharyngeal flap was performed in 7 cases (43.8%). The pharyngeal flap usage rate in cleft palate patients other than those with SMCP was significantly lower than that of SMCP patients (3.5% versus 43.8%, p<0.01). ConclusionsEarly discovery and surgical correction is vital for improving postoperative speech outcomes in SMCP patients. This requires educating physicians about SMCP and future studies regarding simple and effective SMCP screening methods.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children

ObjectiveTo describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children. MethodsProspective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5–12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate. ResultsAll 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively. ConclusionsOur modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.

Changes in Airflow Dynamics After Creation of Pharyngeal Flaps in Nonsyndromic Children

Velopharyngeal insufficiency is a common problem in the cleft palate population that may require a pharyngeal flap. Sleep disordered breathing is a common complication of this surgery and a baseline sleep study is often performed before undergoing the procedure. Few postoperative sleep studies are ever done and little is known about the effects that pharyngeal flaps have on airflow dynamics.Preoperative and postoperative nasometry and polysomnographic data were reviewed and compared from nonsyndromic children requiring pharyngeal flap since 2009. Eighteen children having undergone pharyngeal flap were identified. Of those 18, Nadir oxygen saturations were worsened in 10, improved in 7, and remained the same in 1. Snoring was caused or made worse in 8. Sleep efficiency was worse in 11, improved in 6, and remained the same in 1. Apnea/hypopnea events increased in 9 and decreased in the other 9. Hypernasality was improved in varying degrees in 17 patients, but all required additional speech therapy. Diagnosed preoperative sleep apnea remained in 1 patient. No patient's postpharyngeal flap had any significant sleep disturbance that would warrant continuous positive airway pressure. No flaps required division or takedown.This preliminary study suggests that pharyngeal flaps may increase snoring and apnea/hypopnea events without causing diagnosable sleep disordered breathing and the resultant clinical sequelae. Nasometry shows evidence of nasal airway diversion without complete obstruction. Speech improves more subjectively than nasometry would predict after pharyngeal flap.

Reconstruction of a Rare Palate Defect Originating from Extranodal Natural Killer/T-Cell Lymphoma

Reconstruction of a Rare Palate Defect Originating from Extranodal Natural Killer/T-Cell Lymphoma

Parental perceptions of posterior pharyngeal wall augmentation using autologous fat for treating velopharyngeal dysfunction

Posterior pharyngeal wall augmentation using autologous fat to treat velopharyngeal dysfunction (VPD) is an alternative surgical procedure to more commonly used invasive procedures such as the pharyngeal flap. However, limited research exists on this technique. The aim of this study was to qualitatively investigate parental perceptions of posterior pharyngeal wall augmentation using autologous fat when treating velopharyngeal dysfunction. Furthermore, this research aimed to examine parent's perspectives of their child's speech and quality-of-life following this procedure. A qualitative collective case study methodology was used in the form of semi-structured interviews with seven participants. These were then analysed using constant comparative analysis. Four distinct themes emerged: post-surgical outcomes; speech-language pathology, not just medicine; factors for successful post-operative speech and resonance; and long-term sustainability and worthiness of the procedure. Six out of seven participants expressed positive post-operative speech and resonance results. Five further expressed long-term satisfaction up to 6 years post-operatively. Overall the majority of participants were satisfied that this procedure provided their child with long-term successful speech outcomes. The participants also discussed the importance of receiving speech-language pathology services alongside surgery and the positive impact of the procedure on their child's quality-of-life including social interactions, confidence, friendships, as well as eating and drinking.

Application of a Robotic Telemanipulator to Perform Posterior Pharyngeal Flap Surgery

The instrumentation used during surgery to address velopharyngeal dysfunction has changed little over the past century. Recent advances in the use of robotic surgical systems in transoral surgery have expanded the use of these instruments beyond their traditional laparoscopic applications. The purpose of this study was to evaluate the feasibility of performing superiorly based, "Hogan"-style posterior pharyngeal flaps using a robotic surgical telemanipulator system. The authors hypothesize that use of this surgical platform provides equivalent safety, improved exposure, and more comfortable surgeon ergonomics compared with traditional methods of flap harvest and inset. A pilot study was performed using three fresh cadaveric human heads. Superiorly based posterior pharyngeal flaps were successfully performed in all specimens. The technical aspects of the procedure, including telemanipulator setup, positioning, surgical instrumentation, and timing, are described in detail. All three subjects underwent successful transfer of posterior pharyngeal flaps. Mean surgical time was 113 minutes. Using a 30-degree angled endoscope, the area of the operative field was nearly doubled, and this allowed for easy visualization of the flap ports, an advantage when tailoring the flap. Technically, the learning curve for using the robot telemanipulator was steep, and both operating surgeons (J.M.S. and J.A.T.) felt that the instrumentation and setup were ergonomic. There was no damage to adjacent structures. Transoral robotic surgery for velopharyngeal dysfunction is feasible and may offer improved exposure and ergonomics compared with traditional methods. As the use of robotic surgical systems becomes more widespread, their use in intraoral cleft surgery warrants further investigation.

Superiorly Based Pharyngeal Flap for Treatment of Velopharyngeal Insufficiency in Patients With 22q11.2 Deletion Syndrome

There are no previous blinded studies for comparison of preoperative versus postoperative perceptual speech assessments when using a pharyngeal flap for treating velopharyngeal insufficiency (VPI) in patients diagnosed with 22q11.2 deletion syndrome. The aim of the study was to evaluate the effect of superiorly based pharyngeal flap surgery on speech in these patients using blinded judgments of experienced speech therapists. A retrospective study of 12 consecutive patients who had undergone pharyngeal flap surgery for treatment of VPI between 2002 and 2009 was conducted. Seven girls and 5 boys between 4 and 15 (median, 6) years old at the time of surgery were included in the study. Six patients were born with a submucous cleft palate (including 2 occult), and 1 patient, with an overt cleft palate. The remaining 5 patients had no signs of a palatal pathology. All palatal clefts had been repaired before pharyngeal flap surgery except in 2 patients with occult submucous cleft palate. Preoperative and postoperative audio recordings were blinded for scoring independently by 3 senior speech therapists. There was a significant improvement in hypernasality (P = 0.002), audible nasal emission (P = 0.033), weak pressure consonants (P = 0.008), and speech intelligibility (P = 0.021) after pharyngeal flap surgery. Hyponasality did not develop significantly with surgery. One patient was diagnosed with obstructive sleep apnea. Superiorly based pharyngeal flap resulted in a significant speech improvement in 12 consecutive patients with 22q11.2 deletion syndrome having VPI.

Pharyngeal flap operationの適応基準について

Pharyngeal flap operationの適応基準について

折畳咽頭弁法術後における鼻咽腔閉鎖不全症に対する Unified Velopharyngo Plasty (UVP)法による咽頭弁再形成術

折畳咽頭弁法術後における鼻咽腔閉鎖不全症に対する Unified Velopharyngo Plasty (UVP)法による咽頭弁再形成術

Velopharyngeal Dysfunction

Velopharyngeal dysfunction (VPD) is a generic term which describes a set of disorders resulting in the leakage of air into the nasal passages during speech production. As a result, speech samples can demonstrate hypernasality, nasal emissions, and poor intelligibility. The finding of VPD can be secondary to several causes: anatomic, musculoneuronal, or behavioral/mislearning. To identify the etiology of VPD, patients must undergo a thorough velopharyngeal assessment comprised of perceptual speech evaluation and functional imaging, including video nasendoscopy and speech videofluoroscopy. These studies are then evaluated by a multidisciplinary team of specialists, who can decide on an optimal course for patient management. A treatment plan is developed and may include speech therapy, use of a prosthetic device, and/or surgical intervention. Different surgical options are discussed, including posterior pharyngeal flap, sphincter pharyngoplasty, Furlow palatoplasty, palatal re-repair, and posterior pharyngeal wall augmentation.

The Lateral Port Control Pharyngeal Flap: A Thirty-Year Evolution and Followup

In 1971, Micheal Hogan introduced the Lateral Port Control Pharyngeal Flap (LPCPF) which obtained good results with elimination of VPI. However, there was a high incidence of hyponasality and OSA. We hypothesized that preoperative assessment with videofluoroscopy and nasal endoscopy would enable modification and customization of the LPCPF and result in improvement in the result in both hyponasality and obstructive apnea while still maintaining results in VPI. Thirty consecutive patients underwent customized LPCPF. All patients had preoperative diagnosis of VPI resulting from cleft palate. Patient underwent either videofluoroscopy or nasal endoscopy prior to the planning of surgery. Based on preoperative velar and pharyngeal movement, patients were assigned to wide, medium, or narrow port designs. Patients with significant lateral motion were given wide ports while patients with minimal movement were given narrow ports. There was a 96.66% success rate in the treatment of VPI with one patient with persistent VPI (3.33%). Six patients had mild hyponasality (20 %). Two patients had initial OSA (6.67%), one of which had OSA which lasted longer than six months (3.33%). The modifications of the original flap description have allowed for success in treatment of VPI along with an acceptably low rate of hyponasality and OSA.

Airway obstruction following palatoplasty of a patient with sleep disturbance

Airway obstruction following palatoplasty of a patient with sleep disturbance

A Case of Atlanto-axial Rotatory Fixation Following Cochlear Implantation

We report herein on a 6-year-old girl with atlanto-axial rotatory fixation (AARF) which occurred after cochlear implantation under general anesthesia. The cochlear implantation procedure appeared normal, and took 3 hours and 50 minutes. On the 1st postoperative day, the patient complained of neck and shoulder pain but she could rotate her head. On the 4th postoperative day, she had torticollis without any neurologic damage and neither active nor passive rotation of the head could be achieved. She was diagnosed as having AARF on the basis of the computed tomographic findings. She was treated with Glisson’s traction for 4 days to correct the deformity. AARF is a rare disorder and its diagnosis is often difficult and delayed. CT scans, especially 3-D reconstruction, are useful to diagnose AARF. It is suggested that AARF can occur after a cervical injury or an upper respiratory tract infection. AARF is also occasionally caused after head and neck surgical procedures such as pharyngeal flap plasty, ear surgery, and plastic surgery for microtia. It is important to be aware of the possible occurrence AARF and to start appropriate treatment as soon as possible.