A tendon transplant pharyngopalatoplasty

A new pharyngopalatoplasty procedure utilizing a palmaris longus tendon graft has achieved consistently gratifying results in selected patients with functional palatal musculature. Although originally proposed as a dynamic pharyngopalatoplasty, this technique may also be successfully used as an aid in the salvage of the multiply operated, extensively scarred, and still incompetent palate. This paper describes the evolution of the current procedures and details of the operative technique. Intraoperative photographs of an illustrative case are included. Experience with a preliminary series of thirteen varied patients with follow-ups ranging from seven years, eight months, to one year, eight months, is reported. The results are discussed. The apparent advantages and disadvantages and the indications for the use of the procedure in selected cases are discussed.

The effects of pharyngeal flap surgery on laternal pharyngeal wall motion: a videoradiographic evaluation

Twenty patients undergoing pharyngeal flap surgery to correct velopharyngeal incompetence were studied by speech videofluoroscopy pre- and postoperatively to determine the effects of the surgical procedure on lateral pharyngeal wall motion. Within the limits of clinical judgment and for purposes of surgical planning, the motion was not altered. The implications of this are discussed.

A comparison of transverse and vertical pharyngeal flaps using electromyography and judgments of nasality

Previous studies have reported less than adequate speech results for vertical types of pharyngeal flaps with some patients. However, no controlled judgments of nasality have been reported for transverse pharyngeal flaps, and no comparative studies have been done. In this investigation, 21 listeners evaluated nasality in two groups of seven cleft palate patients. One group had had vertical pharyngeal flaps, while the other group had had transverse pharyngeal flaps. The possible relationship of observable electromyographic activity to nasality was also studied. The results indicated that perceptual ratings of postoperative speech in the two groups did not differ significantly. Also, because similar muscle action potentials were observed in both types of pharyngeal flaps, it was concluded that this activity was not a contributing factor in the judgments of nasality.

Phonosurgery (combined approach palatopharyngoplasty--CAP)

A new surgical approach (CAP--Combined Approach Palatopharyngoplasty) is described for the correction of speech defects in palatopharyngeal incompetence. In palatopharyngeal incompetence the spatial relationships between the various components of the palatopharyngeal mechanism are disturbed. This combined approach brings about near-normal relationships (viz. intrapalatal and palatopharyngeal), as well as providing a competent palatopharyngeal sphincter, thus offering a remarkable improvement in speech. The operation comprises a two-stage procedure: stage I:--(a) submucosal transplantation of the levator palati muscles posteriorly to the region of the uvula and (b) 'crossed' palatopharyngoplasty; isolation of the palatopharyngeus muscles (posterior pillars) with their bases superiorly placed at their junctions with the soft palate, and transplantation of the lower free ends into the transverse retropharyngeal musculo-fascial pockets on the opposite side, the flaps thus crossing each other in the midline: stage II:--'check-valve' palatopharyngoplasty; elevation of a superiorly based posterior pharyngeal flap with anastomosis to the soft palate. The dynamics which are responsible for the improvement in speech are: (a) elevation of the palate to about the level of the atlas; (b) statico-dynamic constriction of the pharyngeal phonetic passage at the following levels: (i) at the newly placed levator eminence, (ii) at the newly constructed dynamic sphincter situated between the above-mentioned crossing and the free margin of the soft palate, and (iii) at the junction of the check-valve flap with the posterior pharyngeal wall; (c) increase in the effective length of the soft palate. The phonetic stream is prevented from entering the nasal chambers during the utterance of non-nasal pressure sounds by the newly constructed three-tier protective mechanism. This is identical with, but a 'reverse' representation of, the normal three-tier protective mechanism of the larynx, which prevents food from entering the tracheo-broncheal tree during deglutition. The operation has been performed in eight cases and the results are satisfactory, in so far as improvement in the quality of speech is better than that observed following other operations. In conclusion, the principles of phonosurgery may well be diagrammatically represented in Fig. 7.

Velopharyngeal incompetence in the absence of cleft palate: results of treatment in 20 cases

The diagnosis and treatment of 20 cases of velopharyngeal incompetence without cleft palate (frank or submucosal) are discussed. A total of 16 out of 18 patients treated by a sphincter pharyngoplasty were greatly improved, and 10 have normal speech.

The role of lateral pharyngeal wall movement in pharyngeal flap surgery

A total of 202 patients with pharyngeal flaps were assessed with nasopharyngoscopy and multiview fluoroscopy to determine the role of lateral pharyngeal wall movement postoperatively. Variations in the construction of flaps resulted in three categories: namely, a long narrow flap with a high insertion, a short broad flap with a low insertion, and an intermediate-size flap that is inserted in a position somewhere between the first two. It was found that in all cases where there was no evidence of velopharyngeal insufficiency, the sole determiner of velopharyngeal closure was the medical excursion of the lateral pharyngeal walls to the sides of the flap. In flap failures, the causes for velopharyngeal insufficiency were inappropriate degree, level, and symmetry of the lateral pharyngeal wall motion. The success of pharyngeal flap surgery depends largely on the preoperative assessment of the velopharyngeal mechanism and the choice of a type of pharyngeal flap that will best assist closure of the velopharyngeal port during speech.

A survey of speech pathologists: current trends in the diagnosis and management of velopharyngeal insufficiency

A questionnaire designed to survey methods of diagnosis and management of velopharyngeal insufficiency associated with cleft palate was distributed to over 1,000 speech pathologists in the United States and Canada. There was a 60% response, and 65% of those responding were associated with cleft palate teams. Findings included: (1) 90% of responding cleft palate team members primarily rely on listener judgment, oral examination, and articulation testing in the diagnosis of velopharyngeal insufficiency (VPI) and for the recommendation of pharyngoplasty. (2) Only 11% indicated that their team had a radiologist. (3) More than half of those responding said that they would prefer palatal repair to be completed after the age of two. (4) 60% of those responding regarded VPI as a voice disorder, yet 84% treated the symptoms of VPI with articulation therapy rather than voice therapy.

[On the reconstructive surgery of the velopharyngeal incompetence (author's transl)]

A new method of sphincter pharyngoplasty for the reconstruction of the velopharyngeal incompetence is described, applicable even in cases of deficiency of the salpingopharyngeus muscle as it may be seen after a tonsillectomy.

Speech prosthesis versus pharyngeal flap: a randomized evaluation of the management of velopharyngeal incompetency

Thirty-nine children with moderate-to-severe velopharyngeal incompetency were randomly assigned to either prosthetic or surgical palatal management. A classification for evaluating velopharyngeal incompetency was designed. The prosthetic speech appliance, when obtained and tolerated, corrected velopharyngeal incompetency as effectively as did pharyngeal flap surgery. However, the noncompliance and failure rate for prosthetic management was 35 percent. The surgical failure rate was 9 percent. Furthermore, 33 percent of patients who received prosthetic management have subsequently undergone pharyngeal flap surgery. The equivalency of these types of palatal management lead one to question the combination of the noncompliance and failure rate for prostheses, the incidence of secondary surgical conversions, and the persistent sense of deformity with prosthetic management.

Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence

We have observed three children who developed obstructive sleep apnea immediately following construction of pharyngeal flaps designed to improve the speech of these patients with velopharyngeal incompetence. Postoperatively the patients were noted to have repeated episodes during sleep of strong respiratory efforts without airflow. Sleep apnea can be debilitating and lethal, and should be looked for following surgery of the upper airway. Respiratory depressants should be avoided. Airway intubation, revision of the surgery, or tracheostomy may be necessary.

Successful correction of velopharyngeal stress incompetence in musicians playing wind instruments

Two professional musicians who played wind instruments developed velopharyngeal stress incompetence which prevented them from generating the high intraoral pressures required to play their instruments. In both cases, we did a V-Y pushback with a superiorly-based pharyngeal flap. At 1 1/2 and two years postoperatively, both patients remain free of velopharyngeal incompetence and are actively engaged in their musical careers.

Articulation skills and oral-nasal resonance in children with pharyngeal flaps

Longitudinal data on speech sound acquisition and oral-nasal balance were analyzed in 52 children who had had pharyngeal flaps for velopharyngeal incompetency. These data were compared to similar data for a group of 48 children with cleft palates who had not required secondary management. Comparisons were made also between the pre- and post surgical performance of the group who had had pharyngeal flaps. Further comparisons were made between children who had surgery before six years. Analysis of data revealed that the children who required pharyngeal flaps lagged behind the group who did not in the development of acceptable resonance and articulation patterns. Further analysis showed that, for the post-pharyngeal flap group, there was an acceleration in the acquisition of acceptable sound production in the year immediately following surgery. The data suggested that children who had flaps before six years of age made faster gains in the development of articulation and acceptable resonance than did children who were treated after the age of six years.

Evaluation of speech after correction of rhinophonia with pushback palatoplasty combined with pharyngeal flap

A comparison is made of the preoperative and postoperative speech evaluations of 15 selected subjects who had pharyngeal flap operations combined with palatal pushback. Postoperatively, 13 of the 15 patients (86 percent) showed no abnormal nasal emission and no evidence of significant hypernasality during word production. Gross substitution errors were also corrected by the surgical repair. While the number of patients is small, this study indicates equal effectiveness of the surgical technique described--regardless of the sex, the medical diagnosis, whether the procedure was primary or secondary, or the amount of postoperative time--providing there is good function of the muscles of the soft palate.

Surgical management of the hypodynamic palate

The most successful surgical correction of velopharyngeal insufficiency (VPI) has been achieved in those patients in whom residual dynamic function of the soft palate/nasopharyngeal sphincter mechanism exists. In spite of the obvious need for rehabilitation, surgical reconstruction has often been advised against in those cases where the palate was hypodynamic or adynamic. We have developed a surgical procedure for these patients by utilizing a modification of Hogan's lateral port control pharyngeal flap method. We present the surgical considerations along with the initial application and results in four patients with hypodynamic palates of differing origins. We think that this technique extends surgical correction of VPI to the previously neglected group of patients in whom this condition is the result of a hypodynamic palate.

A comprehensive study of pharyngeal flap surgery: tailor made flaps

Three methods of pharyngeal flap surgery were analyzed with multiview videofluoroscopy and nasopharyngoscopy at least six months post-operatively. It was found that, by varying the type of insertion of the flap into the palate, post-operative flap width could be "tailored" to the size of the gap in the velopharyngeal sphincter. The value of varying flap width according to gap size was assessed by analyzing speech results in 60 patients specifically assigned for narrow, moderate, or wide flaps. Results show a marked improvement in the effectiveness of pharyngeal flap surgery when operations are prescribed according to the degree of lateral pharyngeal wall motion seen pre-operatively.

Partial palatal split palatoplasty

A partial palatal split technique is described for use with superiorly based pharyngeal flap palatoplasties. This procedure allows (1) increased facility in dissection, (2) precision in the design of the flap for lateral port control, and (3) construction of a one-piece nasomucosal lining flap in comparison to the standard complete palatal split technique.

The case for the inferiorly based posterior pharyngeal flap

The superiorly based and inferiorly based posterior pharyngeal flaps are compared. Reasons for choosing one or the other in specific cases are given. The complications with each are enumerated. The results obtained in speech comparing the two flaps in two retrospective series and one prospective series of cases failed to show a significant difference between them. Therefore, with little difference in the results and some good reasons for preferring one or the other under certain conditions, it would seem logical to select the one best suited for the particular problem.

Posterior pillar webbing and palatopharyngeus displacement: possible causes of congenital palatal incompetence

Three cases of congenital palatal incompetence in the absence of the usual stigmata associated with hypernasality are presented. In two instances, mucosal webbing of the posterior pillars was noted and in one case the palatopharyngeus muscle was displaced. Hypernasal voice quality was apparent in each patient. A z-plasty on both sides of the posterior pillars is suggested as the treatment of choice when no other morphologic abnormalities are present.