Superiorly based flap pharyngoplasty: the degree of postoperative "tubing" and its effect on speech

Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy

The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.

Subjective and Objective Evaluation of Speech in Adult Patients With Repaired Cleft Palate

OBJECTIVE

To explore the speech outcomes of adult patients with repaired cleft palate through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with complete velopharyngeal closure (VPC) and velopharyngeal insufficiency (VPI) patients.

PARTICIPANTS AND INTERVENTION

Subjective evaluation indicators included speech intelligibility, nasality and consonant missing rate, for objective acoustic analysis, we used speech sample normalization and objective acoustic parameters included normalized vowel formants, voice onset time and the analysis of 3-dimensional spectrogram and spectrum, were carried out on speech samples produced by 3 groups of speakers: (a) speakers with velopharyngeal competence after palatorrhaphy (n=38); (b) speakers with velopharyngeal incompetence after palatorrhaphy (n=70), (c) adult patients with cleft palate (n=65) and (d) typical speakers (n=30).

RESULTS

There was a highly negative correlation between VPC grade and speech intelligibility (ρ=-0.933), and a highly positive correlation between VPC and nasality (ρ=0.813). In subjective evaluation, the speech level of VPI patients was significantly lower than that of VPC patients and normal adults. Although the nasality and consonant loss rate of VPC patients were significantly higher than that of normal adults, the speech intelligibility of VPC patients was not significantly different from that of normal adults. In acoustic analysis, patients with VPI still performed poorly compared with patients with VPC.

CONCLUSIONS

The speech function of adult cleft palate patients is affected by abnormal palatal structure and bad pronunciation habits. In subjective evaluation, there was no significant difference in speech level between VPC patients and normal adults, whereas there was significant difference between VPI patients and normal adults. The acoustic parameters were different between the 2 groups after cleft palate repair. The condition of palatopharyngeal closure after cleft palate can affect the patient's speech.

Incidence of New-Onset Obstructive Sleep Apnea After Posterior Flap Pharyngoplasty in Children

INTRODUCTION

Obstructive sleep apnea (OSA) is a well-recognized complication of velopharyngeal insufficiency (VPI) surgery, but studies assessing OSA by means of a respiratory polygraphy (PG) are scarce. The aim of the study was to evaluate the incidence of new-onset OSA after posterior flap pharyngoplasty (PFP).

MATERIALS

The postoperative PG of children with VPI who had a normal preoperative PG were analyzed.

RESULTS

Eighteen patients (mean age, 9.8 ± 4.8 years; Pierre Robin sequence [n = 5], isolated cleft palate [n = 7], 22q11 deletion [n = 3], and 3 other diagnoses) were included in the study. Mean delay between surgery and the postoperative PG was 11.5 ± 13.5 months. Two patients (11%) developed severe OSA after PFP. One patient with 22q11 deletion developed overt OSA symptoms immediately after surgery with an apnea-hypopnea index (AHI) of 39 events per hour, requiring continuous positive airway pressure (CPAP) therapy. Obstructive sleep apnea improved spontaneously after 10 months, with an AHI of 2 events/h after CPAP weaning. The second patient had a cleft palate associated with a fetal alcohol syndrome and developed OSA symptoms after surgery with an AHI of 18 events/h requiring CPAP therapy. He could be weaned from CPAP 6 months later after a complete section of the pharyngeal flap with an AHI of 6 events/h during spontaneous breathing.

CONCLUSIONS

New-onset OSA after PFP in children with VPI who had a normal preoperative PG was uncommon (11%) in the present cohort.

Lateral pharyngeal flap with a double pedicle for repair of unilateral velopharyngeal insufficiency

OBJECTIVES

Conventional pharyngeal flap surgery, which closes the median portion of the velopharynx, has been performed for dysarthria patients with velopharyngeal insufficiency (VPI). However, for VPI due to unilateral pharyngeal paralysis, median closing disrupts pharyngeal contraction of the unaffected side and allows pharyngeal pressure to escape through the nose at the lateral portion of the affected side during speech and swallowing. The purpose of this study was to evaluate the effectiveness of lateral pharyngeal flap (LPF) surgery for unilateral VPI.

METHODS

Seven patients with unilateral VPI (five males and two females with an average age of 54 years) underwent LPF surgery combined with other transoral surgeries for dysphagia. The LPF surgical technique was as follows: after the laterocaudal-based pedicle flap of the soft palate and cranial-based pedicle flap of the posterior pharyngeal wall on the affected side were transorally elevated, each mucosal pedicle flap was sutured together. Functional oral intake scale (FOIS) scores and swallowing pressure before and after surgery were compared.

RESULTS

Unilateral velopharyngeal closure preserved nasal breathing after LPF surgery in all patients. Rhinolalia aperta improved postoperatively in all patients except one. The mean FOIS scores were 2.3 preoperatively and 3.7, 5.3, and 5.9 at 2 weeks, 1 month, and 6 months postoperatively, respectively. The mean pressures significantly increased at the velopharynx (from 49±30mmHg to 92±45mmHg) and oropharynx (from 48±18mmHg to 66±15mmHg) six months after the surgery.

CONCLUSION

LPF surgery leaving the unaffected side intact can be an effective surgical procedure for patients with unilateral VPI.

Investigation of postoperative hypernasality after superiorly based posterior pharyngeal flap

BACKGROUND

Velopharyngeal insufficiency that accompanies speech resonance and articulation disorders can be managed through several intervention methods such as speech-language therapy, prosthetic aids, and surgery. However, for patients with severe hypernasality, surgical interventions are highly recommended. Among available surgical techniques, the posterior pharyngeal flap is most common.

CASE PRESENTATION

Two adult males with high nasalance scores underwent superiorly based posterior pharyngeal flap surgery, followed by speech testing by an expert speech-language therapist. Nasalance scores and articulation accuracy were assessed up until 1 year after the surgery. Nasalance scores were measured five times using a nasometer, after which the average value was calculated.

CONCLUSIONS

Consistent declines in hypernasality over time are not easy to explain since the pedicled pharyngeal flap narrowed over time, secondary to cicatrization. However, scar tethering of the soft palate in a posterior direction could reduce the velopharyngeal port size over time. Therefore, long-term follow-up with intensive speech therapy is suggested for patients with severe hypernasality.

Analysis of Postoperative Bleeding After Posterior Pharyngeal Flap Pharyngoplasty

The aim of this study was to analyze the location and cause of postoperative bleeding after posterior pharyngeal flap pharyngoplasty and to investigate the surgical techniques with the goal of treating the bleeding. The patients received posterior pharyngeal flap pharyngoplasty in the Cleft Lip and Palate Treatment and Research Center of Shanghai Jiaotong University School of Medicine from January 2003 to December 2014, and postoperative bleeding in the surgical area was retrospectively analyzed. According to the record of the exploration of hemostasis, the locations and causes of the bleeding were summarized. In the 12-year study, a total of 1037 patients received posterior pharyngeal flap pharyngoplasty, including 621 males and 416 females with ages ranging from 4 to 40 years and a mean age of 13.7 years. Among these patients, 7 individuals (0.68%) experienced significant postoperative bleeding with the exploration of hemostasis. All patients were male, aged 5 to 26 years with a mean age of 15.7 years, and all were sent back to the operating room for exploration of hemostasis under general anesthesia. The sites of bleeding included 2 patients (28.6%) of the soft palate, 2 patients (28.6%) of the pharyngeal flap pedicle, and 3 patients (42.8%) of the nasopharynx. In posterior pharyngeal flap pharyngoplasty, particular attention should be paid to the protection of the blood vessels in the soft palate and the treatment of the vascular pedicle. Postoperative bleeding is very dangerous and generally requires immediate exploration in the operating room under general anesthesia.

Surgery for velopharyngeal insufficiency: The outcomes of the University Hospitals Leuven

OBJECTIVES

We reviewed the outcomes of patients who underwent a velopharyngoplasty and subsequent speech therapy for velopharyngeal insufficiency (VPI) to determine possible prognostic variables.

METHODS

During the period 2002-2010, 91 patients with VPI underwent a velopharyngoplasty (either the Honig velopharyngoplasty, the modified Honig velopharyngoplasty or the Hynes pharyngoplasty). Of these, 62 had complete data for long-term evaluation of speech outcome and analysis of variables potentially influencing this outcome. Speech outcome was assessed using five criteria that were evaluated pre- and postoperatively: hypernasality, nasal emission, facial grimacing, retro-articulation and glottal stops. The former two variables were transformed into a semi-objective nasality index (NI), the latter three variables were assembled to form a subjective articulation index (AI). Prognostic variables for outcome that were studied included age at velopharyngoplasty, associated 22q11.2 deletion syndrome, intervention type, primary or secondary surgery and pre-intervention speech therapy.

RESULTS

Before surgery, based on the NI, 15 patients had mild VPI and 44 patients had moderate to severe VPI. Postoperatively at 12 months, 46 patients had a good speech outcome (normal or mild VPI), 13 patients had moderate VPI and no more severe VPI was observed. The overall success rate of 78% after one year increased to 90% in the long-term (median 27 months) with further speech therapy. Patients without the diagnosis of 22q11.2 deletion syndrome had better speech outcomes than patients with the syndrome. No statistically significant effect of the age at velopharyngoplasty on speech outcome was found. No cases of sleep apnea syndrome were reported.

CONCLUSIONS

Our protocol of patient tailored surgical interventions and further postoperative speech therapy results in good speech outcomes, with no or only mild remaining VPI for the majority of patients. The correction of VPI is more difficult for the subgroup of patients with 22q11.2 deletion syndrome.

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.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.

Altered speech following adenoidectomy: a 20 year experience

Altered speech related to velopharyngeal insufficiency is a rare but well-recognised complication of adenoidectomy. Over a 20 year period, 42 patients were referred to the Edinburgh cleft team for investigation of altered speech persisting for more than 12 months after adenoidectomy. We studied the cases to ascertain the incidence, clinical features and causes of altered speech in these patients and to assess the efficacy of a selective treatment policy. All data were prospectively collected when the patients were assessed in a multidisciplinary clinic and investigated by videofluoroscopy. Nasopharyngoscopy was also possible in half of the patients. Overall, 27 patients were male and 15 were female, and their mean age was 6.5 years. The incidence was one in 1200 adenoidectomies. Diagnoses included five submucous cleft palates, six occult submucous cleft palates, 22 cases of velopharyngeal disproportion, seven developmental or neurological causes, one iatrogenic palatal injury and one case that defied diagnosis. In six patients treatment was not required, 13 responded to speech therapy and 23 required surgical intervention. The choice of operation was based on the findings at investigation. Ten patients were treated by a superiorly based pharyngeal flap, 10 underwent a sphincteric pharyngoplasty and three had an intravelar veloplasty. Speech outcome was assessed in 36 cases. Treatment resulted in significantly improved speech in all but one patient and normal speech in 16 patients. Persistently altered speech is a rare complication of adenoidectomy. Preoperative screening by clinical examination will prevent some but not all of such problems. When patients present they should undergo multidisciplinary assessment and multi-modality investigation. A good outcome can be anticipated in most patients.

An analysis of the strengths and weaknesses of endoscopic and radiological investigations of velopharyngeal incompetence based on a 20 year experience of simultaneous recording

The simultaneous recording of nasopharyngoscopy and video fluoroscopy allows a comparison to be made of their reliability under various circumstances. While the monocular view and the number of optical fallacies make measurement from endoscopy impossible, radiological views can also be shown to be fallacious, and all measurements should be treated with caution. However, through clinical observation the variability of the final dimensions of tissues raised to treat velopharyngeal incompetence can be roughly gauged. Indeed, the need for more accurate measurement awaits the arrival of a predictable procedure to allow fine tuning of surgery. Simultaneous recording has permitted improved clarity of interpretation and accuracy of measurement in some cases. The chief gain from investigations over the past 30 years has been in the considerably increased understanding of the range of normal and pathological morphology that must be taken into account in surgical treatment.