The lateral port control pharyngeal flap: a thirty-year evolution and followup

Clinical efficacy of Hogan posterior pharyngeal flap in repairing velopharyngeal insufficiency secondary to cleft palate in older patients

OBJECTIVES

The clinical effects and surgical procedures of Hogan posterior pharyngeal flap in the treatment of the older patients with velopharyngeal insufficiency (VPI) after cleft palate repair were investigated.

METHODS

A total of 33 patients (aged 10-35 years; average of 20.4 years) with VPI secondary to cleft palate were included. They underwent Hogan posterior pharyngeal flap to improve velopharyngeal closure function. The clinical efficacy of the ope-ration was evaluated with Chinese speech clarity measurement and nasopharyngeal fiberscope (NPF), and the velopharyngeal closure was graded. The average follow-up time was 13.3 months.

RESULTS

The wounds of all patients were healed by first intention, and speech assessment showed that the consonant articulation increased and the rate of hypernasality and nasal emission decreased significantly (P<0.05). NPF examination showed that the postoperative velopharyngeal closure function significantly improved, 30 cases (91%) were gradeⅠ, and 3 cases (9%) were grade Ⅱ.

CONCLUSIONS

Hogan posterior pharyngeal flap for VPI secondary to cleft palate can significantly improve velopharyngeal closure.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Inspiration After Posterior Pharyngeal Flap Palatoplasty: A Preliminary Study Using Computational Fluid Dynamic Analysis

Posterior pharyngeal flap palatoplasty (PPF) is one of the most commonly used surgical procedures to correct speech, especially for patients suffering from velopharyngeal insufficiency (VPI). During PPF, surgeons use the catheter to control the lateral velopharyngeal port on each side. Airway obstruction and sleep apnea are common after PPF. To understand the air dynamics of the upper airway after PPF, we used computational fluid dynamics (CFD) to demonstrate the airflow. In our previous study, we have revealed the expiration process of the upper airway after PPF and shown the features of how PPF successfully restores the oral pressure for speech. In this study, we focus on examining the inspiration process. Normal airway structures were included. For the normal velopharyngeal structure, one cylinder was applied to each model. For recapitulating the velopharyngeal structure after PPF, two cylinders were used in each model. The ports for borderline/inadequate closure, which can help the oral cavity get the required pressure, were chosen for this study. A real-time CFD simulation was used to capture the airflow through the ports. We found that the airflow dynamics of the upper airway's inspiration were dependent on the velopharyngeal structure. Although the airflow patterns were similar, the velocities between one-port and two-port structures were different, which explained why patients after PPF breathed harder than before and suggested that the one-port structure might be a better choice for secondary VPI reconstruction based on the CFD analyses.

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.