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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 484-489

Superiorly based pharyngeal flap versus endoscopic augmentation of the posterior pharyngeal wall, using cartilage graft in the treatment of velopharyngeal insufficiency


Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission10-Sep-2013
Date of Acceptance02-Jan-2014
Date of Web Publication26-Sep-2014

Correspondence Address:
Ashraf A El-Demerdash
MSc, Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Shibein El-Kom, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141733

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  Abstract 

Objectives
The aim of this study was to compare the functional outcome of the superiorly based pharyngeal flap and endoscopic augmentation pharyngoplasty, using cartilage graft in patients with velopharyngeal insufficiency (VPI).
Background
Surgical alteration of the velopharyngeal sphincter is directed at decreasing the horizontal cross-sectional surface area of the sphincter's tissue boundaries that can be achieved by different surgical operations with different outcomes.
Materials and methods
A total of 30 patients with VPI were enrolled into our study from July 2010 to March 2012. Patients were assessed by preoperative flexible fibro-optic nasopharyngoscopy and tape recording at phoniatrics clinic. Patients were classified into two groups: group I consisted of 12 patients for augmentation pharyngoplasty, and group II consisted of 18 patients for superiorly based pharyngeal flap. Each group was divided into two categories:
(A) With good palatal movement and small central gap
(B) With poor palatal movement and large central gap.
Tape recording was repeated after phonotherapy (3-4 months postoperatively), and hypernasality was assessed using a five-degree rating scale, in which 0 = normal nasality and 4 = severe hypernasality. Complications were documented and statistical comparisons were made between subgroups IA and IIA and subgroups IB and IIB.
Results
We had four subgroups: IA that included seven patients, IB that included five patients, IIA that included 10 patients, and IIB that included eight patients. Subgroup IIA had a mean hypernasality score of 0.4 ± 0.8 SD, which was better than the mean score of 1.6 ± 0.5 SD in subgroup IA. Subgroup IIB had a mean hypernasality score of 0.8 ± 1.1 SD, which was significantly better than the mean score of 1.2 ± 0.8 SD in subgroup IB (P = 0.04). The complications were not significantly different between the two groups, and were all relatively mild.
Conclusion
Superiorly based pharyngeal flap proved to be better than augmentation pharyngoplasty in the management of hypernasality because of VPI, with significant difference in patients with poor palatal movement and a large central retropalatal gap. Both the techniques had accepted incidence of complications with no significant intergroup difference.

Keywords: Augmentation pharyngoplasty, cartilage graft, hypernasality, pharyngeal flap, velopharyngeal insufficiency


How to cite this article:
El-Rashidy ALI, Behairy EW, Abdel-Fattah AA, El-Demerdash AA. Superiorly based pharyngeal flap versus endoscopic augmentation of the posterior pharyngeal wall, using cartilage graft in the treatment of velopharyngeal insufficiency. Menoufia Med J 2014;27:484-9

How to cite this URL:
El-Rashidy ALI, Behairy EW, Abdel-Fattah AA, El-Demerdash AA. Superiorly based pharyngeal flap versus endoscopic augmentation of the posterior pharyngeal wall, using cartilage graft in the treatment of velopharyngeal insufficiency. Menoufia Med J [serial online] 2014 [cited 2019 Nov 17];27:484-9. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/484/141733


  Introduction Top


Velopharyngeal insufficiency (VPI) includes any structural and/or neuromuscular disorder of the velum and/or pharyngeal walls at the level of nasopharynx, which interferes with normal sphincteric closure. VPI may result from anatomic, myoneural, behavioral, or a combination of disorders. It is diagnosed clinically by a constellation of symptoms that includes pathologically incurred nasal resonance (hypernasality), misarticulation, escape of air through the nose (nasal emissions), and aberrant facial movements (grimacing) [1].

The source of VPI may be a palate that is structurally deficient (e.g. too short or lacking muscle bulk), a velopharyngeal (VP) mechanism that is neurologically impaired (e.g. cerebral palsy, myasthenia gravis, head injuries, and cerebrovascular accidents), or the result of faulty learning (e.g. phoneme-specific nasal emission). Most commonly, however, the plastic surgeon will encounter VPI postpalatoplasty [2].

In 1865, after a detailed study on VP physiology, Passavant was the first to tether the uvula to the pharynx in an attempt to restore a competent valvular mechanism during speech. Since that time, the use of removable devices designed correct the VPI; in addition, a number of surgical procedures have been devised to restore the physiological closure of this sphincter-like mechanism [3].

Surgical alteration of the VP sphincter is directed at decreasing the horizontal cross-sectional surface area of the sphincter's tissue boundaries. This can be achieved by the interposition of pedicled pharyngeal flaps (splitting one large port into two smaller ones) or doing endoscopic augmentation of the posterior pharyngeal wall [4].

The pharyngeal flap has probably been the single most popular method of treating individuals with VPI over the past two decades. The procedure was initially described in the 19th century and later refined by surgeons such as Rosenthal, Padgett, Sanvanero-Rosselli, and Conway [5].

The use of the nasal endoscope for visualization of the VP isthmus and posterior pharyngeal wall, and the choana is excellent. This allows additional, endoscopic surgical manipulation to achieve direct access to the nasopharynx for the creation of a bulge in the posterior pharyngeal wall high, and at the reasonable level to control VP incompetence, endoscopic-free cartilage graft pharyngoplasty is a new simple and easy surgical technique for VPI. It helps to approach the velopharynx in a direct and magnified manner instead of the blind and scarring approach through the palate [6].

The aim of this work was to compare the results of endoscopic augmentation pharyngoplasty, using cartilage graft, and the superiorly based pharyngeal flap in the treatment of VPI.


  Materials and methods Top


A random group of 30 consecutive patients with VPI was studied in the Otorhinolaryngology Department, Menoufia University, during the period from July 2010 to March 2012. Full history was obtained from each patient or their parents. All children underwent a physical examination to confirm the absence of the following exclusion criteria: poor anteroposterior motion with poor lateral motion of VP sphincter, patients with upper airway obstruction, patients with retrognathia, patients with medialized internal carotid arteries detected by nasopharyngoscopy, patients with tonsillar hypertrophy (surgical repair is done after 4 weeks of tonsillectomy), and patients with mental retardation or multiple anomalies with poor speech development.

Preoperative assessment

The following diagnostic procedures were performed on all our patients.

Flexible fibro-optic =

Following Groft et al. [7], patients were classified into two categories:

Category A: Good palatal movement, +/− posterior pharyngeal wall movement, and small central retropalatal gap.

Category B: Poor palatal movement, +/− posterior pharyngeal wall movement, and large central retropalatal gap.

Tape recording

According to the results of postoperative tape recording, the hypernasality was categorized by using the five-degree rating scale, where 0 stands for normal and 4 stands for severe hypernasality.

Patients were classified into two random groups:

Group I: This group consisted of 12 patients who were candidates for posterior pharyngeal wall augmentation using cartilage graft. This group was also further divided into two categories, A and B, according to the criteria seen in nasopharyngoscopy. Category A included seven patients, and category B included five patients.

Group II: This group was prone to superiorly based posterior pharyngeal wall flap and it included 18 patients. This group was further divided into two categories, A and B, according to the criteria seen in nasopharyngoscopy. Category A included 10 patients, and category B included eight patients.

Surgical technique

Group I was subjected to a new technique for the augmentation of posterior pharyngeal wall, using cartilage graft after failure of appropriate speech therapy. Under general anesthesia, endoscopic pocket was created, visualized by Karl Storz 0° endoscopic lens of 2.7 mm diameter at the reasonable level (at or above the arch of  Atlas More Details), and slices of the cartilage were inserted into it to reduce the anteroposterior distance.

The conchal cartilage was used in patients less than 18 years old, whereas the septal cartilage was used in patients more than 18 years old. This surgical technique alleviated the need for splitting the soft palate done in previous techniques with less postoperative scarring of the palate. This procedure did not require overnight observation; however, postoperative antibiotics were advisable to minimize the risk of postoperative infection. Neck pain was observed postoperatively as the prevertebral fascia was irritated by the implanted cartilage slices. Therefore, simple analgesia was prescribed for the patients.

Group II was subjected to superiorly based pharyngeal flap, according to the Hogan technique [8]. The patient was positioned in the tonsillectomy position (Rose's position) on a shoulder roll, and a mouth gag with the smallest blade allowing optimum visualization of the operative field was inserted. The posterior pharyngeal wall was visualized and palpated to identify any significant vessels in the operative field. The internal carotid arteries may be medialized in velocardiofacial syndrome patients. These vessels are located deep in the prevertebral fascia and should not interfere with the operation; nevertheless, caution should be exercised while raising the flap.

The proposed posterior pharyngeal wall incision lines were infiltrated with 1% lidocaine with 1 : 100 000 U of epinephrine to affect vasoconstriction and ease the raising of the flap. The standard width of a pharyngeal flap generally approximated the distance between the posterior tonsillar pillars. The inferior extent of the flap was near the midpoint of the tonsil. A pedicled myomucosal flap was created and inserted into the nasal layer of soft palate after vertical splitting of the soft palate into the oral and nasal layers. Then, the oral layer was closed over them with vicryl 3/0. This resulted in a permanent midline connection between the nasopharynx and oropharynx, which bisected the VP port into two lateral ports [8].

The intraoperative use of endotracheal tubes with known diameters (3.5 for children less than 6 years old, and 4 for patients more than 6 years old) and a wide pharyngeal flap was commonly needed to create lateral ports that aim to maintain the delicate balance between nasopharyngeal/oropharyngeal patency and adequate VP function. The stents were removed the next morning if no airway obstruction was identified overnight, and the patients were discharged from the hospital after a second night of observation if no airway compromise was documented [6].

Postoperative details

Oral feeding was allowed 24 h postoperatively and patients were discharged 48 h postoperatively. Phonotherapy was started 1 month postoperatively for all patients and continued for six sessions. Tape recording was repeated after phonotherapy (3-4 months postoperatively). Flexible fibro-optic nasopharyngoscopy was repeated after 3-6 months postoperatively. All patients were regularly followed up every 2 weeks. The least period of follow-up was 5 months, with mean period of 10.4 months.


  Results Top


A random group of 30 patients with VPI was studied. All of them on perceptual evaluation had nasal resonance.

They were classified into two random groups:

Group I: Twelve patients on whom endoscopic augmentation pharyngoplasty was performed.

Group II: Eighteen patients on whom superiorly based pharyngeal flap was performed.

Concerning group I, they were seven female (58.3%) and five male patients (41.7%). The age of patients ranged between 6 and 25 years old [Table 1].
Table 1: Number and percent distribution of the demographic data of the studied group

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According to the preoperative findings by videoendoscopy, patients were categorized as follows.

Subgroup IA (seven patients): Two patients dropped out of follow-up, whereas of the remaining five patients, two (40%) had score 1 hypernasality, and three (60%) had score 2 hypernasality [Table 2].
Table 2: Comparison between postoperative hypernasality of plosives in groups IA and IIA

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Subgroup IB (five patients): One patient (20%) had score 0 hypernasality, two patients (40%) had score 1 hypernasality, and two patients (40%) had score 2 hypernasality [Table 3].
Table 3: Comparison between postoperative hypernasality of plosives in groups IB and IIB

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Incidence of complications was 25% (three of 12 patients). One patient (8.3%) showed migration of the cartilage graft, whereas two patients (16.7%) showed extrusion of the cartilage graft [Table 4].
Table 4: Number and percent distribution of the complications of the studied group

Click here to view


Concerning group II, they were 10 female (55.6%) and eight male (44.4%) patients. The age of patients ranged between 6 and 25 years [Table 1]. According to the preoperative findings by videoendoscopy, patients were distributed as follows.

Subgroup IIA (10 patients): Three patients dropped out of follow-up, whereas five patients (71.4%) had score 0 hypernasality, one patient (14.3%) had score 1 hypernasality, and one patient (14.3%) had score 2 hypernasality [Table 2].

Subgroup IIB (eight patients): Four patients (50%) had score 0 hypernasality, including two patients (25%) with hyponasality, three patients (37.5%) patients with score 1 hypernasality, and one patient (12.5%) with score 3 hypernasality [Table 3].

Incidence of complications was 38.9% (seven of 18 patients). Two patients (11.1%) had infection of the flap, two patients (11.1%) had obstructive sleep apnea, and three patients (16.7%) had dehiscence of the flap [Table 4].

Subgroup IIA had a mean hypernasality score of 0.4 ± 0.8 SD, which was better than the mean score of 1.6 ± 0.5 SD in subgroup IA, but not reaching a statistical significance (P = 0.06) [Table 2]. Subgroup IIB had a mean hypernasality score of 0.8 ± 1.1 SD, which was significantly better than the mean score of 1.2 ± 0.8 SD in subgroup IB (P = 0.04) [Table 3]. The complications were not significantly different between the two groups, and were all relatively mild.


  Discussion Top


The goal of an ideal surgical management of VPI is to eliminate the symptoms of hypernasality and audible nasal emission. The extent to which this goal is realized depends on an appreciation of the preoperative VP anatomy [7]. A comprehensive assessment of VP function involves both a perceptual speech and an instrumental evaluation. Treatment strategies based on only one of these assessments are prone to failure [9]. In our study, the assessment of VP function was based on preoperative and postoperative findings of flexible fibro-optic nasopharyngoscopy and tape recording.

Utilizing the superior constrictor muscle and mucosa from the posterior pharyngeal wall, a pedicled flap is created that is inserted into the soft palate. This results in a permanent midline connection between the nasopharynx and oropharynx that bisects the VP port into two lateral ports [8]. The intraoperative use of rubber catheters with known diameters and a wide pharyngeal flap is commonly used to create lateral ports that aim to maintain the delicate balance between naso-oropharyngeal patency and adequate VP function [10].

Studies have shown success rates for pharyngeal flap surgery to be 80-90%. The classification success depends on the investigator. Certain studies classify patients with hyponasality as success [10]. Other studies classify postsurgical hyponasality as a failure. In these studies, the success rate is somewhat lower [11]. In our study, hyponasality was considered as success.

In our study, superiorly based pharyngeal flap was performed on 18 patients, of whom three patients (16.7%) dropped out of follow-up. Of the remaining 15 patients, six (40%) had persistence of nasal tone. These patients were further categorized as: four patients (26.6%) with score 1 hypernasality, one patient (6.6%) with score 2 hypernasality, and one patient (6.6%) with score 3 hypernasality. Nine patients (60%) had no hypernasality (score 0), including two patients with hyponasality, which was considered as success in our study [Table 2] and [Table 3]. This procedure had an incidence of complications. Seven patients (38.9%) were categorized as thus: two patients (11.1%) with infection of the flap, two patients (11.1%) with obstructive sleep apnea, and three patients (16.7%) with dehiscence of the flap [Table 4].

Pharyngeal flaps can be dangerous if performed on patients with unusually narrow upper airways. Patients requiring surgical VP management who have risk factors for upper airway obstruction are preferentially recommended for sphincter pharyngoplasty based on reports of its minimal effect on the airway [12],[13].

Endoscopic augmentation pharyngoplasty is a new, simple, and easy surgical technique for VPI. It helps to attack the velopharynx in a direct and magnified manner instead of the blind and scarring approach through the palate [6]. Several techniques have been tried to augment the posterior pharyngeal wall. Gray and colleagues described the use of a superiorly based folded pharyngeal flap for posterior wall augmentation to treat VPI in a retrospective study, including patients with very good velar motion. This study indicated that a folded flap to augment the posterior wall is likely to be as effective as other surgical techniques to treat small VP gaps [14].

Nicolas and colleagues conducted a study to assess the efficiency of autologous fat transfer in the management of VPI. Their study included 25 procedures performed on 22 patients. Two patients relapsed once and one patient twice, requiring additional injections. Final postoperative examination 1 year after the last procedure showed an improvement of speech in 90% of cases. They concluded that autologous fat transfer is a safe technique indicated in the primary and secondary management of VPI, with stable results on speech. However, if a complete return to normal is difficult to achieve, its simplicity allows multiple procedures in the same patient [15].

Filip and colleagues conducted a study to evaluate speech in patients who underwent autologous fat transplantation for the treatment of 16 patients with persistent VPI of mild degree secondary to overt or submucous cleft palate. They found that hypernasality improved significantly (P = 0.030), but not audible nasal emission (P = 0.072) or nasal turbulence (P = 0.12). Given the low number of patients and the lack of a control group, the value of fat transplantation for the treatment of mild VPI is not proven for sure [16].

In our study, augmentation pharyngoplasty was performed using cartilage graft on 12 patients, including two patients (16.7%) who dropped out of follow-up. Of the remaining 10 patients, nine (90%) had persistence of nasal tone. These patients were categorized as four patients (40%) with score 1 hypernasality, and five patients (50%) with score 2 hypernasality. However, one patient (10%) had normal nasality [Table 2] and [Table 3]. This procedure had an incidence of complications in three patients (25%), including two patients (16.7%) with extrusion of the cartilage graft, and one patient (8.3%) with migration of the cartilage graft [Table 4].

The postoperative hypernasality of plosives that occurred in our study in patients with preoperative flexible nasopharyngoscopy, showing good velum movement ± poor posterior pharyngeal wall movement and mild central retropalatal gap in groups (IA and IIA), revealed that there was no significant difference between the superiorly based posterior pharyngeal wall flap showed and endoscopic augmentation of posterior pharyngeal wall, using cartilage graft regarding hypernasality of plosives [Table 2].

The postoperative hypernasality of plosives that occurred in our study in patients with preoperative flexible nasopharyngoscopy, showing poor velum movement ± poor posterior pharyngeal wall movement and large central retropalatal gap in groups (IB and IIB), revealed that the superiorly based posterior pharyngeal wall flap showed significantly less hypernasality of plosives than endoscopic augmentation of posterior pharyngeal wall using cartilage graft. This can be explained by the fact that plosives need high intraoral pressure with good closure of VP sphincter, and the superiorly based pharyngeal wall flap gives better closure of VP sphincter than endoscopic augmentation of posterior pharyngeal wall [Table 3].


  Conclusion Top


Superiorly based pharyngeal flap proved to be better than augmentation pharyngoplasty in the management of hypernasality owing to VPI, with significant difference in patients with poor palatal movement and large central retropalatal gap. Both techniques had accepted incidence of complications with no significant intergroup difference.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Seibert RW, Bumsted RM. Cleft lip and palate. In: Cummings CW, et al. editor. Otolaryngology head and neck surgery. Chapter 66, vol. 3. 2nd ed. St Louis: CV Mosby Co.; 1993:1128-11640.  Back to cited text no. 1
    
2. Crockett DM. Velopharyngeal insufficiency. In: Healy GB editor. Common problems in pediatric otolaryngology. Chicago: 1990. 460-463.  Back to cited text no. 2
    
3. Argamaso RV. The pharyngeal flap surgery for velopharyngeal insufficiency. In: Kernahan D, Rosenstein S, editors. Operative techniques in plastic and reconstructive surgery. Philadelphia: Saunders; 233-238.  Back to cited text no. 3
    
4. Marrinan EM, LaBrie RA. Velopharyngeal function in nonsyndromic cleft palate: relevance of surgical technique, age at repair and cleft type. Cleft Palate Craniofac J 1998; 35 :95-100.  Back to cited text no. 4
    
5. Hall CD, Golding-Kushner KJ, Argamaso RV, et al. Pharyngeal flap surgery in adults. Cleft Palate Craniofac J 1991; 28 :179-182.  Back to cited text no. 5
    
6. Willging J. Superiorly based pharyngeal flap and posterior pharyngeal wall augmentation. Operat Tech Otolaryngol 2009; 20 :268-273.  Back to cited text no. 6
    
7. Morris HL, Bardach J, Jones D, et al. Clinical results of pharyngeal flap surgery. Plast Reconstr Surg 1995; 4 :652-662.  Back to cited text no. 7
    
8. Hogan MV. Clarification of the surgical goals in cleft palate speech and the introduction of lateral port control (LPC) pharyngeal flap. Cleft Palate Craniofac J 1973; 10 :331.  Back to cited text no. 8
    
9. Trier WC. Pharyngoplasty. In: Bardach J, Morris HL, editors. Multidisciplinary management of cleft lip and palate. Philadelphia: WB Saunders; 1990. 20 :209-217.  Back to cited text no. 9
    
10.Hassib A. Comparative study between superiorly based pharyngeal flap and sphincteroplasty in treatment of velopharyngeal insufficiency after cleft palate repair. Egypt J Plast Reconstr Surg 2005; 29 :149-156.  Back to cited text no. 10
    
11.Michael Sadove A, Barry LE, David LJ, et al. Velopharyngeal insufficiency in pediatric plastic surgery. Appleton & Lange, a Simon & Schuster Company; 1999. 121-128.  Back to cited text no. 11
    
12.Lesavoy MA, Borud LJ, Thorson T, et al. Upper airway obstruction after pharyngeal flap. Ann Plast Surg 1996; 36 :26-30.  Back to cited text no. 12
    
13.Witt PD, Marsh JL, Muntz HR, et al. Acute obstructive sleep apnea as a complication pharyngoplasty. Cleft Palate Craniofac J 1996; 3 :183-189.  Back to cited text no. 13
    
14.Gray S, Pinborough- Zimmerman J, Catten M. Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 1999; 121 :107-112.  Back to cited text no. 14
    
15.Nicolas L, Marion B, Françoise D, et al. Autologous fat transfer in velopharyngeal insufficiency: indications and results of a 25 procedures series. Int J Pediatr Otorhinolaryngol 2011; 75 :1404-1407.  Back to cited text no. 15
    
16.Filip C, Matzen M, Aagenæs I, et al. Autologous fat transplantation to the velopharynx for treating persistent velopharyngeal insufficiency of mild degree secondary to overt or submucous cleft palate. J Plast Reconstr Aesth Surg 2013; 66 :337-344.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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