Comprehensive Cleft Care, Second Edition: Volume Two by Joseph Losee Richard E. Kirschner

Author:Joseph Losee,Richard E. Kirschner
Language: eng
Format: epub
Publisher: Thieme Medical Publishing Inc.
Published: 2017-02-07T05:00:00+00:00

INDICATIONS FOR POSTERIOR PHARYNGEAL FLAP SURGERY

Indications for treatment of VPI should be derived from both subjective and objective data. Subjective speech assessments should document speech intelligibility, resonance, articulation, and nasal air escape. Objective measures of nasality using various speech stimuli include the nasalance score, which is a ratio of the nasal acoustic output relative to oral plus nasal acoustic output and is expressed as a percentage. This score is matched against age- and dialect-appropriate normal values. Nasendoscopy provides direct visualization of the soft palate and surrounding velopharyngeal structures during speech and nonspeech activities. The type of closure pattern, symmetry of movement, degree of closure, palatal morphology, presence of tonsils and adenoids, and pharyngeal pulsations should all be documented. The velopharyngeal closure rating (out of 1.0 in 0.1 increments) is based on the fraction of the diameter of the velopharyngeal port that is closed off during attempted sphincter closing.23 Multiview videofluoroscopy may also be used for determining the defect size and closure pattern but carries the risk of radiation exposure; at the Hospital for Sick Children in Toronto, it is reserved for noncompliant children in whom nasendosopy is not tolerated or when lateral-view imaging (which cannot be obtained using nasendoscopy) is needed.

The preoperative closure pattern and the selection of best surgical procedure has been a debated topic in the literature.24 Armour et al25 from the Hospital for Sick Children in Toronto hypothesized that the closure pattern of the velopharyngeal sphincter was an important determinant in selecting the proper operation for children with VPI. Closure patterns may be classified into coronal (good velar movement), sagittal (good lateral wall movement), or circular (good velar and lateral wall movement) plus or minus a contribution from Passavant’s ridge26 (Fig. 59-2). In a retrospective correlation, they demonstrated that the preoperative velopharyngeal closure pattern was a significant factor in predicting the effectiveness of superiorly based pharyngeal flaps in correcting the hypernasality associated with VPI. As a static procedure, success of the superiorly based flap depends on lateral port closure because of the medial movement of the lateral pharyngeal walls. This study demonstrated that noncoronal (sagittal and circular) closure patterns were satisfactorily addressed by the superiorly based flap technique. A coronal closure pattern was associated with poor lateral pharyngeal wall movement resulting in a lower success rate. Nabi et al24 found that preoperative circular closure patterns had better posttreatment nasalance scores versus coronal patterns; however, the reverse was true when they looked at longer term results for audible nasal air emission and compensatory articulation perceptual speech scores. Other studies have failed to show an advantage in speech outcomes between coronal and circular closure patterns in patients who have pharyngeal flap surgery and suggest improved lateral pharyngeal wall movement after the procedure.27,28 Shprintzen et al29 advocated for tailor-made flaps based on the degree of preoperative lateral wall adduction.

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