AAMJ,Vol.1, No.1, January,2003

CORRECTION OF VELOPHARYNGEAL INCOMPETENCE BY THE USE OF THE SPUPERIORLY BASED LINED PHARYNGEAL FLAP WITH LATERAL PORTS

Alaa Kamel Abdel Haleem* and Emad Kamel Abdel Haleem** ENT Dep., ** Phoniatric Unit., ENT Dep. Assiut University Hospital, Assiut, Egypt ------SUMMARY In this study the superiorly based lined pharyngeal flap with lateral ports was used to correct modaerate to severe velopharyngeal incompetence (VPI) due to sevseral causes after failure of speech therapy in 20 patients. All the patients were diagnosed and documented preoperatively using the assessment protocol for VPI cases in the Phoniatric Unit. They were referred again one month after surgery in the ENT department for postoperative documentation and speech therapy. All the patients showed marked subjective and objective improvement of the degree of hypernasality and complete closure of the velopharyngeal gap endoscopically. The overall speech intelligibility showed continuous imrovement with postoperative speech therapy. Although all the patients snored postoperatively, none of them suffered from .

INTRODUCTION

A competent velopharyngeal valve is essential for intelligible speech. Velopharyngeal incompetence (VPI) is the term used when the patient is diagnosed as bieng unable to close the sphincter completely (David and Bagnall, 1990). The causes of VPI are divese; anatomic congenital abnormalities of the i.e. clefts, palatal surgery, adenotonsillectomy, midface advancement and neurogenic conditions can all cause VPI.

Successful management of velopharyngeal dysfunction depends on careful evaluation of both velopharyngeal function and speech. It is also influenced by the type and severity of defect, client age, cognitive ability, motivation, availability of services and expertise of service providers (Miyazaki,1989). Surgery aimed at correcting velopharyngeal incopetence is not new. In 1865, Passavant introduced the posterior pharyngeal flap operation which creats adhesions between the and the pharyngeal wall, rather than a formal elevation of a full thickness pharyngeal flap (David and Bagnall,1990). Non surgical managemnt options like

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prosthetic dental appliances and speech therapy may be used in conjunction with or prior to surgery (Gray and Zimmermann,1998).

This work aimed at assessment of the superiorly based lined pharyngeal flap with lateral ports in correcting VPI of variable causes.

PATIENTS AND METHODS

This study included 20 patients with velopharyngeal incompetnce VPI due to many causes (table 1).They were first diagnosed and documented using the assessment protocol for VPI in the Phoniatric Unit and were referred for surgery in the ENT department and re-sent again after one month following complete healing to the Phoniatric Unit for post operative documentaion and speech thrapy. The minimal period of follow up was six months.

The following assessment protocol for VPI cases (Kotby et al.,1993) was done for every case before and after surgery.

Assessment protocol:

(1) Auditory perceptual assessment (APA) of speech: a-Nasality:type and degree. b-Consonant precision. c-Compansatory articulatory mechanism (glottal & pharyngeal). d-Audible nasal escape of air. e-Overall inteligibility of speech. All these elements are graded along a five point scale in which 0=normal 4= severe affection.

(2)Visual assessment of the vocal tract: Using the simple clinical examination tools, a detailed comment on the status of: , dention and bite, alveolus, hard palate,soft palate (length and mobility), lateral and posterior pharyngeal wall mobility, tonsil size, size and mobility, the persence of adenoid, middle and inferior nasal turbinate hypertrophy, nasal septum deviation, tympanic membrane mobility or other abnomalities.

(3)Simple clinical tests: done to detect both hypernasality and nasal emission during speech:

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a-Gutzman’s test /a/- /e/ test b-Czermak’s (cold mirror) test

(4)Documentation of (APA) by high fedility audiorecording: A National RX-CW 55F sterio Cassette recorder is used. Patients are asked to count from 1 to 20 and/or recite a prayer (children are asked to repeat after the examiner). The recorded materials are subjected for analysis by a single phoniatrician. This scoring session is done after randomization of the recorded samples before and after surgery.

(5)Documentation of visual assessment by nasopharyngeal vedio recording: a Machiad ENT P III nasofiberscope with distal end diameter of 3 mm, a COMEG 2070 videoacmera and a Panasonic AG 5700 video recorder are used. The velopharyngeal valve movement is recorded while the subject is repeating the word /ambar/ and the vowels /a/,/i/,and/u/. Movement of the velum and lateral and posterior pharyngeal wall are traced on the monitor. The movement of each component is given a score (0-4) as follows: 0= resting () position, 2=half the distance to the corresponding wall and 4= the maximum movement reaching and touching the opposite wall. The shape of the closed VP port whether coronal, sagittal, circualr or others is specified. The presence or absence of both adenoid masses or Passavant’s ridge is detected. Prints are produced by a Panasonic NV-MPI video printer.

(6)Acoustic “nasometric” Analysis: the Kay nasometer model 6200-2 with a soft ware version 1.5 is used. The Pick-up microphone/ separator device of the Nasometer is fitted at the subject’s face by the face mask provided. The subject is asked to repeat the following speech samples using his/her normal conversational loudness: as an oral sentence devoid علي راح يلعب كورة/ab korah؟ali ra:h iel؟/- of nasal sounds. .as a nasal-loaded sentenceماما بتنيم منال /mama betnaim manal- Both the mean and standard deviation of the nasalance score (which is the percentage ratio of nasal plus oral acoustic energy) are calculated for the previous sentences.

Surgical procedure:

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1-Cuffed orotracheal intubation is carried out and a Dingmann mouth gag is inserted.

2-The soft palate is divided in the midline using scalpel blade No11 transecting the palatal and nasal layers as well as the musculature.

3-A musculomucosal flap is raised, based superiorly, including the posterior pharyngeal wall mucosa and the underlying constrictor muscle till the white prevertebral fascia. The two vertical incisions are made just medial to the junction of the lateral and posterior pharyngeal walls and the transverse one is made in a V shaped manner with its tip directed caudally. Flap elevation is done by blunt and sharp dissection starting caudally taking care not to damage the base of the flap (fig. 2).

4-Two mucoasl flaps are elevated from the nasal mucosa of the soft palate (fig. 3) for lining by making a transverse incision of the nasal mucosa and based on the posterior margin of the soft palate for lining by making a transverse incision of the nasal mucosa and based on the posterior margin of the soft palate.

5-Two cathetrs (14 French) are passed from the nose down to the oropharynx to produce lateral ports.

6-The flap is sutured into the fringes of the nasal mucosa left anterior to the lining flaps as laterally as possible snugly around the cathetrs. Additional finer sutures are used to fix the flap into the intire width of the palate.

7-The two lining flaps are rotated over the raw surface of the pharyngeal flap.

8-The soft palate is closed in two layers.

9-The flap donor site is left to heal by secondary intention.

Post operative care:

The patient is maintained on intravenous fluids for the first 24 hours. The two cathetrs are removed 24-48 hours after the operation. Fluids can be taken orally in the next morning and a soft diet is ordered in the first three weeks. A combination of

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amoxycillin and flucloxacillin is used for five days as well as a suitable analgesic accodring to the needs. After one month patients are scheduled for phoniatric post operative assessment and speech therapy.

RESULTS

From the surgical poin of view, slight difficulty was found in young patients below six years of age. Lining of the falp could not be done in the two patients who developed their VPI after UPPP and partial palatal resection because of marked fibrosis and tissue dificeincy respectively.

Nine patients developed transient fluid regurge from the nose in the first four days that disappeared after that. All the pateints reported that improved within three months but did not disappear completely. The donor site showed complete healing within three weeks. None of the patients developed palatal fistula or obstructive apnea.

From the phoniatric point of view, table (2) summerizes the results of auditory perceptual assessment (APA) and acoustic Nasometric measures. Only APA type and degree of nasality were indicated for simplification. Other APA measures are mainly indices for “severity” of hypernasality (audible nasal air emission, imprercision of the consonants and faulty compansatory articulation).

Postoperative acoustic Nasomertic results were only statistically significant for the oral sentence (p=0.001, t=4.67).

Vedionasoendoscopic findings: fifteen subjects revealed a velar movement of grade 3, three with grade 2 and the last two showed grade 0 ( the cases of palatal paralysis). Most subjects (16 pateints) had lateral pharyngeal movement of grade 2, while four subjects showed gdae 1 mobility. Velopharyngeal gap shape was irregular in most of them (17 patients) due to the presence of variably enlarged adenoid tissue (11 cases), and/or submucous cleft (4 cases) ,surgical defects (2 cases). Only three subjects had circular shape of gap.

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Postoperatively with change of the gap shapes into two separate lateral samll gaps, complete closure of these gaps by the lateral pharyngeal walls have been recorded (fig. 4&5).

DISCUSSION

To improve velopharyngeal competence surgically, procedures that obturate the middle of the velopharyngeal area or the lateral portion of the velopharynx can be used. With the increase of the objective, quantitative preoprative data particularely those gained from direct viewing of the pattern of the sphincter closure defect, it is possible to approach the problem of treatment choice more rationally.

The range of defects of sphincter clousure may include: 1-A central defect with good palatal and lateral wall movements. 2-A transverse, slit like defect in the sphincter with weak lateral wall component and falp like action of the palate. 3-Poor palatal movement with satisfactory lateral pharyngeal wall movement. 4-Asymetric gaps 5-Gross failure of all elements of the sphincter.

Techniques for correcting VPI include palatal legthening (David and Bagnall,1990), augmentation of the posterior pharygeal wall (Freidman et al.,1992 and Kamel et al.,1998), sphincter reconstruction (Ortichochea,1968) and pharyngeal flaps(Witsell et al.,1994).

The palatal lengthening proceduers can produce retrodispalcement and lengthening of the soft palate but can be used only in patients with VPI due to palatal clefts when primary palate closure failed to achieve sufficient palate legnth for competence and not for other VPI cases. These proceduers are advised to be used as a secondary operation (Dorance 1930).

The second surgical procedures to correct VPI are those that simply bring the posterior pharyngeal wall forward namely augmentation of the posterior pharyngeal wall. Such a concept appears to be appealing in many patients and seems theoritically to receive more attention becaues of its simplicity, lower risk of producing hyponasality and airway obstruction and because most patients with VPI have relatively good palatal movements (Gray

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and Zimmermann 1996). Various materials have been used either by injection such as teflon (Ward 1968) or implantation such as cartilage (Hill and Hagert 1968) and fascia (Gray and Zimmermann 1998). Extrusion of the implanted material was common and the level at which it was placed was often ineffective owing to migration. In practice many posterior pharyngeal wall augmentation techniques have failed to meet expectation. In the study of Kamel et al.,1998 none of their patients achieved copmlete closure of the VP valve as seen by the nasofiberscope.

One of the best techniques currently used to augment the posterior pharyngeal wall utilizes a superiorly baesd pharyngeal flap lifted up and buckled to create a ridge across the posterior pharyngeal wall (Gray et al., 1999). In a recent article Ahmed ,2002 stated that such buckles have the drawback of inconsistant closure of large velopharyngeal gaps and may require some ancillary procedures.

One of the most popularly used pharyngeal techniques is the Jackson modification of the Orticochea pharyngoplasty. In such techniques the posterior tonsillar pillars are used as donor flaps and sutured either across a transverse incision higher in the nasopharynx (Jackson 1983), or by raising a small inferior pharyngeal flap (Orticochea 1968).

Sphincter pharyngoplasty seems to be a good choice only for patients with good velar motion, significant augmentation of the posterior pharyngeal wall and poor lateral wall movement (Gray and Zimmermann1998). Again the need for a possible is another drawback. Of course the procedure can’t be done in an injured or scarred palatopharyngeal muscle from a previous tonsillectomy. This procedure awaites long term assessment of its efficasy compared with the pharyngeal flap techniques (David and Bagnall 1990).

Many studies on large population of patients up to 500 reported good results (90%) in effective reduction of hypernasality by pharyngeal flaps (Hirschburg 1983). Such good results are still reported even in long term studies for 10 years. In this procedure , a musculomucosal flap is lefted up from the posterior pharyngeal wall based superiorly or inferiorly and sutured to palate in the midline thus dividing the VP port into two smaller lateral ports that open during breathing and closed during speech.

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Among its major advantages are its effectiveness in most types of defective sphincter closure and that posterior wall and velar motion are unimportant when choosing this procedure. Despite the small sample in this study nasofiberoscopy showed competnt closure of VP sphincter in all patients (fig. 4&5).

Pharyngeal flaps have been criticised to cause tethering of the palate. In order to avoid this, the present study utilized the superiorly based flap. Airway obstruction is another problem currently related to pharyngeal flaps. Utilising the technique of lateral port in this study seemed to adequately avoid such complication. Although all patients snored postoperatively, yet snoring improved, but never disappeared, after tissue oedema subsided and none of the patients developed obstructive sleep apnea.

Four points are of importance from the surgical point of view; the width of the flap, its vertical placement, using the lateral port technique and lining of the flap.

The width of the flap and its vertical placement should be decided on the basis of preoperative videoendoscopy. However in this study the maximal width was used because all patients showed big gap. It’s usually advisable to elevate the flap a little highre than the level of the least “gap” seen on the endoscopic recording.

Inserting two 14 French cathetrs is essential to ascertain formation of two lateral ports for breathing to avoid the problems of postoperative airway narrowing. These tubes were removed 24- 48 hours later.

Lining will maintain the falp width and hence its effectiveness in competent closure of the VP defect that explains the long term results obtained by the procedure. Although lining could’t be done in two patients in whome the VPI followed UPPP and partial palatal resection, yet they fourtunately showed the best speech intelligibility resuts. This was because they had componsating lateral wall movements and because they didn’t suffer much from faulty componsatory articulation mechanisms.

All the patients in this study were suffering from moderate to severe VPI that failed speech therapy. All patients showed

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improved nasality and disappearance of the regurge. However they showed contiually improving overall speech intelligibility with postoperative speech therapy a point of importance in counselling the patients and their parents about the results of surgery.

Tables and figures: Table 1: Data of patints with VPI in the study

No of Age Cause Persenting symptoms cases 9 5-13 y Cleft palate (repaired) Hypernasality and regurge 4 5-50 y Submucous cleft Hypernasality and regurge 3 5-8 y Congenital VP Hypernasality disproportion 2 20-25 y Palatal paralysis Hypernasality and regurge 2 25-43 y Post-surgical* Hypernasality and regurge * The post surgical VPI developed after uvulopalatopharyngoplasty UPPP in one patient (fig.1) and partial palatal resection for a benign palatal tumour in another patient.

Table ( 2 ) : Summary of perceptual and acoustic nasometric results pre – and post-operatively.

No of APA degree and type Mean nasalance scores (%) subjects (*) of nasality Oral sent. Nasal sent. Pre - Post- Pre- Post- Pre- Post- 5 2 (open)* 1: 3open 45.8 39.1 63.7 59.1 2 mixed)* 13 3(open)* 2(open)* 53.6 41.2 66.8 62.3 2 4(mixed)* 2(mixed)* 62.6 31.5 65.9 63.7

Fig.1: Peroperative phtograp of a patient with VPI after UPPP

Fig.2: Intraoperative photograph showing the pharyngeal flap after its elevation (hold by the forceps) after transecting the soft palate in the midline (hold by two sutures)

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Fig.3: Intraoperative photograph showing one of the lining mucosal flaps (hold by the forceps)

Fig.4: Fiberoptic nasopharyngoscopic photograph of a patient with VPI showing: (a) the VP gap preoperatively (b) two months postoperaively during rest with change of the gap into two small lateral ports (c) during ambar/. Notice almost closure by the active؟ عنبر/ uttering the word movements of both lateral pharyngeal walls.

Fig.5: Fiberoptic nasopharyngoscopic photograph of a patient with VPI caused by submucous cleft showing: (a) the irregular VP gap preoperatively (b) two months postoperaively during rest with change of the gap into two small lateral ports (c) during uttering the word /ambar/. Notice almost closure by the active movements of both lateral pharyngeal walls and velum.

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REFERENCES 1-Ahmed MH 2002: Surgiacl treatment of post-adeoidectomy velopharyngeal insufficeincy. Egypt J Otolaryngol 19 (1) 49-52

2-David JD and Bagnall AD 1990: Velopharyngeal incompetence. In: Plastic Surgery. Vol (4). Editor: McArtthy JS. WB Saunders Company 2903-2921

3-Dorance GM 1930: Congenital insufficiency of the palate. Arch Sirg 21:185-190

4-Friedmann HI, Hains PC, Coston GN, Lett ED and Edgerton MT 1992: Augmentation of the failed pharyngeal flap. Plast Reconstr Surg 90 (2): 314-318

5-Gray SP and Zimmermann JP1996: Diagnosis and treatment of velopharyngeal incompetence. Facial Plast Surg Clin North Am 4: 233-241 .

6-Gray SP and Zimmermann JP1998: Velopharyngeal incompetence. In: Otolaryngology- Head and Neck Surgery. Vol (5). Third edition. Editors; Cummings CW et al., Mosby 174-187

7- Gray SP, Zimmermann JP and Catten M 1999: Posterior wall augmentaion for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 121 (1): 107-112

8-Hill HJ, Hagerty RF 1996: Efficacy of pharyngoplasty for speech improvement in postoperative cleft . Cleft Palate Bull 10: 66- 74

9-Hirschberg J 1983: Pediatric otolaryngological relations of velophayngeal insufficiency. Int J Pediatr Otorhinolaryngol 5: 199- 203.

10-Jackson I 1983: Discussion: A review of 236 cleft palate patients treated with dynamic muscle sphincter. Plast Reconstr Surg 71: 187

11-Kamel AH, Abdel Haleem EK and Abdel Razek MA 1998: Assessment of posterior pharyngeal wall augmentation in cases of velopharyngeal insufficiency by conchal cartilage graft. Assuit Med J 22 (3): 167-178

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12-Kotby, MN, Abdel Haleem EK, Hegazi MA, Safe I and Zaki M 1993: Validity of some diagnostic procedures of velopharyngeal incompetence. Poceedings of XV World Congress of Oral and Head nad Neck Surgery. Istanpol, Turkey.

13-Miyazaki T1989: Commentary on the use of vedionasoendoscopy for biofeedback therapy in adults after pharyngeal flap surgery.Cleft Palate Craniofac J 26: 136

14-Orticochea 1968: Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg 41: 323-330

15-Ward PH 1968: Uses of injectable Teflon in otolaryngology. Arch Otolaryngol 87:637-641

16-Witsell DL, Drake AF and Warren DW 1994: Preliminary data on effect of pharyngeal flaps on the upper airway in children with velopharyngeal inadequacy. Laryngoscope 104: 12-15.

الملخص العربى تصحيح القصور اللهائى البلعومى باستخدام رقعة مغطاة من الجدار الخلفى للبلعوم عالء كامل عبد الحميم* ـ عماد كامل عبد الحميم** قسم األنف واألذن والحنجرة* - وحدة التخاطب بقسم األنف واألذن والحنجرة ** ------فى هذا البحث استخدمت الرقعة المغطاة من الجدار الخمفى لمبمعوم فى تصحيح القصور المهائى البمعومى لعشرين من المرضى المذين يعانون من قصور فى الصمام المهائى البمعومى بعد فشل العالج بجمسات التأهيل التخاطبى. تم تشخيص وتسجيل جميع المرضى بوحدة أمراضالتخاطب بقسم األنف واألذن والحنجرة بمستشفى أسيوط الجامعى ثم أعيدوا بعد شهر من الجراحةالتى أجريت بقسم األنف واألذن والحنجرة بمستشفى أسيوط الجامعى الستئناف جمسات التأهيل التخاطبى. تحسنت درجة الخنف بشكل ممحوظ بعد نجاح الرقعة فى إغالق التسيب فى الصمام كما ظهر ذلك فى التسجيل باستخدام المنظار األنفى البمعومى ذو األلياف الضوئية.

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