Simultaneous Posterior Pharyngeal Flap and Tonsillectomy

Davin B. ReaAtH, M.D. Donato LaRossaA, M.D. PETER RANDALL, M.D.

Posterior pharyngeal flap (PPF) construction in patients with hyper- trophied raises a significant concern for adequate airway main- tenance. Most often, tonsillectomy, as a separate procedure, is done first. The authors have preferred to do both the PPF and the tonsillec- tomy simultaneously. Twenty consecutive cases are reviewed retrospectively to determine whether this has increased morbidity. All patients underwent posterior pharyngeal flaps for correction of velopharyngeal incompetence (VPI). Postoperative fevers that resolved without specific treatment occurred in four patients. Three patients ex- perienced postoperative problems, but only two were of ton- sillar origin. No patient developed immediate , although a single patient was observed overnight in the intensive care unit. Another developed several months after the opera- tion, which required that the posterior pharyngeal flap be taken down. This patient had an unusual amount of hypertrophic in the nasopharyngeal area, but not in the oropharynx. No other operative or postoperative complications were experienced. The average hospitali- zation was 4.2 days. It is concluded that simultaneous tonsillectomy and PPF construc- tion may be performed safely in patients who need both procedures.

The posterior pharyngeal flap operation was procedure. However, it has been the preference first proposed and performed by Schoenberg in of the authors to perform both operations simul- 1875 (Trier, 1986). Since that time, it has at- taneously. The question arises as to whether a tained critical importance in the treatment of combined procedure can be performed safely, velopharyngeal incompetence. The key concern for these patients in the immediate postoperative period is the maintenance of an adequate upper airway (Millard, 1980). By the nature of its de- sign, the flap obstructs the central portion of the pharyngeal airway. In patients with hyper- trophied tonsils (Fig. 1), construction of such a flap may seriously compromise the airway if a tonsillectomy is not also performed. This was the case in a previously reported patient who deve- loped upper airway obstruction immediately fol- lowing a posterior pharyngeal flap (Graham et al, 1973). Although we were prepared to per- form a tracheostomy in this child, a tonsillecto- my alone relieved the airway obstruction. Frequently, tonsillectomy is performed prior to the posterior pharyngeal flap as a separate

The authors are affiliated with the Division of Plastic Sur- gery at The University of Pennsylvania School of Medicine FIGURE 1 Hypertrophied tonsils partially obstructing the and The Cleft Clinic at The Children's Hospital of airway of a child about to undergo posterior pharyngeal flap Philadelphia, Philadelphia, PA. construction. 250

Reath et al, SIMULTANEOUS PPF AND TONSILLECTOMY 251

TABLE 1 Palatal Pathology of Patients Undergoing Simultaneous Posterior Pharyngeal Flap Operation and Ton- sillectomy _

Patients Palatal Pathology (N) _

Soft palate cleft Submucous cleft Noncleft palate

without increasing the incidence of perioperative sillectomy was not appreciated until the time of complications. The present study was undertaken the posterior pharyngeal flap operation. No to address this question. problems were encountered from the intraoper- ative decision to proceed with tonsillectomy. The operation was done after discussion with the RESULTS parent. ' Charts of patients treated through the Cleft Pa- The majority of flaps were wide and based su- late Clinic of The Children's Hospital of periorly. However, in three cases, inferiorly Philadelphia were reviewed retrospectively. based flaps were lined with palatal mucosa. The Since 1972, 20 patients have undergone simul- tonsillar beds were not sutured closed. Some pa- taneous tonsillectomy and posterior pharyngeal tients had a 3-0 or 4-0 chromic catgut ligature flap operation. At the time of operation, their or suture ligature of the inferior tonsillar vessels. ages ranged from 2 to 16 years with a median The donor site for the posterior pharyngeal flap age of 5 years. was routinely closed. "Lateral port control"" All patients were being treated for velopharyn- (Hogan, 1973) was not used. geal incompetence, which was evidenced by the Most patients also underwent additional proce- presence of hypernasality or nasal escape. Six- dures at the time of operation (Table 2). Place- teen patients had both hypernasality and nasal es- ment of myringotomy tubes, closure of palatal cape as noted by the speech pathologist. Two fistulas ("'palatal surgery"), and nasal surgery patients had just nasal escape. One patient had were the most common additional procedures. severe hoarseness with radiologic evidence of Four patients did not have additional procedures. velopharyngeal incompetence. One patient had Although no intraoperative complications were a severe congenitally short palate with poor mo- encountered, eight patients had postoperative tion in the palate and inability to impound air complications (Table 3). Four patients developed orally at the age of 2 years. fevers during the first 48 hours following oper- The majority of patients had clefts of the soft ation, which resolved without treatment prior to palate (Table 1). A submucous cleft was diag- their discharge. nosed in one patient. The remainder had non- Upper airway problems were encountered in cleft , which were either congenitally short two patients. Because of the possibility of par- or moved abnormally and inadequately (con- tial airway obstruction, one child was observed firmed by radiography). All clefts had in the intensive care unit overnight but required been closed primarily by 18 months of age. no other treatment. The other child developed Tonsillectomies were uniformly performed be- partial upper airway obstruction presenting as cause of concern about possible airway com- sleep apnea several months postoperatively promise. This was planned preoperatively in 13 secondary to a most unusual and intense hyper- patients. In the other seven, the need for ton- trophic scarring of the palate and nasopharynx. -

TABLE 2 Additional Procedures Done at the Time of Simultaneous Pharyngeal Flap Operation and Tonsillectomy Patients Additional Procedures (N)

Myringotomy tubes 1 -

Palatal surgery O

Nasal surgery Ui

Teeth extraction to

Other w

252 Cleft Palate Journal, July 1987, Vol. 24 No. 3

TABLE 3 Postoperative Complications After Simultaneous Pharyngeal Flap Operation and Tonsillectomy

Postoperative Patients Complications (N)

Fever 4 Bleeding 3 Airway problems 2

This did not appear to be precipitated by, or Though multi-view videofluoroscopy and related to, the tonsillectomy. Ultimately, the flap nasendoscopy have improved our diagnostic abili- was taken down, and subsequent nasopharyngeal ties, these were not all available in our clinic 6 dilations were required to maintain this child's to 14 years ago. The occasional case, recently airway. described, where hypertrophic tonsils seem to Three patients developed bleeding complica- contribute to velopharyngeal incompetence, was tions, two of which occurred during the immedi- also not appreciated until the last few years. In ate postoperative period. One of these patients, severe VPI, it seems unlikely that tonsillectomy who also underwent closure of the hard palate, alone would correct the condition, although nasen- required only the transfusion of a single unit of doscopy would be helpful in making this deter- . The other patient was returned to the mination. In our hands, nasendoscopy on 2-, 3-, operating room from the recovery room for con- and 4-year-old children has been almost im- trol of persistent bleeding from the palate. The possible. only case of secondary hemorrhage occurred on No patient suffered airway obstruction in the the tenth postoperative day. This patient required immediate postoperative period that required in- hospital readmission and a suture ligature in one tubation, surgical intervention, or any procedures tonsillar bed. There were no long-term compli- other than observation. The only long-term com- cations from the bleeding in any of these patients. plication resulted from an idiosyncratic type of Average hospitalization was 4.2 days with a hypertrophic scarring, which ultimately did cause range of 3 to 6 days. All patients have been fol- partial airway obstruction requiring the flap to lowed through the Cleft Palate Clinic by both be taken down. This complication appeared to speech pathologist and surgeon to determine the be unrelated to the tonsillectomy. quality of postoperative speech. Normal speech For reasons that are not apparent in this ser- was observed in five patients. Thirteen patients ies, the incidence of bleeding complications was had moderate or marked improvement in their slightly higher than might have been expected speech, with elements of residual, intermittent (Capper, 1984; Carmody, 1982). It is possible nasal escape, hypernasality, or hoarseness. Two that a more complex operation has increased the patients had poor speech and might require fur- incidence of postoperative bleeding more than ther intervention. However, one of these was the might have been anticipated from either proce- patient who required the take down of the flap dure undertaken separately. Alternatively, the because of hypertrophic palatal scarring and par- small sample size may be insufficient to estab- tial airway obstruction. lish accurately the incidence of bleeding com- plications. The anticipated result of this operation is im- DISCUSSION proved speech. All but two patients were able to achieve normal or considerably improved When a posterior pharyngeal flap is required speech once the palate had healed and speech in a patient with significant tonsillar hypertrophy, therapy continued. Thus, it appears that the ad- tonsillectomy should also be performed to avoid dition of a tonsillectomy to the posterior pharyn- upper airway obstruction postoperatively (Ran- geal flap operation does not adversely affect the dall, 1979). Although tonsillectomy performed primary purpose of improved speech. first, as a separate procedure, is preferred by Additionally, deciding to perform tonsillecto- most surgeons, simultaneous tonsillectomy and my intraoperatively (with appropriate parental a posterior pharyngeal flap have the advantage permission) did not substantially complicate the of requiring a single hospitalization and a single operation. anesthetic. In addition to simplifying patient care, this lessens the potential for anesthesia-related CONCLUSION complications. It appears that a combined proce- dure may be carried out without a serious in- A tonsillectomy should be performed in pa- crease in the postoperative complications. tients requiring a posterior pharyngeal flap, when Reath et al, sImMULIANEOUs PPF AND ToNsILLEctomMy 253 significant tonsillar hypertrophy exists, in order CARMODY D, VamapEvaAn T, CooPErR SM. Post tonsillecto- to avoid airway obstruction in the immediate my hemorrhage. J Laryngol Otol 1982; 96:635. postoperative period. Both procedures may be GRAHAM WP, HamIToN R, RANDALL P, WINCHESTER R, StooL S. Complications following posterior pharyngeal performed simultaneously, safely, and without flap surgery. Cleft Palate J. 1973; 10:176. early or long-term side effects or alterations in HogaAN VM. A clarification of the surgical goals in cleft pa- the ultimate outcome of the patient's speech. The late speech and the introduction of the lateral port control decision to proceed with tonsillectomy need not (L.P.C.) pharyngeal flap. Cleft Palate J 1973; 10:331. MILLARD DR JR. Cleft craft: the evolution of its surgery, Vol be made preoperatively, but can be determined 3. Alveolar and palatal deformities. Boston: Little, Brown, at the time of operation. 1980: 289. RANDALL P. Cleft palate, In: Grabb WC, Smith JW, eds. REFERENCES Plastic surgery. Boston: Little, Brown, 1979:205. TRIER WC. The pharyngeal flap operation. Clin Plast Surg CAPPER WR, RanpaLL C. Postoperative hemorrhage in ton- 1986; 12:697. sillectomy and in children. J Laryngol Otol 1984; 98:363.