Original Article - Evaluative study

Postoperative evaluation of the folded pharyngeal flap operation for cleft patients with velopharyngeal insufficiency

Access this article online Hidemi Yoshimasu, Yutaka Sato1, Takashi Mishimagi1, Akihide Negishi2 Website: www.amsjournal.com Department of Oral Care for Systemic Health Support, Graduate School, Tokyo Medical and Dental University, DOI: 1Department of Maxillofacial Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 10.4103/2231-0746.161066 2Department of Stomatology and Oral Surgery, Graduate School of Medicine, Gunma University, Quick Response Code: Gunma, Japan

Address for correspondence: Prof. Yutaka Sato, Department of Maxillofacial Surgery, Graduate School, Tokyo Medical and Dental University, 1‑5‑45, Yushima, Bunkyo‑ku, Tokyo 113‑8549, Japan. E‑mail: [email protected]

ABSTRACT

Background: Velopharyngeal function is very important for patients with cleft palate to acquire good speech. For patients with velopharyngeal insufficiency, prosthetic speech appliances and speech therapy are applied first, and then pharyngeal flap surgery to improve velopharyngeal function is performed in our hospital. The folded pharyngeal flap operation was first reported by Isshiki and Morimoto in 1975. We usually use a modification of the original method.Purpose: The purpose of this research was to introduce our method of the folded pharyngeal flap operation and report the results.Materials and Methods: The folded pharyngeal flap operation was performed for 110 patients with velopharyngeal insufficiency from 1982 to 2010. Of these, the 97 whose postoperative speech function was evaluated are reported. The cases included 61 males and 36 females, ranging in age from 7 to 50 years. The time from surgery to speech assessment ranged from 5 months to 6 years. In order to evaluate preoperative velopharyngeal function, assessment of speech by a trained speech pathologist, nasopharyngoscopy, and cephalometric radiography with contrast media were performed before surgery, and then the appropriate surgery was selected and performed. Postoperative velopharyngeal function was assessed by a trained speech pathologist. Results: Of the 97 patients who underwent the folded pharyngeal flap operation, 85 (87.6%) showed velopharyngeal competence, 8 (8.2%) showed marginal velopharyngeal incompetence, and only 2 (2.1%) showed velopharyngeal incompetence; in 2 cases (2.1%), hyponasality was present. Approximately 95% of patients showed improved velopharyngeal function. Conclusions: The folded pharyngeal flap operation based on appropriate preoperative assessment has been shown to be an effective method for the treatment of cleft palate patients with velopharyngeal insufficiency.

Keywords: Cleft palate, folded pharyngeal flap operation, velopharyngeal insufficiency

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows INTRODUCTION others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Velopharyngeal function is very important for patients For reprints contact: [email protected] with cleft palate to acquire good speech. Approximately 90% of patients after primary showed good velopharyngeal function in our hospital. For patients with Cite this article as: Yoshimasu H, Sato Y, Mishimagi T, Negishi A. velopharyngeal insufficiency, a speech appliance is applied, Postoperative evaluation of the folded pharyngeal flap operation for cleft and speech therapy is performed first, followed by a palate patients with velopharyngeal insufficiency. Ann Maxillofac Surg 2015;5:62-6. pharyngeal flap operation to improve velopharyngeal function.

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The purpose of this paper was to report our method for the folded in a cephalometric radiograph taken during phonation of "i" pharyngeal flap (FPF) operation and its results. [Figure 3]. The type of FPF was selected based on Table 2. Type I was performed in three patients, type II was performed in 45, and Operative technique type III was performed in 36, while the FPF with palatal push back The FPF operation was first reported by Isshiki and Morimoto[1] in operation (PB) was performed in 13 [Table 3]. 1975. Later, Hiramoto et al. reported its modification,[2] and we also reported its modification for patients with severe velopharyngeal Postoperative velopharyngeal function was assessed by a trained insufficiency.[3] We usually use modifications of the original speech pathologist. method. Our operative technique is as follows [Figures 1 and 2]. The incisions are placed on the posterior pharyngeal wall, and RESULTS the superior‑based flap is elevated following splitting of the in the middle. The flap is folded with the mucosa outside. Of the 97 patients who underwent the FPF operation, 85 (87.6%) The mucosa on the ridge of the flap is denuded for attachment of showed velopharyngeal competence, 8 (8.2%) showed marginal the flap to the soft palate. Incisions are made in the nasal mucosa velopharyngeal incompetence, and only 2 (2.1%) showed of the soft palate. In the case of a very short palate or in the case of velopharyngeal incompetence; hyponasality was present in poor mobility of the soft palate and pharyngeal walls, the incisions 2 cases (2.1%). Approximately 95% of the patients showed are extended toward the flap base [type III in Figure 2]. Sutures improved velopharyngeal function [Table 4]. are placed between the flap and the soft palate from the lateral side to the medial side. In severe cases, sutures are placed around With regard to the types of FPF used, 44 (91.7%) of 48 cases a 5 mm diameter suction tube. Finally, the soft palate is sutured. of types I and II, 30 (83.3%) of 36 cases of type III, and 11 (84.6%) of 13 cases of the PB + FPF showed velopharyngeal MATERIALS AND METHODS competence [Table 5]. The FPF operation was performed for 110 patients with With regard to the age of operation, 48 (88.9%) of velopharyngeal insufficiency from 1982 to 2010. Of these, 97 patients who underwent postoperative speech function 54 cases <20 years old (mean age 13.1 ± 3.7 years) showed evaluations were analyzed and reported [Table 1]. The cases velopharyngeal competence postoperatively, and 37 (86.0%) of included 61 males and 36 females, ranging in age from 7 to 43 cases 20 years old and older (mean age 29.3 ± 8.9 years) 50 years (mean 20.3 ± 10.4 years). The time from surgery to showed velopharyngeal competence postoperatively [Table 6]. speech assessment ranged from 5 months to 6 years. With regard to preoperative treatment by prosthetic speech In order to evaluate preoperative velopharyngeal function, appliances, 15 (88.2%) of 17 cases with an appliance with assessment of speech by a trained speech pathologist, velopharyngeal competence preoperatively showed velopharyngeal nasopharyngoscopy, and cephalometric radiography with competence postoperatively, while 10 (76.9%) of 13 cases with contrast media were performed before surgery. For evaluation an appliance with velopharyngeal insufficiency preoperatively of velopharyngeal function, a test battery proposed by the showed velopharyngeal competence postoperatively [Table 7]. Committee on Cleft Palate Speech of the Japan Society of Logopedics and Phoniatrics,[4] was used. The distance between the With regard to complications, was reported in eight cases, soft palate and the posterior pharyngeal wall was also measured a feeling of nasal obstruction was reported in five, earache was

a b c d

e f g h Figure 1: Folded pharyngeal flap operation technique. (a) Incision. (b) The soft palate is split in the midline. (c) The flap is folded. (d) The mucosa on the ridge of the flap is denuded. (e) Incision of the nasal mucosa. (f) Suture between flap and velum. (g) Suture between flap and velum. (h) Postoperative condition

Annals of Maxillofacial Surgery | January - June 2015 | Volume 5 | Issue 1 63 Yoshimasu, et al.: Postoperative evaluation of the folded pharyngeal flap operation for cleft palate patients

Figure 3: Examination of velopharyngeal function by cephalogram with contrast medium

Table 1: Cleft types in patients undergoing the FPF operation Type of cleft Number of cases Unilateral cleft and palate 36 Bilateral cleft lip and palate 16 Isolated cleft palate 27 Submucous cleft palate 9 Congenital velopharyngeal incompetence 7 Figure 2: Types of folded pharyngeal flap operation Others 2 Total 97 FPF=Folded pharyngeal flap reported in one, and postoperative bleeding occurred in one, but none of these was severe [Table 8]. Table 2: Preoperative assessment of velopharyngeal DISCUSSION function and type of flap used Type of flap V‑P distance Movement of Various methods of pharyngeal flap operation and pharyngoplasty during phonation/i:/ pharyngeal wall [5,1,6-9] have been reported. They are classified as a superior‑based Type I or type II (mm) <10 Good [10] flap, an inferior‑based flap, and others. Schmelzeisen et al. Type II (mm) <10 Poor recommended a superior‑based flap, because it has a more Type III (mm) 10≤ and <15 Good or poor physiologic effect on the velum compared with an inferior‑based Type III+PB (mm) ≤15 Good or poor flap. Wattanawong et al.[11] reported that the inferior‑based V‑P distance=The distance between velar and posterior pharyngeal wall; pharyngeal flap was more effective than the superior‑based PB=Palatal push back operation flap. The FPF is a superior‑based flap. The method for this operation was first reported by Isshiki and Morimoto[1] in 1975, Table 3: Types of FPF operation and number of cases and Hiramoto et al. later reported its modification.[2] We also reported its modification for patients with severe velopharyngeal Types of FPF Number of cases insufficiency.[3] Rogers et al. reported a similar method for children Type I 3 in 2013.[12] Type II 45 Type III 36 Type III+PB 13 The advantages of the FPF include no raw surface in the flap Total 97 and prevention of scar contracture of the flap, because the flap FPF=Folded pharyngeal flap operation; PB=Palatal push back operation is folded. It is also possible to adjust the size of the remaining lateral apertures for each case. The disadvantage is that when a long flap is needed, it may be difficult to make a long enough has a generally less favorable outcome because of habitually [16] flap and fold it; however, only one such case was seen 20 years retained compensations in articulation. In our study, the ago, and a tubed flap was used. No further such cases have been postoperative velopharyngeal function of patients younger seen since then. than 20‑year‑old seemed to be slightly better than that of patients 20 years and older. In our clinic, most patients with With regard to timing of the pharyngeal flap operation, many velopharyngeal insufficiency use a speech appliance and studies reported that postoperative velopharyngeal function undergo speech therapy before the pharyngeal flap operation. was better in young patients than in adult patients.[13-15] It has Yamashita et al.[17] and Fukuda et al.[18] reported that a speech been assumed that the pharyngeal flap operation in adults appliance was effective for improvement of velopharyngeal

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Table 4: Postoperative velopharyngeal function For young children <10 years old who show velopharyngeal insufficiency after a primary palatoplasty, we try prosthetic speech Velopharyngeal Function Number of cases (%) appliances before secondary surgery because there are some Competence 85 (87.6) reports that 10–40% of cases treated by speech appliances could Marginal competence 8 (8.2) have them removed without secondary surgeries.[17,18] Incompetence 2 (2.1) Hyponasality 2 (2.1) Total 97 (100.0) We usually use cephalometric radiography with contrast media to measure V‑P distance during pronunciation of "i" before surgery.[19] We use this measurement to decide the type of FPF Table 5: Operative approach and postoperative to use and the length of the flap. velopharyngeal function Velopharyngeal No. of cases With regard to complications, desaturation, hemorrhage, infection, function Type I or II Type III PB + FPF , flap separation, persistent significant nasal obstruction, snoring, etc. are reported.[16,14,20] In the present cases, Competence 44 (91.7%) 30 (83.3%) 11 (84.6%) Marginal competence 2 (4.2%) 4 (11.1%) 2 (15.4%) snoring, a feeling of nasal obstruction, earache, and postoperative Incompetence 2 (4.2%) 0 0 bleeding were observed, but they were not severe. Hyponasality 0 2 (5.6%) 0 Total 48 36 13 We propose that the FPF operation be used in patients at the age of about 10 years, and that patients with velopharyngeal insufficiency use a speech appliance prior to surgery. These Table 6: Postoperative velopharyngeal function by age at guidelines were adopted for several reasons. First, approximately operation 10–40% of patients treated by a speech appliance showed Velopharyngeal Number of cases improved velopharyngeal function and velopharyngeal Function <20 years 20 years and more competence without the appliance and additional surgery a few Competence 48 (88.9) 37 (86.0) years after this treatment. Second, we can examine and assess Marginal competence 4 (7.4) 4 (9.3) a patient’s velopharyngeal function by nasopharyngoscopy Incompetence 1 (1.85) 1 (2.3) and other methods before surgery. Third, postoperative care Hyponasality 1 (1.85) 1 (2.3) is straightforward with this approach. Finally, a few patients Total 54 (100) 43 (100) under the age of 6 years who underwent pharyngeal flap surgery reportedly suffered from sleep apnea following surgery.[16,21] Table 7: Postoperative velopharyngeal function by preoperative treatment with speech appliances CONCLUSION Velopharyngeal Good VPC with SA Poor VPC with SA The results of the present research demonstrate that the FPF Function operation based on appropriate preoperative assessment is an Competence 15 10 effective method for the treatment of cleft palate patients with Marginal competence 1 2 velopharyngeal insufficiency. Incompetence 1 0 Hyponasality 0 1 Total 17 13 Acknowledgments VPC=Velopharyngeal competence; SA=Speech assessment The authors would like to thank Ms. Ayako Ohira and Ms. Michiko Mibu of the Speech Clinic, Tokyo Medical and Dental University Dental Hospital. Table 8: Complications Complications Number of cases Financial support and sponsorship Snoring 8 Nil. Feeling of nasal obstruction 5 Postoperative bleeding 1 Conflicts of interest Earache 1 There are no conflict of interest. incompetence and hypernasality. Therefore, we think that REFERENCES our adult patients could acquire good speech results soon after the operation. According to the present data, cases with 1. Cole P, Banerji S, Hollier L, Stal S. Two hundred twenty‑two consecutive good velopharyngeal function with speech appliances showed pharyngeal flaps: An analysis of postoperative complications. J Oral better results than cases with poor velopharyngeal function Maxillofac Surg 2008;66:745‑8. with speech appliances preoperatively. Therefore, cases with 2. Fukuda T, Wada K, Tachimura T, Tanimoto K. Effects of speech appliance for improvement of velopharyngeal incompetence and hypernasality. poor velopharyngeal function with speech appliances should J Jpn Cleft Palate Assoc 1998;23:75‑82. undergo a more active method, such as type III. Application of 3. Fukushiro AP, Trindade IE. Nasometric and aerodynamic outcome speech appliances to patients will give us useful information analysis of pharyngeal flap surgery for the management of velopharyngeal for selecting the operative approach. insufficiency. J Craniofac Surg 2011;22:1647‑51.

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