Annals of Pediatric Surgery, Vol 4, No 1,2, January-April, 2008 PP 22-36 Original Article Sphincter Pharyngoplasty: the One Procedure That Fits All Patterns of Closure in Velopharyngeal Insufficiencies* Amir Elbarbary, MD, Hassan Ghandour, MD Plastic & Reconstructive Surgery Department & Phoniatric Unit, ENT Department, Faculty of Medicine, Ain-Shams University Abstract Background/ Purpose: Velopharyngeal insufficiency occurs in a considerable number of patients following cleft palate repair. It disrupts speech intelligibility leading to breakdown of the ability to communicate verbally. Substantial uncertainty occurs in choosing between sphincter pharyngoplasty and pharyngeal flap in restoring the velopharyngeal function. This prospective study aimed to assess the treatment outcome of modified sphincter pharyngoplasty applied to patients with residual velopharyngeal insufficiency following palatal repair regardless of their pattern of velopharyngeal closure. Materials & Methods: Preoperatively, patients underwent in-depth speech and endoscopic evaluations for symptoms of velopharngeal insufficiency. Six to twelve weeks following the surgical procedure they underwent the same thorough evaluation prior to receiving any speech therapy. Speech evaluation was carried out using the protocol of assessment that is applied in the phoniatric unit, Ain-Shams University which included auditory perceptual assessment (APA), nasopharyngeal videofibroscopy and nasometry. Results: Forty three patients were included in this study. Statistical analysis of the results documented a significant reduction in the degree of open nasality, glottal articulation and pharyngalization following a modified sphincter pharyngoplasty. A significant increase in the overall intelligibility was delineated regardless of the pattern of velopharyngeal closure. Postoperatively, velopharyngeal port achieved functional closure in the majority of patients as detected by nasopharyngeal videofibroscopy and was categorized as circular in thirty patients and coronal in thirteen. Conclusion: The results of this study demonstrated that sphincter pharyngoplasty could be applied effectively to patients with velopharyngeal insufficiency following cleft palate repair regardless of their velopharyngeal pattern of closure. Index Word: Velopharyngeal inefficiency, sphincter pharyngoplasty, closure pattern. INTRODUCTION elopharyngeal insufficiency (VPI) refers to produce optimal sphincter-like closure between the V excessive nasal resonance or hypernasality as oro- and nasopharynx.1 It occurs in a substantial the consequence of anatomical abnormalities and number of patients after cleft palate repair2-5 and can failure of the velum and the pharyngeal muscles to be attributed to a variety of factors: scarring as a *Presented at the 22nd annual meeting of Egyptian Pediatric Surgical Association (EPSA) 14-16 December 2006 Correspondence to: Amir Elbarbary, MD, Plastic & Reconstructive Surgery Department, Faculty of Medicine, Ain-Sham University, Phone: + 20 12 228 7582, Email: [email protected] El Barbary & Ghandour result of the initial palatoplasty can shorten the following sphincter pharyngoplasty,27 a number of velum; making it impossible for the velum to reach patients have persistent unacceptable vocal resonance the posterior pharyngeal wall "target" during speech; and residual air escape postoperatively.21,28 Advances a deep nasopharynx relative to the position of the in patient selection and surgical technique to enhance velum; a poor velar movement despite an adequate successful valving of sphincter pharyngoplasty have length resulting from insufficient restoration of the been reported.8,28 palatal muscle sling at the time of primary repair.6 Velopharyngeal insufficiency results in the inability In an attempt to enhance the success of the sphincter of the cleft patients to communicate coherently and is palatoplasty and further improve the outcome, a considered the most disabling and devastating result modified sphincter pharyngoplasty is presented. It among the various secondary problems that may included the elevation of bilateral superiorly based follow cleft lip/palate repair.7 palatopharyngeus muscle with overlying mucosa that are sutured overlapped to each another and to a When surgical management is indicated for transverse incision on the posterior pharyngeal wall restoration of the velopharyngeal function, the at the level of attempted velopharyngeal closure. pharyngeal flap and the sphincter pharyngoplasty are among the most commonly used surgical The aim of this prospective study is to assess the procedures8. Considerable uncertainty of choice exists treatment outcome for patients with residual both within variations of flap and sphincter velopharyngeal insufficiency after palatal repair pharyngoplasty and between the two approaches. undergoing a modified technique of sphincter Authorities such as Riski9 agree that if surgical pharyngoplasty regardless of the pattern of intervention is needed, the procedure should be velopharyngeal closure. tailored to the size and nature of the velopharyngeal defect. However, reports of morbidity and mortality associated with pharyngeal flap surgery10-16 have led PATIENTS AND METHODS a lot of operators to adopt sphincterplasty instead. Several publications have advocated sphincter Patients diagnosed with residual velopharyngeal 17-19 pharyngoplasties citing their additional insufficiency after cleft palate repair presenting to the advantages as (1) technical ease of execution, (2) outpatient cleft palate clinic at Ain-Shams University superior speech results, (3) low complication rate, (4) Hospital from January of 2004 to December of 2006 reduced anaesthesia time, (5) non-obstruction of the had been considered potentially eligible for the study. nasal airway. Similar to other studies,8,29 the patients had to meet The sphincter pharyngoplasty operation is designed the following criteria to qualify for the study: (1) to form a ridge on the posterior pharyngeal wall, undergone a primary repair of the palate (with or narrow the pharynx from side to side, and to produce without a cleft lip or alveolus), (2) chronological age 20 a sphincteric type of closure. The objective of the between 4 and 16 years with apparent VPI diagnosed procedure is to create a muscular valve capable of by an experienced speech specialist, (3) had at least isolating the nasal cavity from the remainder of the 75% of normal language development for their age. vocal tract during appropriate speech tasks. This is Exclusion criteria comprised patients with: (1) size of necessary to eliminate hypernasality and to allow oral the velopharyngeal gap exceeding 2 cm in pressure to build in the oral cavity for the production anteroposterior dimension which necessitated a 21 of many consonant phonemes. Several lengthening procedure, (2) hearing impairment, (3) modifications of sphincter pharyngoplasty have been the cleft being part of a syndrome, (4) any preexisting 22-24 described since it was first introduced by Hynes palatal fistulae, (5) obstructive sleep apnea syndrome. who used superiorly based flaps from the salpingopharyngeus. Orticochea25 used The surgical procedure and study methods were palatopharyngeus instead and sutured them to an carefully explained to all parents. Patients underwent inferiorly based pharyngeal flap to below the palatal in-depth speech and endoscopic evaluations for plane. Jackson & Silverston26 replaced the inferiorly symptoms of velopharyngeal insufficiency. Six to based flap by a superiorly based posterior wall flap in twelve weeks, with a mean of two months, following an attempt to raise the flap insertion and improve the the surgical procedure they underwent the same outcome. Despite the reported high success rate thorough evaluation prior to receiving any speech 23 Vol 4, No 1,2, January-April, 2008 El Barbary & Ghandour therapy if they needed any. Evaluation was carried on a chair) a nasal loaded sentence /mama out using the protocol of assessment that is applied in betnajem mana:l/ and an oral sentence devoid of the phoniatric unit, Ain-Shams University which nasal sounds /ς ali rah jelς ab korah/ according to includes subjective as well as quasi-objective the protocol of assessment of VPI in the phoniatric measures of evaluation30.This protocol includes: unit, Ain-Shams University.30 The nasometer calculates the nasalance which is the ratio of the I- Preliminary Diagnostic Procedures: nasal to the nasal plus oral acoustic energy Auditory Perceptual Assessment (APA) was used multiplied by 100. The degree of hypernasality as a subjective tool for evaluation of patients' depends on the percent nasalance.31 Similar to language, speech and voice through listening to Abyholm et al,8 the nasalance results were reported every patient in a free conversation and a recorded as an overall measure of preoperative and speech sample. Passive and active aspects of postoperative mean changes as opposed to language were investigated including semantic, comparing each patient with the norm. syntactic and pragmatic aspects. Speech evaluation included the type and degree of open nasality, All patients included in the study received a consonant precision, the compensatory articulatory modified sphincter pharyngoplasty regardless of mechanisms (glottal articulation, pharyngealization the pattern of velopharyngeal closure or the of fricatives, and facial grimace), audible nasal air severity of the symptoms. The retractor and tongue escape and