Central Defect-Control Pharyngeal Flap Surgery Based on Nasoendoscopic Assessment and Speech Outcomes Following Surgery

Purpose

The main strategy behind Hogan's lateral port control pharyngeal flap surgery is to change a single central incompetent sphincter to two competent lateral sphincters.¹ The concept of tailoring pharyngeal flaps, introduced in 1972 by Skolnick and McCall, was an improvement on existing techniques in that they varied the dimension and location of flap according to the patients’ velopharyngeal anatomy and lateral pharyngeal wall motion seen on fluoroscopy.² The purpose of this study was to describe a central defect-control pharyngeal flap, as we call it, with varying dimensions determined by preoperative nasoendoscopic findings, and assess surgical outcomes by perceptual speech evaluation and nasometric analysis.

Materials and methods

The authors reviewed medical records of all children who underwent central defect-control pharyngeal flap performed by a single surgeon from May 2008 to January 2014. 74 patients were included. Preoperative nasopharyngeal endoscopy had been performed to make a complete observation of sphincteric movement and central velopharyngeal port during speech. Soft tissue landmarks, different for each patient, had been utilized to determine the dimension of flap.  During surgery, watertight closure was performed at all sites to prevent scar contracture of raw surfaces. Preoperative and postoperative velopharyngeal function was assessed through perceptual speech evaluation and nasometric analysis. The correlation factors of long-term surgical outcome were analyzed.

Results

96.3 % of the patients showed velopharyngeal competency after surgery. No obstructive sleep apnea was seen. Significant improvement was observed in perceptual speech evaluation and nasometric analysis at both short term(6 months) and long term(2 years) follow-up (p<0.001). The preoperative size of velopharyngeal gap, the closure pattern of velopharyngeal sphincter, symmetry of lateral pharyngeal wall, degree of hypernasality, degree of nasal emission, age at surgery, and the etiology of VPI did not correlate with long-term postoperative velopharyngeal function.

Conclusion

The central defect-control pharyngeal flap with emphasis on filling the central velopharyngeal port defect with individually-sized flaps, is highly successful in treating velopharyngeal insufficiency without major complications.  Preoperative nasopharyngoscopy is a valuable tool in determining the size and location of flap.  Individualized design of flap dimension, together with elimination of all raw surfaces during surgery, seems to produce adequate velopharyngeal closure that lasts over time, as demonstrated in the patients' speech evaluation and nasometric analyses.