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

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.

INTRODUCTION

Velopharyngeal function is very important for patients with cleft palate to acquire good speech. Approximately 90% of patients after primary palatoplasty showed good velopharyngeal function in our hospital. For patients with velopharyngeal insufficiency, a speech appliance is applied, and speech therapy is performed first, followed by a pharyngeal flap operation to improve velopharyngeal function. The purpose of this paper was to report our method for the folded pharyngeal flap (FPF) operation and its results.

Operative technique

The FPF operation was first reported by Isshiki and Morimoto[1] in 1975. Later, Hiramoto et al. reported its modification,[2] and we also reported its modification for patients with severe velopharyngeal insufficiency.[3] We usually use modifications of the original method. Our operative technique is as follows [Figures 1 and 2]. The incisions are placed on the posterior pharyngeal wall, and the superior-based flap is elevated following splitting of the soft palate in the middle. The flap is folded with the mucosa outside. The mucosa on the ridge of the flap is denuded for attachment of the flap to the soft palate. Incisions are made in the nasal mucosa of the soft palate. In the case of a very short palate or in the case of poor mobility of the soft palate and pharyngeal walls, the incisions are extended toward the flap base [type III in Figure 2]. Sutures are placed between the flap and the soft palate from the lateral side to the medial side. In severe cases, sutures are placed around a 5 mm diameter suction tube. Finally, the soft palate is sutured.

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

Figure 2

Types of folded pharyngeal flap operation

MATERIALS AND METHODS

The FPF operation was performed for 110 patients with velopharyngeal insufficiency from 1982 to 2010. Of these, 97 patients who underwent postoperative speech function evaluations were analyzed and reported [Table 1]. The cases included 61 males and 36 females, ranging in age from 7 to 50 years (mean 20.3 ± 10.4 years). The time from surgery to speech assessment ranged from 5 months to 6 years.

Table 1

Cleft types in patients undergoing the FPF operation

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. For evaluation of velopharyngeal function, a test battery proposed by the Committee on Cleft Palate Speech of the Japan Society of Logopedics and Phoniatrics,[4] was used. The distance between the soft palate and the posterior pharyngeal wall was also measured in a cephalometric radiograph taken during phonation of “i” [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 type III was performed in 36, while the FPF with palatal push back operation (PB) was performed in 13 [Table 3].

Figure 3

Examination of velopharyngeal function by cephalogram with contrast medium

Table 2

Preoperative assessment of velopharyngeal function and type of flap used

Table 3

Types of FPF operation and number of cases

Postoperative velopharyngeal function was assessed by a trained speech pathologist.

RESULTS

Of the 97 patients who underwent the FPF operation, 85 (87.6%) showed velopharyngeal competence, 8 (8.2%) showed marginal velopharyngeal incompetence, and only 2 (2.1%) showed velopharyngeal incompetence; hyponasality was present in 2 cases (2.1%). Approximately 95% of the patients showed improved velopharyngeal function [Table 4].

Table 4

Postoperative velopharyngeal function

With regard to the types of FPF used, 44 (91.7%) of 48 cases 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 competence [Table 5].

Table 5

Operative approach and postoperative velopharyngeal function

With regard to the age of operation, 48 (88.9%) of 54 cases <20 years old (mean age 13.1 ± 3.7 years) showed velopharyngeal competence postoperatively, and 37 (86.0%) of 43 cases 20 years old and older (mean age 29.3 ± 8.9 years) showed velopharyngeal competence postoperatively [Table 6].

Table 6

Postoperative velopharyngeal function by age at operation

With regard to preoperative treatment by prosthetic speech appliances, 15 (88.2%) of 17 cases with an appliance with velopharyngeal competence preoperatively showed velopharyngeal competence postoperatively, while 10 (76.9%) of 13 cases with an appliance with velopharyngeal insufficiency preoperatively showed velopharyngeal competence postoperatively [Table 7].

Table 7

Postoperative velopharyngeal function by preoperative treatment with speech appliances

With regard to complications, snoring was reported in eight cases, a feeling of nasal obstruction was reported in five, earache was reported in one, and postoperative bleeding occurred in one, but none of these was severe [Table 8].

Table 8

Complications

DISCUSSION

Various methods of pharyngeal flap operation and pharyngoplasty have been reported.[516789] They are classified as a superior-based flap, an inferior-based flap, and others. Schmelzeisen et al.[10] recommended a superior-based flap, because it has a more physiologic effect on the velum compared with an inferior-based flap. Wattanawong et al.[11] reported that the inferior-based pharyngeal flap was more effective than the superior-based flap. The FPF is a superior-based flap. The method for this operation was first reported by Isshiki and Morimoto[1] in 1975, and Hiramoto et al. later reported its modification.[2] We also reported its modification for patients with severe velopharyngeal insufficiency.[3] Rogers et al. reported a similar method for children in 2013.[12]

The advantages of the FPF include no raw surface in the flap and prevention of scar contracture of the flap, because the flap 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 flap and fold it; however, only one such case was seen 20 years ago, and a tubed flap was used. No further such cases have been seen since then.

With regard to timing of the pharyngeal flap operation, many studies reported that postoperative velopharyngeal function was better in young patients than in adult patients.[131415] It has been assumed that the pharyngeal flap operation in adults has a generally less favorable outcome because of habitually retained compensations in articulation.[16] In our study, the postoperative velopharyngeal function of patients younger than 20-year-old seemed to be slightly better than that of patients 20 years and older. In our clinic, most patients with velopharyngeal insufficiency use a speech appliance and undergo speech therapy before the pharyngeal flap operation. Yamashita et al.[17] and Fukuda et al.[18] reported that a speech appliance was effective for improvement of velopharyngeal incompetence and hypernasality. Therefore, we think that our adult patients could acquire good speech results soon after the operation. According to the present data, cases with good velopharyngeal function with speech appliances showed better results than cases with poor velopharyngeal function with speech appliances preoperatively. Therefore, cases with poor velopharyngeal function with speech appliances should undergo a more active method, such as type III. Application of speech appliances to patients will give us useful information for selecting the operative approach.

For young children <10 years old who show velopharyngeal insufficiency after a primary palatoplasty, we try prosthetic speech appliances before secondary surgery because there are some reports that 10–40% of cases treated by speech appliances could have them removed without secondary surgeries.[1718]

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 to use and the length of the flap.

With regard to complications, desaturation, hemorrhage, infection, obstructive sleep apnea, flap separation, persistent significant nasal obstruction, snoring, etc. are reported.[161420] In the present cases, snoring, a feeling of nasal obstruction, earache, and postoperative bleeding were observed, but they were not severe.

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 guidelines were adopted for several reasons. First, approximately 10–40% of patients treated by a speech appliance showed improved velopharyngeal function and velopharyngeal competence without the appliance and additional surgery a few years after this treatment. Second, we can examine and assess a patient's velopharyngeal function by nasopharyngoscopy and other methods before surgery. Third, postoperative care is straightforward with this approach. Finally, a few patients under the age of 6 years who underwent pharyngeal flap surgery reportedly suffered from sleep apnea following surgery.[1621]

CONCLUSION

The results of the present research demonstrate that the FPF operation based on appropriate preoperative assessment is an effective method for the treatment of cleft palate patients with velopharyngeal insufficiency.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.