Summary
There is not one single surgical technique to correct velopharyngeal insufficiency. The surgical approach typically depends on the pattern of the vellopharyngeal closure, its location and size, as well as on the surgeon’s surgical experience. The goal is to achieve the best possible outcome without causing upper airway obstruction and sleep apnea.
41 Surgery for Velopharyngeal Insufficiency
41.1 Introduction
Attaining optimal outcomes and low long-term morbidity in surgical intervention for velopharyngeal insufficiency (VPI), requires the surgeon’s ability to tailor the surgical correction to the specific defect of the child. Various surgical procedures are performed depending on the pathology contributing to VPI. As the pattern of VPI closure impact the surgical type of correction that is planned, recognition of basic closure patterns of the velopharynx is essential. 1
41.2 Patterns of Velopharyngeal Closure
Coronal closure is the most common closure pattern, and is present in 55% of patients with normal velar function. The major contribution to closure is from the soft palate as it contacts a broad area of the posterior pharyngeal wall. Little medial motion of the lateral pharyngeal walls occurs. A coronal closure pattern is often present with an enlarged adenoid pad.
Circular closure is present in approximately 20% of individuals with normal closure. It involves contributions from both the soft palate and the lateral pharyngeal walls. This results in a closure that resembles a circle getting smaller.
Circular closure with the Passavant ridge occurs in 15% to 20% of the population. It is a circular pattern that involves anterior motion of the posterior pharyngeal wall (known as Passavant ridge).
Sagittal closure is the least common pattern, and is present in 10% to 15% of people. Here, palatal elevation is minimal. The main contribution is from medial motion of the lateral pharyngeal walls. This is the pattern seen most commonly in patients with persistent velopharyngeal dysfunction (VPD) after repair of a cleft palate. See ▶ Fig. 41.1 .
41.3 Velopharyngeal Assessment
The assessment of velopharyngeal function is best performed in the setting of a multispecialty team evaluation composed of a speech-language pathologist (SLP), otolaryngologist, prosthodontist, and plastic surgeon. Multiple modalities should be utilized to perform a complete evaluation of the patient. After a thorough review of the patient’s history, the standard workup involves perceptual speech evaluation, followed by video nasoendoscopy (VNE) and multiview speech videofluoroscopy (SVF). 3 , 4
There is considerable variation in the utilization of imaging studies to guide treatment of VPD. Different institutions will preferentially utilize VNE or SVF or other novel imaging modalities; other institutions use both studies for comprehensive evaluation. Lipira et al 5 evaluated the relative benefits of videofluoroscopy versus nasoendoscopy and concluded that both studies were best used in tandem to optimally evaluate patients with VPD.
41.4 Surgical Treatment Options
Patients with a history of previously repaired cleft palate and anatomic findings of VPD are frequently candidates for surgical intervention. Once the decision for surgery has been established, a choice must be made as to which intervention would best fit the needs of the patient. The two most commonly discussed procedures for correction of VPD remain the posterior pharyngeal flap and the sphincter pharyngoplasty. Both procedures aim to decrease the size of the residual velopharyngeal port.
More recently, procedures designed to improve palatal closure have gained increasing popularity. The Furlow palatoplasty and palatal re-repair are two techniques performed to either lengthen the palate or otherwise tighten the levator sling. Some authors have also reported a success with posterior pharyngeal wall augmentation procedures.
Surgical procedures should be tailored to the patient’s specific anatomy, as visualized on VNE and SVF studies. Based upon these studies, a pattern of closure can be determined as well as the size of the defect.
Pharyngeal flaps are designed to bring tissue into the central portion of the velopharynx. Therefore, they are best utilized to correct central gaps (sagittal or circular patterns of closure) where good lateral pharyngeal wall motion is visualized on VNE or SVF in the AP dimension. 6 Sphincter pharyngoplasty, on the other hand, brings in tissue laterally toward the center and appears most useful for lateral defects (coronal and bowtie patterns), especially when lateral wall motion is poor. Furlow palatoplasty has shown success primarily in smaller central gaps, especially in circumstances where evidence exists of diastasis of the levator muscle sling (i.e., midline notch on VNE). Posterior pharyngeal augmentation procedures are similarly utilized for very small residual defects. Little consensus exists in regards to the treatment of large “black hole” deformities, which tend to have the poorest results when reconstruction is attempted. Some have noted success with sphincter pharyngoplasty alone 7 or with wide, nearly obstructing pharyngeal flaps. Others have suggested that results are best when palatal lengthening procedures such as Furlow palatoplasty are performed in conjunction with a sphincter pharyngoplasty. 8
Despite the theories and preferences for reconstruction that have been noted above, little evidence exists suggesting whether pharyngeal flap or sphincter pharyngoplasty is superior to the other. Rather, both procedures appear to have equivalent efficacy when performed by experienced surgeons. 9 , 10
41.5 Surgical Procedures
41.5.1 Superiorly Based Pharyngeal Flap
Indications
Central gaps (sagittal or circular patterns of closure) with good lateral pharyngeal wall motion.
Preparation and Anesthetic Considerations
Adenotonsillar hyperplasia may require adenotonsillectomy before flapplacement to prevent postoperative obstructive apnea. A 4- to 6-week interval for healing should elapse between procedures.
General endotracheal anesthesia.
There is a high prevalence of velo-cardio-facial syndrome (chromosomal microdeletion 22q11.2) in VPI patients. Phenotypic expression includes VPI, submucous cleft palate, learning disabilities, cardiac anomalies, retrognathia, malar flattening, pharyngeal hypotonia, slender hands and fingers, small stature, and medialized carotid arteries. 11 Cardiac status should be investigated.
Antibiotic prophylaxis is often necessary to prevent subacute bacterial endocarditis.
The patient is positioned on a shoulder roll to maintain hyperextension of the neck.
Procedure
A mouth gag is inserted, and the patient is placed into suspension.
The posterior pharyngeal wall is visualized and palpated to identify any significant vessels in the operative field. The internal carotid arteries may be medialized in velo-cardio-facial syndrome patients. These vessels will be deep to the prevertebral fascia and not interfere with the operation, but increased care in raising the flap is necessary.
Proposed posterior pharyngeal wall incision lines as well as the soft palate are infiltrated with 1% lidocaine with 1:100,000 units of epinephrine to affect vasoconstriction and ease the raising of the flap.
Nasal stents are placed transnasally into the hypopharynx to size the lateral ports. Smaller endotracheal tubes, 3.5, are used for children, and 4.0 endotracheal tubes are used for adolescents.
A midline vertical incision is made to split the soft palate from the edge of the uvula to a point close to the junction of the hard palate. This is an important step in order to expose the posterior nasopharyngeal wall and enable measuring the length of the flap and raising it high enough for optimal closure of the velopharynx. Traction sutures placed on the free edge of the soft palate can improve visualization (▶ Fig. 41.2).
The standard flap width should not be larger than the distance between the nasal stents.
The length of the flap can be checked by measuring the distance from the posterior pharyngeal wall to the free margin of the soft palate, and then measuring down from the level of velopharyngeal closure.
The superiorly based pharyngeal flap is elevated by incising down to the prevertebral fascia. This fascial layer is white in color, and the plane will be essentially avascular.
Flap elevation needs to be high into the nasopharynx, to the natural level of velopharyngeal closure. Failure to raise the flap high enough will result in an inferior tethering of the free edge of the soft palate, further compromising velopharyngeal function. This will also cause the flap to be located in a position precluding its participation in velopharyngeal closure (▶ Fig. 41.3).
4–0 Vicryl sutures are used to sew the oral mucosa and muscle of the flap to the anterior nasopharyngeal mucosa of the soft palate (▶ Fig. 41.4).
The donor site is closed with 3–0 Vicryl suture (▶ Fig. 41.5).
Overzealous closure of the donor site superiorly can lead to nasopharyngeal stenosis.
A mirror is used to evaluate the lateral ports.
At the conclusion of the procedure, the pharyngeal flap should not be visible in the oropharynx; it must be high in the nasopharynx (▶ Fig. 41.6).
The palate is closed in three layers. Meticulous technique is necessary to minimize fistula formation.
The nasal stents are positioned with their distal end in the mid-oropharynx, and are then secured with tape to the nose.
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