International Journal of Pediatric Otorhinolaryngology 78 (2014) 934–937
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Trans-oral endoscopic cerclage pharyngoplasty for treatment of velopharyngeal insufficiency Mohammed Rashed a, Nader Naguib a, Mosaad Abdel-Aziz b,* a b
Department of Otolaryngology, Beni Suef University, Egypt Department of Otolaryngology, Cairo University, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 January 2014 Accepted 14 March 2014 Available online 27 March 2014
Objectives: Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair, it leads to speech distortion with consequent affection of speech intelligibility. Many techniques have been used in the treatment of VPI with varying results and complications. The aim of this study was to evaluate the efficacy of trans-oral endoscopic cerclage pharyngoplasty in the treatment of VPI. Methods: Eighteen patients with hypernasality after palatoplasty were subjected to trans-oral endoscopic cerclage pharyngoplasty. Pre and postoperative evaluation of velopharyngeal function were performed by using auditory perceptual assessment, nasometric assessment, and flexible nasopharyngoscopy. Results: Significant postoperative improvement of speech parameters measured with auditory perceptual assessment were achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Also, flexible nasopharyngoscopy showed significant improvement of velopharyngeal closure. No marked postoperative complications were reported apart from throat pain and dysphagia that disappeared with time. Conclusions: Trans-oral endoscopic cerclage pharyngoplasty is an effective method for the treatment of VPI. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Velopharyngeal insufficiency Cleft palate Pharyngoplasty Hypernasality
1. Introduction Failure of complete closure of the velopharyngeal port during speech and/or swallowing is called velopharyngeal insufficiency (VPI), it leads to leakage of air into the nasal cavity that results in hypernasal vocal resonance and nasal emissions of air. The effect of VPI ranges from mild speech distortion to a catastrophic disruption of speech intelligibility [1]. About 15–45% of children may have this problem after cleft palate repair, it may be due to abnormally weak palatal musculature, and also it is affected by the technique used in repair and weather the levator sling has been constructed or not [2]. Surgical techniques available to correct VPI are posterior pharyngeal wall augmentation (obtained, for example, by fat, Teflon, or hydroxyapatite injections), posterior pharyngeal flaps, or sphincter pharyngoplasty. The common goal of these surgical
* Corresponding author at: 2 El-Salam St., King Faisal, Above El-Baraka Bank, Giza, Cairo, Egypt. Tel.: +20 1005140161; fax: +20 225329113. E-mail address:
[email protected] (M. Abdel-Aziz). URL: http://www.ent-egypt.com http://dx.doi.org/10.1016/j.ijporl.2014.03.018 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
techniques is to create a permanent partial obstruction of the velopharyngeal space to correct hypernasal speech. Teflon injection has received attention owing to its relative simplicity. Unfortunately, long-term evolution is usually associated with local chronic inflammatory response, which eventually leads to pharyngeal mucosa lesions and Teflon extrusion. This technique is no longer used in the treatment of VPI [3]. Sipp et al. [4] used calcium hydroxyapatite, and Leuchter et al. [5] used autologous fat for augmentation of the posterior pharyngeal wall; they achieved good results, but their patient samples were small. Posterior pharyngeal flap is created by suturing a superior or, more rarely, an inferior posterior pharyngeal wall flap to the soft palate, leaving a lateral port on either side for breathing [6]. This method is ideal for patients with sagittal velopharyngeal closure (VPC) pattern with good lateral wall motion, which is necessary for closure of the lateral ports; however, complications may include hyponasality, nasal obstruction, snoring, and sleep apnea [2]. Sphincter pharyngoplasty is created by elevation of bilateral myomucosal flaps from the lateral pharyngeal wall to be inserted into an incision on the posterior pharyngeal wall. It could obturate the central and lateral portions of the velopharynx, and it is used in patients with coronal VPC pattern with good palatal
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motion [7]. The incidence of obstructive breathing that may follow pharyngeal flap is lower after sphincter pharyngoplasty [2]. The aim of this study was to evaluate the efficacy of trans-oral endoscopic cerclage pharyngoplasty in the treatment of VPI. 2. Methods The study was conducted on 18 patients who presented with hypernasal speech after cleft palate repair in the period from March 2010 to April 2012 in the Departments of Otolaryngology in both Cairo University and Beni Suef University. The ages of the patients ranged between 4 and 9 years with a mean age of 6.5 years, 12 females and 6 males. The original defects included 7 cases of bilateral complete cleft lip and palate, 6 cases of unilateral complete cleft lip and palate and 5 cases of cleft soft palate, complete clefts were repaired by 2 flap palatoplasty while incomplete clefts were repaired by Veau–Wardill–Killner technique. The surgery was performed to narrow the velopharyngeal port. Patients who underwent secondary corrective surgery for VPI, who presented with obstructive airway diseases such as tonsillar and/or adenoid hypertrophy, and who presented with craniofacial anomalies or palatal fistulae were excluded. Children under the age of 4 years were also excluded. Informed consent was obtained from the parents of all patients, and the principles outlined in the Declaration of Helsinki were followed. In addition, the research protocol was approved by the ethics committee of our institute. Patients underwent extensive pre- and postoperative assessment as described below. 2.1. Otolaryngologic examination Full ear, nose and throat, and head and neck examination was performed for detection of other associated diseases. Ear examination, including tympanometry, was performed for detection of middle ear effusion, and oral examination was performed to assess the condition of the palate, and to exclude any cause of airway obstruction. 2.2. Preoperative assessment of velopharyngeal function Patients underwent three methods of quantitative assessment of velopharyngeal function: auditory perceptual assessment (APA) of speech, nasometry, and flexible nasopharyngoscopy, as follows. 2.3. Auditory perceptual assessment of speech Hypernasality, nasal emission of air, and weak pressure consonants were analyzed. Parameters were graded on a fivepoint scale (0–4) in which 0 indicates normal and 4 indicates severe hypernasality, with a total score of 12 on the three elements. A lower score on this scale indicates less dysfunction.
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videotape recording. The system was composed of a high resolution Karlheinz Hinze S/N 151385 endoscope, a Storz endoscope video camera, and a Panasonic SR 500 video recorder. The velopharynx was inspected, and VPC was assessed while the patients were repeating Arabic sentences loaded with high oralpressure consonants. Consistent with recommendations of an international working group, velopharyngeal gap size was measured during maximal closure on phonation [8]. Gap size categories were defined as large (VPC 80%). 2.6. Operative procedure Under general anesthesia with oral endotracheal intubation, a Davis-Boyle mouth gag was inserted and retraction of the soft palate with two rubber catheters was done, a 708 Hopkins 4-mm nasal endoscope was introduced through the mouth. A camera was mounted on the endoscope and the endoscopic view was projected on a monitor (Fig. 1). Trans-oral endoscopic cerclage pharyngoplasty was performed, in which the nasal surface of the soft palate, posterior pharyngeal wall and both lateral pharyngeal walls were marked with methelyne blue at the level of VPC as seen preoperatively by flexible nasopharyngoscopy. The marked circle was injected with adrenaline in saline 1/200,000, a 1–0 polypropylene suture material was used circumferentially to narrow the velopharyngeal port. The needle was inserted in the midpoint of the posterior pharyngeal wall just 1 mm above the marked line, deep to the muscular layer, passing to the left lateral pharyngeal wall, soft palate, and again to the midpoint of the posterior pharyngeal wall forming a submuscular circle. Another circle was created using the same maneuver but just 1 mm below the marked line. The distance between both circles is 2 mm, each circle was tied separately with the knots deepened in the posterior pharyngeal wall. The degree of suture tightness was dependant on the severity of VPI seen on the preoperative flexible nasopharyngoscopy for each individual patient. 2.7. Postoperative assessment of velopharyngeal function Following routine postoperative instructions and follow up, patients were directed to return after 6 months for auditory perceptual assessment, nasometric assessment, and flexible nasopharyngoscopy using the same parameters that were used preoperatively. 2.8. Statistical methods Data were coded and summarized using Statistical Package for Social Sciences version 19.0 for Windows (SPSS Inc., Chicago, IL). [(Fig._1)TD$IG]
2.4. Nasometric assessment Assessment of nasalance was performed using a nasometer, which provides an acoustic measure of movement of the vibrational energy through the vocal tract. Nasometric data were obtained while the patients read or repeated standardized Arabic nasal and oral sentences. 2.5. Flexible nasopharyngoscopy Visualization of the velopharyngeal port was performed using a fiberoptic flexible nasopharyngoscope, equipped with a highintensity cold light and a special endoscopic television system for
Fig. 1. Trans-oral endoscopic view for the velopharyngeal port with two catheters retracting the soft palate.
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[(Fig._2)TD$IG]
M. Rashed et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 934–937
Quantitative variables are presented as mean standard deviation, and categorical data as frequency and percentage. Comparison of preoperative and postoperative results of auditory perceptual assessment and nasometric assessment was done using paired two-sample t test, and Pearson x2 was used for comparison of preoperative and postoperative results of velopharyngeal gap size. P < .05 was considered statistically significant. 3. Results Eighteen children with hypernasality after cleft palate repair were enrolled in the study. Each underwent trans-oral endoscopic cerclage pharyngoplasty with preoperative and postoperative assessment of velopharyngeal function. Speech was significantly improved following surgery. The mean preoperative baseline of auditory perceptual assessment was 7.85 (0.098), whereas the postoperative was reduced to 3.95 (0.14) (Fig. 2). The difference between preoperative and postoperative scores was significant. Nasalance was also improved following surgery. The preoperative scores were 36.31 (0.26) for the nasal sentences and 14.51 (0.1) for the oral sentences, whereas postoperative scores declined to 31.26 (0.31) for the nasal sentences and 11.37 (0.13) for the oral sentences (Fig. 2). The changes were statistically significant for both nasal and oral sentences. Flexible nasopharyngoscopy (Fig. 3) showed a preoperative large velopharyngeal gap in 6 patients, moderate gap in 9 patients, and small gap in 3 patients. Postoperatively, moderate gap was detected in 3 patients, small gap in 10 patients, and no gap in 5 patients. The difference between preoperative and postoperative results was statistically significant. All patients showed preoperative coronal closure pattern except one with circular closure. However, all velopharyngeal walls were seen approximating each other postoperatively, the closure appeared to be circular in all patients with a ridge in the posterior pharyngeal wall. There was a ridge all round the velopharyngeal wall even during breathing, it indicated that the sutures were in place. No complications were reported postoperatively apart from throat pain and severe dysphagia which disappeared completely after about 3 weeks. 4. Discussion
[(Fig._3)TD$IG]
Velopharyngeal insufficiency is a common problem after cleft palate repair, it may be due to abnormal short palate, deep nasopharynx, weak palatal muscles, and/or stiffness of the fibrotic palatal tissues. Many techniques have been used for treatment of this problem; some surgeons prefer palatal procedures in the form
Fig. 2. Comparison between preoperative and postoperative results of auditory perceptual assessment and nasalance score for nasal and oral sentences.
of either Furlow z-plasty or intravelar veloplasty aiming for construction of levator sling, while others prefer pharyngeal procedures in the form of either pharyngeal flap, sphincter pharyngoplasty, or posterior pharyngeal wall augmentation aiming for narrowing of the velopharyngeal port. However, all these procedures eventually objective for closure of the velopharyngeal valve during speech preventing escape of air that results in hypernasality [9]. In 2007, Ragab [10] described a new cerclage pharyngoplasty technique in which he circumvents the velopharyngeal port with 2 level sub-muscular cerclages to tighten the area. Although he achieved good results, his patients’ sample was small (6 patients). In our study, we performed a similar technique with the addition of a 708 nasal endoscope inserted trans-orally for better visualization and more accessibility for the velopharyngeal area. In this study, 18 children with VPI after cleft palate repair were subjected for trans-oral endoscopic cerclage pharyngoplasty. We achieved postoperative significant improvement of speech and nasalance score. Also, postoperative flexible nasopharyngoscopy showed significant improvement of velopharyngeal closure in all patients; 5 patients demonstrated complete closure and 13 patients demonstrated a better closure compared to their preoperative state. The technique was not difficult with ascending learning curve by time. No patients developed complications, however all cases complained of throat pain and severe dysphagia which disappeared over time, they returned to their normal life after the 3rd week postoperatively. Surgical management of VPI is a challenge of balancing between achievement of acceptable nasal resonance and avoidance of development of postoperative airway obstruction. As the definition of success is not standardized, so reporting surgical
Fig. 3. Flexible nasopharyngoscopic views during articulation. (A) Preoperative view with a moderate velopharyngeal gap. (B) Postoperative view with the velopharyngeal valve is completely closed and no gap.
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results and comparing these results with that of others can be confusing and misleading [11]. Although palatal procedures used for correction of VPI have a lower incidence of postoperative airway obstructive effects, it remains unclear whether these procedures are adequate to restore the whole velopharyngeal sphincter activity or not, in addition they are only suitable for selected patients [12]. Pharyngeal flap and sphincter pharyngoplasty may result in a considerable velopharyngeal narrowing with better speech results, but they have remarkable obstructive airway effects with consequent postoperative snoring and even sleep apnea [13]. Cerclage pharyngoplasty used in our study has more physiologic solution as it approximates all velopharyngeal walls to each others with no shelving inside the air space of the velopharynx. Our technique is unlike other pharyngeal procedures as it does not sacrifice any of the pharyngeal walls; pharyngeal flap needs elevation of posterior pharyngeal wall to be attached to the free edge of the soft palate, while both lateral pharyngeal walls are elevated and attached together in the posterior pharyngeal wall in sphincter pharyngoplasty. Cerclage pharyngoplasty does not alter the circumferential integrity of the velopharyngeal anatomy, it enhances VPC by tightening the velopharyngeal valve. Cerclage pharyngoplasty is an easy technique and it can be performed for any velopharyngeal closure pattern, it does not need additional equipments in the operating theater of otolaryngology, and it is a physiologic solution for VPI. It is worth mentioning that our study has some weakness, it does not measure the obstructive effect of the cerclage pharyngoplasty on the airway. So polysomnography should be used in the future studies to assess the possibility of development of obstructive sleep apnea postoperatively. As the suture may be extruded or may relax overtime, so a longer follow up period is needed. 5. Conclusion Trans-oral endoscopic cerclage pharyngoplasty is an effective method for the treatment of VPI. It tightens the velopharyngeal sphincter without altering its anatomy. Financial disclosure None.
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Conflict of interest None. Acknowledgment We are grateful to the staff of the Phoniatric Units in our departments who carried out the speech evaluation.
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