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    *Presented at the 22nd

    annual meeting of Egypt ian 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: amir_elbarbary@yahoo.com

    Original Article

    Annals of Pediatric Surgery, Vol 4, No 1,2, January-April, 2008 PP 22-36

    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 palaterepair. It disrupts speech intelligibility leading to breakdown of the ability to communicate verbally. Substantial uncertaintyoccurs 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 withresidual 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 ofvelopharngeal insufficiency. Six to twelve weeks following the surgical procedure they underwent the same thoroughevaluation prior to receiving any speech therapy. Speech evaluation was carried out using the protocol of assessment that isapplied 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 significantreduction 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 velopharyngealclosure. Postoperatively, velopharyngeal port achieved functional closure in the majority of patients as detected bynasopharyngeal 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 patientswith 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 toexcessive nasal resonance or hypernasality as

    the consequence of anatomical abnormalities andfailure of the velum and the pharyngeal muscles to

    produce optimal sphincter-like closure between theoro- and nasopharynx.1 It occurs in a substantialnumber of patients after cleft palate repair2-5 and canbe attributed to a variety of factors: scarring as a

    V

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    El Barbary & Ghandour

    23 Vol 4, No 1,2, January-April, 2008

    result of the initial palatoplasty can shorten thevelum; making it impossible for the velum to reachthe posterior pharyngeal wall "target" during speech;a deep nasopharynx relative to the position of thevelum; a poor velar movement despite an adequatelength resulting from insufficient restoration of thepalatal muscle sling at the time of primary repair.6Velopharyngeal insufficiency results in the inabilityof the cleft patients to communicate coherently and isconsidered the most disabling and devastating resultamong the various secondary problems that mayfollow cleft lip/palate repair.7

    When surgical management is indicated forrestoration of the velopharyngeal function, thepharyngeal flap and the sphincter pharyngoplasty areamong the most commonly used surgicalprocedures8. Considerable uncertainty of choice existsboth within variations of flap and sphincter

    pharyngoplasty and between the two approaches.Authorities such as Riski9 agree that if surgicalintervention is needed, the procedure should betailored to the size and nature of the velopharyngealdefect. However, reports of morbidity and mortalityassociated with pharyngeal flap surgery10-16 have leda lot of operators to adopt sphincterplasty instead.Several publications have advocated sphincterpharyngoplasties17-19 citing their additionaladvantages as (1) technical ease of execution, (2)superior speech results, (3) low complication rate, (4)reduced anaesthesia time, (5) non-obstruction of the

    nasal airway.

    The sphincter pharyngoplasty operation is designedto form a ridge on the posterior pharyngeal wall,narrow the pharynx from side to side, and to producea sphincteric type of closure.20 The objective of theprocedure is to create a muscular valve capable ofisolating the nasal cavity from the remainder of thevocal tract during appropriate speech tasks. This isnecessary to eliminate hypernasality and to allow oralpressure to build in the oral cavity for the productionof many consonant phonemes.21 Severalmodifications of sphincter pharyngoplasty have been

    described since it was first introduced by Hynes22-24who used superiorly based flaps from thesalpingopharyngeus. Orticochea25 usedpalatopharyngeus instead and sutured them to aninferiorly based pharyngeal flap to below the palatalplane. Jackson & Silverston26 replaced the inferiorlybased flap by a superiorly based posterior wall flap inan attempt to raise the flap insertion and improve theoutcome. Despite the reported high success rate

    following sphincter pharyngoplasty,27 a number ofpatients have persistent unacceptable vocal resonanceand residual air escape postoperatively.21,28 Advancesin patient selection and surgical technique to enhancesuccessful valving of sphincter pharyngoplasty havebeen reported.8,28

    In an attempt to enhance the success of the sphincterpalatoplasty and further improve the outcome, amodified sphincter pharyngoplasty is presented. Itincluded the elevation of bilateral superiorly basedpalatopharyngeus muscle with overlying mucosa thatare sutured overlapped to each another and to atransverse incision on the posterior pharyngeal wallat the level of attempted velopharyngeal closure.

    The aim of this prospective study is to assess thetreatment outcome for patients with residualvelopharyngeal insufficiency after palatal repair

    undergoing a modified technique of sphincterpharyngoplasty regardless of the pattern ofvelopharyngeal closure.

    PATIENTS AND METHODS

    Patients diagnosed with residual velopharyngealinsufficiency after cleft palate repair presenting to theoutpatient cleft palate clinic at Ain-Shams UniversityHospital from January of 2004 to December of 2006had been considered potentially eligible for the study.

    Similar to other studies,8,29 the patients had to meetthe following criteria to qualify for the study: (1)undergone a primary repair of the palate (with orwithout a cleft lip or alveolus), (2) chronological agebetween 4 and 16 years with apparent VPI diagnosedby an experienced speech specialist, (3) had at least75% of normal language development for their age.Exclusion criteria comprised patients with: (1) size ofthe velopharyngeal gap exceeding 2 cm inanteroposterior dimension which necessitated alengthening procedure, (2) hearing impairment, (3)

    the cleft being part of a syndrome, (4) any preexistingpalatal fistulae, (5) obstructive sleep apnea syndrome.

    The surgical procedure and study methods werecarefully explained to all parents. Patients underwentin-depth speech and endoscopic evaluations forsymptoms of velopharyngeal insufficiency. Six totwelve weeks, with a mean of two months, followingthe surgical procedure they underwent the samethorough evaluation prior to receiving any speech

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    El Barbary & Ghandour

    Annals of Pediatric Surgery 24

    therapy if they needed any. Evaluation was carriedout using the protocol of assessment that is applied inthe phoniatric unit, Ain-Shams University whichincludes subjective as well as quasi-objectivemeasures of evaluation30.This protocol includes:

    I-Preliminary Diagnostic Procedures:

    Auditory Perceptual Assessment (APA) was usedas a subjective tool for evaluation of patients'language, speech and voice through listening toevery patient in a free conversation and a recordedspeech sample. Passive and active aspects oflanguage were investigated including semantic,syntactic and pragmatic aspects. Speech evaluationincluded the type and degree of open nasality,consonant precision, the compensatory articulatorymechanisms (glottal articulation, pharyngealizationof fricatives, and facial grimace), audible nasal airescape and overall unintelligibility of speech. All

    these elements are graded along a 5-point scale inwhich 0 = normal and 4 = severe affection.

    II-Clinical Diagnostic Aids:

    (A) Nasopharyngeal videofibroscopy:

    All patients were examined using nasopharyngealvideo-fibroscopy Henke-Sass-Wolf, type 10,connected to a Lemke video camera (MC 204) andPanasonic video cassette recorder 357. Thenasofibroscope was introduced through the nasalcavity to a position superior to the soft palate. Thevelopharyngeal valve movement was recordedwhile the patient repeated the speech samplesapplied in the protocol of assessment of VPI in thephoniatric unit, Ain-Shams University.30Movements of the velum, lateral, and posteriorpharyngeal walls were traced on the monitor. Themovement of each component