SURGICAL-MANAGEMENT OF VELOPHARYNGEAL DYSFUNCTION - OUTCOME ANALYSIS OF AUTOGENOUS POSTERIOR PHARYNGEAL WALL AUGMENTATION

Posterior pharyngeal wall augmentation has been advocated for patients having velopharyngeal dysfunction with a small coronal gap. Nonautoge nous augmentation has not been accepted widely because of migration or extrusion of alloplastic implants and resorption of injected material s. Autogenous posterior pharyngeal wall augmentation has been performe d for decades by Italian surgeons. A retrospective study was conducted to evaluate the efficacy of this procedure. Autogenous posterior phar yngeal wall augmentation, using a rolled superiorly based pharyngeal m yomucosal flap, was performed on 14 patients, between November of 1989 and June of 1992, who fulfilled two criteria: velopharyngeal dysfunct ion unresponsive to speech therapy and a small (<20 percent) coronal g ap on velopharyngeal nasendoscopy. Of these, 3 patients had prior pros thetic velopharyngeal management, including 2 patients with Robin sequ ence. AU patients were evaluated preoperatively and 3 months postopera tively with recorded (audio-videotape) perceptual, nasendoscopic, and fluoroscopic standardized speech and airway evaluations. The tapes wer e used for construction of a randomized master tape that was presented in blinded fashion and random order to three skilled raters for indep endent assessment of numerous perceptual and instrumental parameters o f speech. The raters were uninvolved in the care of the patients or th is study, and their intraobserver and interobserver reliabilities were known. Preoperatively, the majority of patients had nasal turbulence. All patients had variable degrees of hypernasality ranging from inter mittent to pervasive. Parameters rated included (1) resonance (hyperna sality, hyponasality, mixed), (2) auditory nasal emission (including n asal turbulence), and (3) visual characteristics regarding velopharyng eal closure. The visual parameters consisted of questions about whethe r a pharyngeal bulge was present or absent, descriptions of posterior pharyngeal wall movements with speech, level of closure, completeness of velopharyngeal closure, and quantitative descriptions of the percen tage of velopharyngeal closure postoperatively. Examiners were instruc ted to look for a static and/or dynamic projection or bulge (i.e., Pas savant's ridge) and, if a bulge was present, whether the level of velo pharyngeal closure was on the same plane as the neoposterior pharyngea l bulge. Results of the extramural judgments of these parameters Showe d that there was no statistically significant tendency for patients' s peech to be rated as more normal after the augmentation procedure than before it. We conclude that (1) autogenous posterior pharyngeal wall augmentation does not result in speech improvement and (2) autogenous posterior pharyngeal wall augmentation does not impair the nasal airwa y.