REVISION OF THE FAILED SPHINCTER PHARYNGOPLASTY - AN OUTCOME ASSESSMENT

This paper reports results of surgical management of failed sphincter pharyngoplasties that were performed for velopharyngeal dysfunction. R evisional surgery consisted of tightening of the sphincter pharyngopla sty port or reinsertion of sphincter pharyngoplasty flaps following de hiscence. We critique the anatomic abnormalities associated with unacc eptable vocal resonance and nasal air escape following sphincter phary ngoplasty and analyze the effect of sphincter pharyngoplasty revision on ultimate speech outcome. The results of initial sphincter pharyngop lasty surgery were evaluated in 46 patients with velopharyngeal dysfun ction. Nine (20 percent) of these patients were considered surgical fa ilures because of persistent hypernasality and/or nasal turbulence on perceptual speech evaluation at least 3 months postoperatively. These patients underwent sphincter pharyngoplasty revision and form the basi s of this report. All patients who failed sphincter pharyngoplasty ini tially underwent both preoperative and postoperative perceptual speech evaluations, lateral phonation radiographic studies with still refere nce views, and flexible nasendoscopic studies. Evaluations of upper ai rway status were conducted by the same experienced otolaryngologist. F ollowing sphincter pharyngoplasty revision, 7 of 9 (78 percent) patien ts demonstrated resolution of velopharyngeal dysfunction, and to some degree, all patients managed with revision became hyponasal. The prima ry cause of failure was partial or complete flap dehiscence; a seconda ry cause was hypotonicity of the velopharyngeal mechanism. Failure was not correlated with the level of insertion of the pharyngoplasty flap s with respect to the point of attempted velopharyngeal contact. Sphin cter pharyngoplasty is an effective means of management for velopharyn geal dysfunction in many patients. The objective of removing the stigm ata of velopharyngeal dysfunction without causing upper airway obstruc tion may not be realistic in some patients with microretrognathia (i.e ., Pierre Robin sequence), in whom anatomic constraints predispose to flap dehiscence; Problems with surgical technique contributing to fail ure appeal to be related to experience of the surgeon, and improvement in outcome can be anticipated as the ''learning curve'' is overcome.