Salvaging the failed pharyngoplasty: Intervention outcome

Objective: This paper reports on the rates of failure of operations (pharyn geal flap and sphincter pharyngoplasty) performed for management of velopha ryngeal dysfunction, and outcome following their revision. Design: Anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following pharyngeal flap and sphincter pharyngoplast y were critiqued. The results of primary pharyngeal flap were evaluated for 65 patients, and the results of primary sphincter pharyngoplasty were eval uated for 123 patients. All patients were treated for velopharyngeal dysfun ction. The definition of surgical failure was based on persistent hypernasa lity and/or nasal turbulence on perceptual speech evaluation, and incomplet e velopharyngeal closure on instrumental evaluation, at least 3 months post operatively. Setting: All patients were evaluated and managed at the Cleft Palate and Cr aniofacial Deformities Institute, St. Louis Children's Hospital, a tertiary cleft care center. Patients. Participants: All patients had failed surgical management initial ly, either with pharyngeal flap or sphincter pharyngoplasty, and all underw ent repeat preoperative and postoperative perceptual speech evaluations; re al-time lateral phonation fluoroscopy including still reference views; and flexible nasendoscopy of the velopharynx using standard speech protocols. Interventions: Revisional surgery for both procedures consisted of either t ightening of the sphincter pharyngoplasty or pharyngeal flap port(s) or rei nsertion of the sphincter pharyngoplasty or pharyngeal flaps following dehi scence. Main Outcome Measures: The main outcome measure was normalcy of velopharyng eal function, i.e., elimination of perceptual hypernasality and instrumenta l evidence of complete velopharyngeal closure. The rates of pharyngeal flap failure and sphincter pharyngoplasty failure were determined for those pat ients requiring surgical revision. Results: Thirteen of 65 patients (20%) who underwent primary pharyngeal fla p required revisional surgery. Of these 13 patients, eight were managed suc cessfully with a single revisional operation. The remaining five patients ( 38%) continued to exhibit velopharyngeal dysfunction and underwent a second revision consisting of tightening or augmentation of the lateral ports. Sp eech results were satisfactory in all patients so treated; however, hyponas ality with no other airway morbidity occurred in ail five. Twenty of 123 pa tients (16%) who underwent primary sphincter pharyngoplasty required surgic al revision. Of these 20 patients, 17 were managed successfully. For both p rocedures, the principal cause of failure was partial or complete flap dehi scence. Conclusions: Rates of primary pharyngeal flap failure are roughly equivalen t to rates of primary sphincter pharyngoplasty failure. Pharyngeal flap and sphincter pharyngoplasty failures can be salvaged with revisional surgery, which can provide a velopharyngeal mechanism capable of complete closure. Revisional surgery is usually associated with denasal speech.