Secondary Pharyngoplasty: Management and Outcomes
John H. Pang, M.D., Wendy Chen, M.D., Xiao Zhu, B.A., Isaac James, M.D., Jack E. Brooker, MB BChir, Jesse A. Goldstein, M.D., Joseph E. Losee, M.D..
University of Pittsburgh Department of Plastic Surgery, Pittsburgh, PA, USA.
Background: Velopharyngeal insufficiency (VPI) is a stigmatizing, audible hallmark of palatal dysfunction, occurring across the spectrum of pediatric craniofacial disorders. Several surgical options exist, including palatoplasty, posterior pharyngeal flap (PPF) and sphincter pharyngoplasty (SP). Reported failure rates of primary pharyngoplasty range from 15-20%. There is a paucity of literature on the role, technique, and most importantly, speech outcomes of secondary pharyngoplasty. We present our single center experience.
Methods: This is a retrospective review from 2003-2016 of all patients who underwent pharyngoplasty by the senior author. Data points include demographics, medical comorbidities (airway, feeding, central nervous system, syndromic status, cleft type), surgical details, complications, and speech history (Pittsburgh weighted speech score at each visit). Given the heterogeneous surgical history of patients who have transferred care into our institution, a subset analysis was also performed on patients exclusively taken care of by a single senior attending with a homogeneous treatment algorithm for VPI.
Results: 258 patients who underwent a pharyngoplasty were identified, with 240 PPF and 18 SP. Index procedures were either pharyngoplasty 39 (15%) or palatoplasty 219 (85%). 185 (72%) were nonsyndromic patients, 72 (28%) were syndromic. Thirty-one (12%) had Pierre Robin Sequence (PRS), 21 (8%) had velocardiofacial syndrome (VCF), with an even distribution of cleft types.
Twenty-eight patients (26 PPF, 2 SP) required secondary pharyngoplasty, either PPF (21) or SP (7). Nine (32.1%) were syndromic, 6 (21.4%) had PRS, 1 (3.6%) had VCF, and the most frequent cleft was a Veau II (35.7%). The most common complication requiring secondary pharyngoplasty was VPI 13 (46%). Other complications included OSA 3 (10.7%), ONF 3 (10.7%), PPF dehiscence 2 (7.1%). Complications following secondary pharyngoplasty occurred in 18 (64.3%), most commonly VPI or OSA. Average speech scores improved (12 vs. 8) and were near normal (3) by the time of tertiary procedures.
A subgroup analysis of patients exclusively operated on by the senior author (76) demonstrated a much lower complication rate (19.7% vs 56.0% p=0.000), reoperation rate (7.9% vs 51.9% p=0.000), and need for secondary Pharyngoplasty (1.3% vs. 11.7% p=0.000), with similarly optimal speech outcomes.
Conclusion: Secondary procedures can improve speech outcomes in complex VPI patients. Current literature lacks a comprehensive description of secondary pharyngoplasty, from technique to outcomes. We analyzed a large cohort of patients who underwent pharyngoplasty, 28 of whom required a secondary pharyngoplasty and improved speech outcomes. Additionally, a subset analysis of patients treated exclusively by our institution's protocol suggests an optimized, less complicated management algorithm for VPI.
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