Superiorly Based Posterior Pharyngeal Flaps: Management and Outcomes in the Treatment of Velopharyngeal Insufficiency
Megan Pencek1, James Butterfield*1, Keith Sweitzer1, Eileen Marrinan3, Sara Neimanis1, Heidi Connolly2, Clinton Morrison1
1Surgery, University of Rochester, Rochester, NY; 2Pediatrics, University of Rochester, Rochester, NY; 3Speech and Language Pathology, University of Rochester, Rochester, NY
Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) pre-operative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient specific surgical approach via appropriately sized pharyngeal flaps can result in excellent speech outcomes while limiting occurrence of OSA.
This was a retrospective chart review of all patients with VPI (ages 2-20) seen at the University of Rochester from 2015-2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine pharyngeal flap width. Patients underwent polysomnography and speech evaluation prior to and at least 6 months after PF surgery.
41 children aged 8.5±4.1 years (range 4 to 18 years) were identified who underwent posterior pharyngeal flap surgery for VPI. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin Sequence. 39 patients had both pre- and post-operative speech data and underwent both a pre- and post-operative sleep study. Polysomnography showed no significant difference in obstructive apnea hypopnea index (O-AHI) following posterior pharyngeal flap surgery (O-AHI pre-op 1.3±1.2 events/hour; post-op 1.7±2.1 events/hour; p=0.111). Significant improvements in speech outcome was seen in patients who underwent PF (modified Pittsburgh score pre-op 11.52±1.37; post-op 1.09±2.35; p<0.05).
Utilization of preoperative staged adenotonsillectomy as well as patient specific pharyngeal flap dimensions results in effective resolution of velopharyngeal insufficiency and a low risk of OSA.
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