Revision Pharyngoplasty in Cleft Palate and Velopharyngeal Insufficiency: Management and Outcomes
Madeleine Bruce, BA1; Samantha Maliha, MD2; Lena Vodovotz, BS1; Miles Pfaff, MD MHS1; Matthew Ford, MS, CCC-SLP1; Jesse Goldstein, MD1; Joseph Losee MD1
1Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 2University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA
Introduction: Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15-20%. While revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes following such procedures. The purpose of this study is to describe the authors’ experience with indications for and outcomes following revision pharyngoplasty.
Methods: A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2003 and 2016. Demographic data and Pittsburgh Weighted Speech Scores (PWSS), diagnoses, comorbidities, and complications were tabulated. Two-tailed Student's t-test was used and a p ≤ 0.05 was considered statistically significant.
Results: Thirty-nine patients (61.5% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (69.2%), submucous cleft palate (20.5%), and congenital VPI (7.7%). The majority of patients (82.1%) underwent palatoplasty prior to their primary pharyngoplasty. The primary indication for primary pharyngoplasty was VPI (mean age 6.9 ± 4.3 years). The PWSS improved significantly from an average of 19 to 12.6 following primary pharyngoplasty (p=0.01). The most common indication for revision pharyngoplasty included persistent VPI (n=22), followed by obstructive sleep apnea (OSA, n=10), dehiscence of the pharyngeal flap (n=5), and nasal obstruction (n=2) (mean age 10.9 ± 4.9 years). Persistent VPI (n=10) and OSA (n=10) were the most common complications following secondary pharyngoplasty, followed by flap dehiscence (n=3), oronasal fistula (ONF, n=1) & stenosis/scarring (n=1). PWSS improved significantly from an average of 12.6 to 6 after secondary pharyngoplasty (p=0.002). Eighteen patients (46.2%) within our revision pharyngoplasty cohort required additional surgical intervention: 7 (17.8%) underwent tertiary pharyngoplasty, 4 (10.3%) underwent takedown of their pharyngeal flap for persistent (n=2) or new onset (n=2) OSA, 6 (15.4%) underwent conversion Furlow for persistent VPI or OSA, and 1 underwent repair of bilateral #4, 5, 6, & 7 oronasal fistulas. Of the 7 patients who required a tertiary pharyngoplasty, the mean age at repair was 8 ± 2.5 years and their speech scores improved from 10.8 to 2.8 after tertiary pharyngoplasty. The overall speech score following completion of all procedures improved significantly from 19 to 3.4.
Conclusion: Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.
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