Superiorly Based Pharyngeal Flap for Velopharyngeal Dysfunction

Video Type: CVideo
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Author: Adrian Williamson
Published:
Specialties: Craniofacial and Pediatric Plastic Surgery, Otolaryngology, Paediatric Airway, Pediatric Surgery, Plastic Surgery
Schools: Arkansas Children's Hospital, University of Arkansas for Medical Sciences
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Basic Info

Velopharyngeal dysfunction (VPD) refers to the improper control of airflow through the nasopharynx. The term VPD denotes the clinical finding of incomplete velopharyngeal closure. Other terms used to describe VPD include velopharyngeal insufficiency, inadequacy and incompetence. However, the use of VPD has gained popularity over these terms as they may be used to infer a specific etiology of impaired velopharyngeal closure.1

Control of airflow through the nasopharynx is dependent on the simultaneous elevation of the soft palate and constriction of the lateral and posterior pharyngeal walls. Disruptions of this mechanism caused by structural, muscular or neurologic pathology of the palate or pharyngeal walls can result in VPD. VPD can result in a hypernasal voice with compensatory misarticulations, nasal emissions and aberrant facial movements during speech.2

The assessment of velopharyngeal function is best preformed by a multispecialty team evaluation including speech-language pathologists, prosthodontists, otolaryngologists and plastic surgeons. The initial diagnosis of VPD is typically made with voice and resonance evaluation conducted by a speech-language pathologist. To better characterize the patient’s VPD, video nasopharyngeal endoscopy or speech videofluoroscopy can be used to visualize the velopharyngeal mechanism during speech.

VPD may first be managed with speech-language therapy and removable prostheses. For those who are good surgical candidates and do not fully respond to speech-language therapy, surgical intervention may be pursued.

Surgical management of VPD is most commonly accomplished by pharyngeal flap procedures or sphincter pharyngoplasty. In this video, a superiorly based pharyngeal flap with a uvular mucosal lining flap was preformed for VPD in a five-year-old patient with 22q11 Deletion Syndrome and aberrantly medial internal carotid arteries.

Advanced

Procedure

1. Following intubation a shoulder roll was placed and the Dingman retractor mouth gag was inserted.
2. The superiorly based pharyngeal flap was designed and five insertion sites on the soft palate were marked.
3. 1% lidocaine with epinephrine was injected at the surgical site.
4. The posterior pharyngeal wall was incised with a 15-blade scalpel and the pharyngobuccal plane was located to elevate the pharyngeal flap.
5. The nasal surface of the soft palate was incised with an angled Beaver blade and a pocket was extended past the insertion sites creating the recipient site.
6. The pharyngeal flap was advanced into the recipient pocket with 3-0 vicryl sutures in a mattress fashion.
7. The nasopharynx was cannulated with two 14-French suction catheters to ensure adequate port size.
8. The uvula flap was released, unfurled and tacked down with 4-0 vicryl in the midline and interrupted 4-0 vicryl on either side to achieve at least 90% coverage of the pharyngeal flap.
9. The donor site was closed vertically and laterally to achieve partial closure of the donor site.
10. Finally, the area was irrigated and the stomach was suctioned. A tongue stitch was placed to help with ventilation in the event of airway obstruction during the immediate postoperative recovery period.

Indications

Velopharyngeal Dysfunction

Contraindications

1. Pre-existing obstructive sleep apnea
2. Note that medially aberrant internal carotid arteries can be considered a relative contraindication and should be approached on a case-by-case basis.

Instrumentation

Setup

1. Place a Shoulder roll following intubation
2. Dingman retractor and secure endotracheal tube
3. Prepare 1% lidocaine with epinephrine for injection
4. Prepare oxymetazoline irrigation to control bleeding in the surgical field
5. Obtain 3-0 vicryl for the pharyngeal flap and 4-0 vicryl for the uvular flap

Preoperative Workup

1. Voice and resonance evaluation by speech-language pathology
2. Video nasopharyngeal endoscopy
3. Speech videofluoroscopy

Anatomy and Landmarks

1. Uvula
2. Oroharynx and nasopharynx
3. Soft and hard palates
4. Aberrantly medial internal carotid arteries

Advantages/Disadvantages

Pharyngeal flaps bring tissue into the central portion of the velopharynx and are theoretically best suited for impaired sagittal or circular patterns of velopharyngeal closure. Despite this theoretical advantage, there is little evidence to support the use of pharyngeal flap over sphincter palatoplasty (Ysunza et. al, 2002).

Complications/Risks

1. Obstructive Sleep Apnea
2. Hyponasal voice
3. Excessive mouth breathing
4. Bleeding, especially in patients with coagulopathies, those requiring anticoagulation, or in patients with medially aberrant internal carotid arteries
5. Infection

Disclosure of Conflicts

The contributors to this video have no conflicts of interest to disclose.

Acknowledgements

The contributors would like to thank the Department of Otolaryngology at Arkansas Children’s Hospital and the University of Arkansas for Medical Sciences.

References

1. Woo AS. Velopharyngeal dysfunction. Semin Plast Surg. 2012;26(4):170-177. doi: 10.1055/s-0033-1333882 [doi].

2. Lewis JR, Andreassen ML, Leeper HA, Macrae DL, Thomas J. Vocal characteristics of children with cleft lip/palate and associated velopharyngeal incompetence. J Otolaryngol. 1993;22(2):113-117.

3. Ysunza A, Pamplona C, Ramirez E, Molina F, Mendoza M, Silva A. Velopharyngeal surgery: A prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg. 2002;110(6):1401-1407. doi: 10.1097/01.PRS.0000029349.16221.FB [doi].

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