Review of Current Techniques of Cleft Palate Repair Concerning Palatal Innervation: A Preliminary Assumption.

OBJECTIVE: To highlight the possible surgical steps that could affect the neural supply of soft palate and velopharyngeal sphincter during Furlow palatoplasty and posteriorly-based myo-mucosal buccal flaps in patients with persistent velopharyngeal insufficiency after primary cleft palate repair. DESIGN: Institution-based retrospective study. SETTING: Academic Medical Center. PATIENTS: Non-syndromic patients with persistent hypernasality (after primary cleft palate repair) who had Furlow palatoplasty or posteriorly-based buccal myo-mucosal flaps and were followed up for at least 60 months after the secondary surgery. INTERVENTIONS: All patients were examined using a fiberoptic endoscopy, the movement of components of the velopharyngeal sphincter: soft palate, and lateral pharyngeal walls were traced on the monitor and given a score from 0-4. The pattern of VPS closure was reported whether coronal, circular, or sagittal for each case. MAIN OUTCOME MEASURES: Patients' characteristics, auditory perceptual assessment, the severity of hypernasality, intraoperative lengthening of the palate, and operative complications were recorded. RESULTS: At postoperative (at least 60 months) evaluation of the patients statistically non-significant differences were reported when comparing the pre-versus post-operative auditory perceptual assessment following both procedures (P value ≥0.05). A greater tendency towards improvement was noticed with BF but was non-significant. CONCLUSION: The nerve supply of the palate could be jeopardized by many techniques of primary or secondary repair of the cleft palate leaving behind a deceiving intact but weak poor-functioning palate. All efforts should be made to provide more neural-preservation techniques in primary/secondary repair of the cleft palate. Further wide-scale research is essential to have final clear conclusions.

Palatal Sphincter Pharyngoplasty With Cephalic Mucosa Preservation in Selected Cases of Velopharyngeal Insufficiency.

OBJECTIVES: Sphincter pharyngoplasty is a commonly performed procedure for the treatment of velopharyngeal insufficiency and is often indicated in patients with circular or coronal closure patterns of the velopharyngeal sphincter. The authors present a modified technique of sphincter pharyngoplasty (partially mucosalized palatal sphincter pharyngoplasty [PMPSP]) in which bilateral superiorly based myomucosal palatopharyngeal flaps were elevated (in a newly designed fashion) and inserted in the palate through preformed palatal tunnels. METHODS: This case series included 14 patients (5 male, 9 female) with persistent hypernasality who were subjected to treatment by PMPSP between May 2015 and August 2018. The palatopharyngeal flap was designed to be full thickness at its caudal segment, while its cephalic segment was denuded of its mucosa. The cephalic mucosa (of the flap) was elevated off the bed muscles as a medially based mucosa flap to be used at the end of the procedure to drape the upper part of the bed. RESULTS: Pain assessed using a visual analog scale had decreased significantly at day 10 after surgery, and normal oral feeding was regained within 7 to 10 days. No major complications were recorded. Postoperative nasoendoscopic and phoniatric assessments were reported. Statistically significant improvements were reported when comparing pre- versus postoperative auditory perceptual assessment following PMPSP. CONCLUSIONS: The newly reported PMPSP might be a useful technique for correction of velopharyngeal insufficiency in patients with weak palatal motion (coronal or circular pattern of velopharyngeal sphincter closure). PMPSP had good reported surgical and phoniatric outcomes.

Cephalic de-mucosalized superiorly-based pharyngeal flap: A modified mucosa-preserving technique for velopharyngeal insufficiency.

INTRODUCTION: Superiorly-based pharyngeal flap (PF) is the most frequently employed surgical technique to correct velopharyngeal insufficiency (VPI). Bared posterior pharyngeal wall might prolong the period of convalescence with throat pain and discomfort. Delayed donor site healing problems and subsequent fibrosis with downward migration of the transposed flap might be one a cause of failure and might necessitate revision. AIM OF THE WORK: To present a modified technique of PF aiming at dealing with the problems of donor site defects via immediate self-mucosal covering of the cephalic portion of the bed. METHODS: This case series study was conducted on patients with persistent VPI. All patients underwent the new modified technique of cephalic de-mucosalized pharyngeal flap (CDPF). The basic premise was to harvest a laterally-based mucosal flap from the upper part of the posterior pharyngeal wall. A superiorly-based pharyngeal flap (with a bared cephalic segment and a mucosalized caudal segment) was elevated off the posterior pharyngeal wall and inserted in the soft palate. Then the laterally-based mucosal flap was spread over the superior part of donor site of the posterior pharyngeal wall. RESULTS: 13 VPI patients were included in this study. Their age ranged from 5 to 12 years with a mean of 5.6 ±â€¯1.2. The follow-up period ranged from 8 to 14 months. All flaps and beds were completely healed within 2-3 weeks and no patients showed flap dehiscence, infection or palatal fistula. Postoperative speech assessment showed significant improvement of velopharyngeal function, resonance balance, and reduction in nasal emission. CONCLUSIONS: The modified technique provides an immediate self-mucosa cover to the superior part of the posterior pharyngeal wall, thus it could promote primary healing at the donor site with a short period of convalescence. CDPF separates the two opposing raw surfaces of the flap and the posterior pharyngeal wall. The mucosal flap might guard against downward migration of the flap.

Linear Measurements of Vocal Folds and Laryngeal Dimensions in Freshly Excised Human Larynges.

INTRODUCTION: Understanding the morphology of the larynx, one of the most complex organs of the human body, is an important step toward understanding the detailed laryngeal anatomy, and physiology. Different studies have described the linear measurements of the larynx in different measuring methods, but no studies have been structured to describe vocal fold length in freshly excised larynges. OBJECTIVES: The aim of this study was to describe exact anatomical measurements of vocal folds and some laryngeal structures in freshly excised larynges, and to compare such measurements between males and females. This can help improve the diagnostic and therapeutic procedures in the laryngology field. SUBJECTS AND METHODS: This study was applied on 21 patients having different types of laryngeal carcinoma: 11 males and 10 females with the age range 41-75 years old. Every patient was assessed using laryngeal endoscopy and photography, and the length of the membranous vocal fold was measured using a millimeter-graded ruler that was photographed with focus with the same magnification used in the video laryngoscopy of the glottis. Then patients were exposed to total laryngectomy, and excised larynges were used for a direct measuring of the membranous and cartilaginous vocal folds. Then measures of men and women were compared statistically. Measures of excised larynges were also compared with those of the video endoscopy using a video-printed ruler. CONCLUSION: Freshly excised larynges can be used for accurate quantitative measuring of the vocal fold length and laryngeal dimensions. There are considerable differences in all measured dimensions between males and females.

Voice and Swallowing Outcomes after Hyoid Suspension Surgery in Patients with Obstructive Sleep Apnea.

OBJECTIVE: The role of hyoidthyroidpexia (HTP) surgery in the management of patients with obstructive sleep apnea (OSA) is well described with good reported outcomes. The effect of HTP on other laryngeal functions is not well discussed. This study was designed to evaluate voice and swallowing outcomes after HTP. PATIENTS AND METHODS: This study was applied on a selected group of OSA patients. HTP (as a sole procedure) was performed in 17 patients and 14 patients had simultaneous palatal procedures (e.g., anterior palatoplasty). Pre- and postoperative assessment of voice and swallowing were done. RESULTS: Comparison between pre- and postoperative results of voice and swallowing measures revealed a nonsignificant difference. CONCLUSION: HTP (as a sole technique or as part of a multilevel intervention) could help with airway collapse and might be considered a safe, simple, and effective technique in the management of selected patients experiencing OSA. In addition, it seems to have no hazardous effect on either the voice or swallowing function of patients.

Powered instrumentation for transnasal endoscopic partial adenoidectomy in children with submucosal cleft palate.

OBJECTIVES: Partial adenoidectomy is the selective removal of the obstructing part of adenoid tissue, thus relieves obstruction symptoms and preserves the velopharyngeal valve action. Patients with palatal dysfunction are candidates for the technique. This study describes the use of microdebrider, transnasally (guided by the nasal endoscope) to perform partial adenoidectomy in patients with submucosal cleft palate, who presented with adenoidal hypertrophy and also it discusses its effects on nasal obstruction and speech. SUBJECTS AND METHODS: This prospective study was carried out on twenty-three submucosal cleft palate patients who were referred to the ORL-HN department; Zagazig University Hospitals complaining of respiratory obstruction and sleep disturbances due to adenoids hypertrophy. After preoperative nasoendoscopic and speech evaluation, transnasal endoscopic, power-assisted partial adenoidectomy was done for all patients. All patients were followed up at regular visits including nasoendoscopy and speech evaluation. RESULTS: The procedure insured fast, safe, reliable, under vision and well controlled steps. Intraoperatively no major complications were recorded. During follow up, nasal obstruction and respiratory obstruction symptoms were improved. Speech outcome results were reported. CONCLUSION: The study demonstrates the feasibility of using the microdebrider for performing transnasal partial adenoidectomy (under endoscopic guidance). The procedure is precise, rapid, safe and well-tolerated with the advantage of direct visualization of a traditionally difficult-to-expose area. The study reported improvement of respiratory obstruction symptoms with good speech results.