Pharyngeal flap and sphincterplasty for velopharyngeal insufficiency have equal outcome at 1 year postoperatively: results of a randomized trial.

OBJECTIVE: The aim of this trial was to compare the relative effectiveness (efficacy and morbidity) of two surgical procedures for correcting velopharyngeal insufficiency (VPI). DESIGN: This was an international multicenter randomized trial to study the outcome of two surgical procedures (flap and sphincter pharyngoplasty) for speech, incidence of sleep apnea, and surgical complications. METHOD: Ninety-seven patients 3 to 25 years old with repaired cleft palate and previously identified VPI were enrolled from five centers in the United States, Norway, and the U.K. Data were collected at presurgery, 3 months postsurgery, and 12 months postsurgery for subsequent analysis blind to the procedure. Main outcome measures included perceptual speech parameters, sleep apnea, nasalance measures, endoscopic features, and surgical complications. RESULTS: Groups for both surgical procedures achieved a high level of clinical improvement. At 3 months postsurgery, elimination of hypernasal resonance was achieved in twice as many patients after the flap procedure. This reached significance. However, at 12 months postsurgery, no statistically significant difference in outcomes remained between the two procedures for resonance, nasalance, endoscopic outcomes, or surgical complications. Flap and sphincter pharyngoplasty rarely resulted in clinically significant sleep apnea, and no difference was detected between the two procedures in the long-term incidence of sleep apnea. CONCLUSIONS: Despite strongly held views in the literature concerning the relative effectiveness and safety of flap and sphincter pharyngoplasty, no significant differences were detected 1 year postoperatively.

Airway obstruction following palatoplasty: analysis of 247 consecutive operations.

OBJECTIVE AND METHODS: Between February 1987 and September 1997, 247 patients underwent primary repair of a cleft of the secondary palate by one surgeon, using the double-opposing Z-plasty (Furlow) technique. This retrospective study reviews perioperative and postoperative airway compromise among these patients. The purposes of this study were to identify factors associated with airway obstruction following palatoplasty and to analyze the management of those patients. Although infants experiencing airway problems following Wardill-Kilner and Von Langenbeck palatoplasty have been described, airway complications in a group of Furlow repair patients has not been previously reported. RESULTS: Fourteen patients (5.7%) had airway problems. The average age of these patients was 18 months, which was not significantly different from those without airway problems. Airway obstruction occurred as late as 48 hours after the completion of surgery. Twelve of the 14 patients had severe airway compromise requiring continued postoperative intubation, reintubation, or tracheostomy (one). There were no deaths. Thirteen of the 14 patients with postoperative airway problems (93%) had other congenital anomalies in addition to clefting, a named congenital disorder, or both. Seven of those 13 had Pierre Robin sequence. In contrast, only 40 of the 233 patients without airway problems (17%) had additional congenital anomalies or named disorders. Presence of other congenital anomalies was associated with a significantly increased risk of airway obstruction (p =.005). CONCLUSION: Patients with cleft palate with the Pierre Robin sequence or other additional congenital anomalies had an increased risk of airway problems following palatoplasty. Awareness of this risk permits identifying those patients prior to surgery so that they can be monitored and managed appropriately, minimizing the likelihood of major complications or death.

Speech benefits of posterior pharyngeal flap are preserved after surgical flap division for obstructive sleep apnea: experience with division of 12 flaps.

Attachment of a posterior pharyngeal flap is commonly performed for the surgical management of velopharyngeal insufficiency. Obstructive sleep apnea has been found to occur in as many as 38% of patients undergoing posterior pharyngeal flap attachment. Often, this is temporary in the early postoperative period. When it occurs later after surgery, however, it can require active treatment. Many patients improve with the use of nighttime nasal C-PAP. Those patients who do not improve sufficiently with nasal C-PAP may require surgical flap division. We report surgical flap division in 12 such patients. All patients had preoperative and postoperative perceptual speech evaluations, and most had preoperative and postoperative pressure flow studies. In 11 of the 12 patients who underwent surgical flap division, velopharyngeal function did not deteriorate. We hypothesized that the persistence of the speech improvement in those patients is either secondary to the bulk of tissue from the flap, which remains in the posterior pharyngeal wall and provides a pad to assist with velopharyngeal closure, or is secondary to the speech mechanisms that the patients learned with the flap in place and were able to continue even after flap division.