Palatopharyngeal sling: a new technique in treatment of velopharyngeal insufficiency

OBJECTIVE: (a) Pharyngeal flap and sphincter pharyngoplasty are the procedures most frequently chosen by craniofacial surgeons for surgical management of velopharyngeal insufficiency. Both operations may be complicated by obstructive breathing and even sleep apnea. (b) The purpose of this study is to evaluate the efficacy of a palatopharyngeal sling in the treatment of velopharyngeal insufficiency in cases with weak palatal mobility and its effect on breathing. METHODS: Seventeen cases of post-palatoplasty velopharyngeal insufficiency were subjected to treatment by palatopharyngeal sling. This sling, created by elevation of bilateral myomucosal flaps formed of palatopharyngeus and superior constrictor muscles, passed through palatal split, sutured together and to a raw area on the oral surface of the soft palate. Pre- and post-operative evaluation was carried out by perceptual speech analysis and flexible nasopharyngoscopy. Polysomnography was used to assess the effect of the operation on breathing. RESULTS: Complete closure was achieved in 13 cases (76.5%) while 4 cases showed incomplete closure (2 of them showed improvement when compared with the pre-operative video). The overall improvement of speech and velopharyngeal closure was 88.2%. Polysomnography showed no obstructive breathing. CONCLUSIONS: Palatopharyngeal sling is a useful technique for correction of velopharyngeal insufficiency in cases with little palatal motion and it carries no risk of obstructive sleep apnea.     

Lateral pharyngeal flap with a double pedicle for repair of unilateral velopharyngeal insufficiency

ObjectivesConventional pharyngeal flap surgery, which closes the median portion of the velopharynx, has been performed for dysarthria patients with velopharyngeal insufficiency (VPI). However, for VPI due to unilateral pharyngeal paralysis, median closing disrupts pharyngeal contraction of the unaffected side and allows pharyngeal pressure to escape through the nose at the lateral portion of the affected side during speech and swallowing. The purpose of this study was to evaluate the effectiveness of lateral pharyngeal flap (LPF) surgery for unilateral VPI.MethodsSeven patients with unilateral VPI (five males and two females with an average age of 54 years) underwent LPF surgery combined with other transoral surgeries for dysphagia. The LPF surgical technique was as follows: after the laterocaudal-based pedicle flap of the soft palate and cranial-based pedicle flap of the posterior pharyngeal wall on the affected side were transorally elevated, each mucosal pedicle flap was sutured together. Functional oral intake scale (FOIS) scores and swallowing pressure before and after surgery were compared.ResultsUnilateral velopharyngeal closure preserved nasal breathing after LPF surgery in all patients. Rhinolalia aperta improved postoperatively in all patients except one. The mean FOIS scores were 2.3 preoperatively and 3.7, 5.3, and 5.9 at 2 weeks, 1 month, and 6 months postoperatively, respectively. The mean pressures significantly increased at the velopharynx (from 49 ± 30 mmHg to 92 ± 45 mmHg) and oropharynx (from 48 ± 18 mmHg to 66 ± 15 mmHg) six months after the surgery.ConclusionLPF surgery leaving the unaffected side intact can be an effective surgical procedure for patients with unilateral VPI.     

Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency

OBJECTIVES: Several surgical techniques are available for the treatment of velopharyngeal insufficiency (VFI). Each method has its own complications and non-dynamic roles. So the aim of this study was to present a novel physiological surgical technique designed by the author for reconstruction of the velopharyngeal sphincter in VFI. METHODS: This prospective study included six patients with VFI (two males and four females) with ages from 5 to 20 years (mean: 12.50 years). Speeches, nasopharyngeal and oral endoscopies for velopharyngeal valve closure were measured according to a 5-point scale where 0 was equivalent to normal and 4 meant a severe (constant) deviation. They were scheduled for cerclage sphincter pharyngoplasty after failure of appropriate speech therapy. Under general anaesthesia and the patient in semiflower's position; two level cerclages (1-0 polypropylene suture materials) were inserted behind the muscles of the velopharynx. The first at the level of junction of posterior and middle one-thirds of the soft palate passing through soft palate, left lateral pharyngeal wall, posterior pharyngeal wall, right lateral pharyngeal wall and the soft palate. The second was at 3mm in front of the latter. The surgical technique was described in details. RESULTS: Before surgery five patients (83.3%) had sever hypernasality (rating scale 3). After the cerclage operation and speech therapy four patients (66.6%) significantly improved to normal nasality (rating scale 0) and the remaining two patients improved to mild and moderate hypernasality (rating scale 1 and 2), respectively (p<0.05). By endoscopy the closing activity was (rating scale 3) in five patients (83.3%) and (rating scale 2) in one patient (18%). After the cerclage operation and speech therapy five patients (83.3%) changed significantly to complete closure (rating scale 0) and to (rating scale 1) in one patient (p<0.05). CONCLUSIONS: Cerclage sphincter pharyngoplasty is a new procedure designed by the author in VFI. It helps the velopharynx to function physiologically in three-dimensional patterns without dependency on the type of closure. Also it is an easy technique; without tissue flaps transfer, upper airway obstruction or hyponasality.     

Nasoseptal "rescue" flap: a novel modification of the nasoseptal flap technique for pituitary surgery

Objectives:

The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a “rescue” flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks.

Results:

The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest.

Conclusions:

This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.