Is surgical treatment of hypernasal
speech in VCFS special?
Sherard A. Tatum, MD, FAAP, FACS
Associate Professor of Otolaryngology
Associate Professor of Pediatrics
Upstate Medical University
Syracuse, NY, USA
Velopharyngeal insufficiency (VPI)
Failure of the velar
and pharyngeal
musculature to close
the portion of the
throat that separates
the oral cavity from
the nasal cavity
during speech.
Treatment goal
Block sound and air from coming
out of the nose without causing
respiratory problems, sleep
apnea, and excessive stuffiness.
Surgical Options
There are many available surgical
procedures available to treat VPI,
and all of them will work in some
cases. However, VCFS is a special
case. Many strategies that work in
other patients have consistently poor
outcomes in VCFS.
Special Factors in VCFS
•Hypotonia of the palate and pharynx
•A very deep, large pharynx
•Structural and functional asymmetry of
the palate and pharynx
•Abnormal placement of the internal
carotid arteries
•Abnormal articulation patterns
•Higher frequency of airway obstruction
•Speech and language delay
Hypotonia
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Hypotonia
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Deep, large pharynx
Posterior rotation
As theofskull base rotates back, the
the skull basepharynx
is a
moves back increasing
common VCFS
pharyngeal
feature depth
Internal carotid arteries
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Asymmetry
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Asymmetry
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Causes of airway/apnea problems
Research has shown the following factors
contribute to airway/apnea problems:
•Tonsils
•Narrowing of the pharynx caused by side-toside closure of the flap donor site
•Flaps that are too low, increasing negative
pressure in the hypopharynx
Solution
Upstate Protocol
• Modified superiorly based pharyngeal flap
• Adenotonsillectomy before flap
• Adenoidectomy allows the nasopharyngeal
mucosa to be available for high flap
• Tonsillectomy to prevent lateral port and
oropharyngeal obstruction
• Flap raised at or above above the velum to
make it as high as possible
• Donor site closed by elevation of posterior
pharyngeal wall rather than side-to-side
Short, High, Wide Flap
Lateral ports
flap
velum
flap
velum
VPI Rating Scale
International Working Group, 1990
(Golding-Kushner et al., 1990, CPJ, 20:337-347)
Based on: videofluoroscopy and
nasopharyngoscopy
Palate and pharyngeal wall motion
rated using a ratio scale
Studies done immediately before
surgery
Multiview Videofluoroscopy
MVF Frontal View
0.0
0.5
0.0
Rest: 0.0
Side wall function: 0.0 - 1.0
Typical: 0.3 - 0.5
0.3
0.3
MVF Lateral View
REST
SPEECH
1.0
0.0
MVF Base View
Side Wall Movement: 0.0 - 1.0
typical: 0.3 - 0.5
1.0
0.0
Palate Movement: 0.0 - 1.0
typical: 0.5 - 1.0
Posterior Wall Movement: 0.0 - 1.0
typical: 0.0 - 0.5
0.4
0.4
Nasopharyngoscopy
What We See
What Patient Sees
Nasopharyngoscopy
• Rating scale
•
•
•
•
0.0 - 1.0
Palate
Posterior wall
Lateral walls (ML 0.5)
• Tonsils and adenoids
• SMCP
At Rest
1.0
0.5
0.0
1.0
0.0
Partial Closure
1.0
0.2
0.0
1.0
0.3
0.0
Complete Closure
LW 0.5
LW 0.5
Surgical Technique
Technique
Conventional Flap
Soft Palate
Short Flap
Soft Palate
Donor Site
D
O
N
O
R
Traditional
S
I
T
E
C
L
O
S
U
R
E
Modified
Donor Site Closure
Modified
Traditional
Closure of Donor Site
Lateral Closure
Vertical Closure
Lateral pharyngeal wall
Measures and Follow-up
• Immediately post-op
• Cardiac/apnea monitors
• Continuous oximetry
• Follow up at 1 week, 3 - 6 months,
annually
• Clinical screening for OSA
• Polysomnogram if symptoms and
signs of obstruction
• Nasopharyngoscopy
• Speech assessment
Obstructive Symptoms
• Snoring
• Exercise intolerance
• Restlessness
• Sinusitis
• Nasal dyspnea
• Otitis media
• Chronic rhinorrhea
• Denasality
• Mouth breathing
• Sleep disordered
breathing
Results
• 94 pharyngeal flaps
• 12 had previous operations elsewhere
• 9 had 1 previous operation
• 5 Sphincter pharyngoplasties
• 2 previous secondary palatoplasties, one
combined with a sphincter pharyngoplasty
• 2 pharyngeal flaps
• 3 had multiple operations
• 1 had sphincter pharyngoplasty with 2 revisions
• 1 had 2 palatoplasties and fat injections
• 1 had 5 previous palatoplasties
Flap design based on
diagnostic information
• 94 pharyngeal flaps
• 71 very wide
• 14 moderately wide
• 1 narrow
• 8 skewed to one side
Complications
• 94 pharyngeal flaps
• 3 returns to OR for bleeding
• 3 surgical revisions for partial
dehiscence
• 1 port dilation
• 5 with moderate hyponasality
• 2 with persistent obstructive symptoms
• negative PSGs - RDI < 5
Outcomes
• 94 pharyngeal flaps
• 88/94 with elimination of
hypernasality (93.6%)
• 5 with hypernasality, 3 revised, 2
would benefit from additional
treatment and are pending treatment
depending on outcome of speech
therapy
Summary
• Small gap VPI can be managed
successfully multiple ways, but such cases
are rare with VCFS
• Large gaps, asymmetric gaps are common
in VCFS and are best managed with wide
pharyngeal flaps
• Preoperative adenotonsillectomy and
short flaps with vertical donor site closure
reduce the obstructive symptoms
associated with wide flaps
Example: before and after
Example: speech before and after
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Thank You