speech surgery-crafting technique to problem · speech surgery: crafting technique to problem...
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Speech Surgery: Crafting Technique to Problem
Speech Surgery: Crafting Technique to ProblemTechnique to ProblemTechnique to Problem
Sherard A. Tatum, MD, FAAP, FACSP f f O l l d P di i
Sherard A. Tatum, MD, FAAP, FACSP f f O l l d P di iProfessor of Otolaryngology and Pediatrics
Upstate Medical UniversityS U N Y Syracuse
Professor of Otolaryngology and PediatricsUpstate Medical University
S U N Y SyracuseS.U.N.Y. SyracuseS.U.N.Y. Syracuse
Velopharyngeal FunctionVelopharyngeal Function
Sh f VP j i Sh f VP j i • Shape of VP port just prior to closure
• Patterns not discrete
• Shape of VP port just prior to closure
• Patterns not discretePatterns not discrete• Continuum• Asymmetry
Patterns not discrete• Continuum• Asymmetry• Incomplete closure\VPI
• ResonanceE i i
• Incomplete closure\VPI• Resonance
E i i• Emission• Articulation
• Large vs small gaps
• Emission• Articulation
• Large vs small gapsg g pg g p
l h l fl h l fVelopharyngeal DysfunctionVelopharyngeal Dysfunction
• Goals - consensus• Complete correction
• Goals - consensus• Complete correction
• Problems - no consensus• Improvement vs. correction
• Problems - no consensus• Improvement vs. correctionp
• No side effects• Minimal
p• No side effects• Minimal
p• Tolerable side effects• Acceptable burden of
p• Tolerable side effects• Acceptable burden of
interventionsinterventions treatment• What works?
• Anything works for small gaps
treatment• What works?
• Anything works for small gaps• Anything works for small gaps• Anything works for small gaps
llSurgical OptionsSurgical Options
• Large gaps > 80%• Pharyngoplasty
• Large gaps > 80%• Pharyngoplasty
• Small gaps < 20%• Tonsillectomy
• Small gaps < 20%• Tonsillectomy • Pharyngoplasty
• Pharyngeal flap
• Pharyngoplasty
• Pharyngeal flap
• Tonsillectomy• Rarely alone
• Palatal lengthening\
• Tonsillectomy• Rarely alone
• Palatal lengthening\g gmuscle repair
• Posterior wall
g gmuscle repair
• Posterior wall augmentation
• Implants
I j ibl
augmentation• Implants
I j ibl• Injectibles• Injectibles
Pharyngeal Flap HistoryPharyngeal Flap HistoryPharyngeal Flap HistoryPharyngeal Flap History• Passavant (1862)
S gi l tt h t f th • Passavant (1862)
S gi l tt h t f th • Surgical attachment of the soft palate to posterior pharyngeal wall
• Schoenborn (1875)
• Surgical attachment of the soft palate to posterior pharyngeal wall
• Schoenborn (1875) • Schoenborn (1875) • Inferiorly based
• Sanvanero-Rosselli (1935)
• Schoenborn (1875) • Inferiorly based
• Sanvanero-Rosselli (1935)• Superiorly based• Less tension• Better strength
• Superiorly based• Less tension• Better strength• Visualization of donor bed
• Hogan• Lining
• Visualization of donor bed
• Hogan• Liningg• Lateral port control• Palate division
g• Lateral port control• Palate division
h l lh l lPharyngeal FlapPharyngeal Flapl bl b• Central obturator
• Lateral ports• Central obturator• Lateral ports• Donor site defect• Secondary airway • Donor site defect• Secondary airway
narrowing• Two levels of
b t ti
narrowing• Two levels of
b t tiobstruction• Flap
obstruction• Flap• Space inferior
to flap• Space inferior
to flap
Procedure of Choice for Procedure of Choice for Procedure of Choice for Large Gaps?
Procedure of Choice for Large Gaps?
Ph g l FlPh g l Fl Ph g l tPh g l t• Pharyngeal Flap• Elimination of VPI:
75%-98%
• Pharyngeal Flap• Elimination of VPI:
75%-98%
• Pharyngoplasty• Elimination of VPI:
50%-80%
• Pharyngoplasty• Elimination of VPI:
50%-80%75% 98%• Higher risk of OSA
75% 98%• Higher risk of OSA
50% 80%• Lower risk for OSA
50% 80%• Lower risk for OSA
OSA with Superiorly Based OSA with Superiorly Based OSA with Superiorly Based Pharyngeal Flap (SBPF)
OSA with Superiorly Based Pharyngeal Flap (SBPF)
• Early postop airway obstruction• 90% n=10 (Orr et al 1987)
10% n 300 (Shprintzen 1988)
• Early postop airway obstruction• 90% n=10 (Orr et al 1987)
10% n 300 (Shprintzen 1988)• 10%, n=300 (Shprintzen 1988)• 2.4%, n= 585 (Ysunza 1993)• 9.2%, n=219 (Valnicek 1994)
• 10%, n=300 (Shprintzen 1988)• 2.4%, n= 585 (Ysunza 1993)• 9.2%, n=219 (Valnicek 1994)• 38%, n=38 (Lesavoy et al 1996)• 3.2%, n=222 (Fraulin et al 1998)• 38%, n=38 (Lesavoy et al 1996)• 3.2%, n=222 (Fraulin et al 1998)
• OSA on follow up• 20% (2/10)- at 3 months (Orr et al 1987)
1% (3/300) t 6 th (Sh i t 1988)
• OSA on follow up• 20% (2/10)- at 3 months (Orr et al 1987)
1% (3/300) t 6 th (Sh i t 1988)• 1% (3/300) at 6 months (Shprintzen 1988)• 4% (9/219) at 3 weeks (Valnicek 1994)• 1% (3/300) at 6 months (Shprintzen 1988)• 4% (9/219) at 3 weeks (Valnicek 1994)
Potential Etiology of OSA Potential Etiology of OSA Potential Etiology of OSA with SBPF
Potential Etiology of OSA with SBPF
• Velopharyngeal obstruction
• Circumferential
• Velopharyngeal obstruction
• Circumferential Circumferential narrowing of airway• Lateral wall
advancement for
Circumferential narrowing of airway• Lateral wall
advancement for closure
• Scar contraction from second intention healing
closure• Scar contraction from
second intention healing
• Length of flap (donor site)• Larger segment of
• Length of flap (donor site)• Larger segment of g g
airway narrowing
• Palate length
g gairway narrowing
• Palate length
Potential Etiology of OSA Potential Etiology of OSA Potential Etiology of OSA with Pharyngeal Flap
Potential Etiology of OSA with Pharyngeal Flap
• Narrow Flap• Narrow Flap• Tonsils in
ports• Tonsils in
portsp• VPI after
tonsillectomy?
p• VPI after
tonsillectomy?tonsillectomy?tonsillectomy?
hhHypothesisHypothesis
• The risk of OSA is decreased by limiting length of PF, vertical closure of donor
• The risk of OSA is decreased by limiting length of PF, vertical closure of donor g ,site, and routine adenotonsillectomy. Short flap also pulls palate posteriorly
g ,site, and routine adenotonsillectomy. Short flap also pulls palate posteriorly p p p p yand superiorly away from retrolingualspace.
p p p p yand superiorly away from retrolingualspace.pp
h h d lh h d lShort, High, Wide FlapShort, High, Wide Flap
septumflap flap
portport
velum velum
Flap/Port SizeFlap/Port SizeFlap/Port SizeFlap/Port Size
• Medium 50%• Wide 75-85%• Medium 50%• Wide 75-85%• Very wide 90-95%• Asymmetry• Very wide 90-95%• Asymmetryy yy y
VPI Rating ScaleVPI Rating ScalegInternational Working Group, 1990
(Golding-Kushner et al., 1990, CPJ, 20:337-347)
gInternational Working Group, 1990
(Golding-Kushner et al., 1990, CPJ, 20:337-347)( g , , , )( g , , , )
u Based on: videofluoroscopy and nasopharyngoscopyP l t d h l ll t d
u Based on: videofluoroscopy and nasopharyngoscopyP l t d h l ll t d u Palate and pharyngeal walls are rated separately relative to each otherSt t t d l g t j t f
u Palate and pharyngeal walls are rated separately relative to each otherSt t t d l g t j t f u Structures rated along trajectory of movement at level of VP port
u Ratio scale of 0 0 to 1 0
u Structures rated along trajectory of movement at level of VP port
u Ratio scale of 0 0 to 1 0u Ratio scale of 0.0 to 1.0u Ratio scale of 0.0 to 1.0
MVF Frontal ViewMVF Frontal View
0.50.0 0.0
Rest: 0.0Rest: 0.0
Side wall function: 0.0 - 1.0
0.3 0.3Typical: 0.3 - 0.5
MVF Lateral View
REST SPEECHREST SPEECH
1.0
0.0
MVF Base ViewMVF Base View
1.0Side Wall Movement: 0.0 - 1.0
0.0typical: 0.3 - 0.5
Palate Movement: 0.0 - 1.0ltypical: 0.5 - 1.0
Posterior Wall Movement: 0.0 - 1.0typical: 0 0 0 5typical: 0.0 - 0.5
0.40.4
NasopharyngoscopyNasopharyngoscopyp y g pyp y g py
What We See What Patient SeesWhat We See What Patient Sees
hhNasopharyngoscopyNasopharyngoscopy
• Rating scale• 0.0 - 1.0
• Rating scale• 0.0 - 1.0• Palate• Posterior wall
l ll
• Palate• Posterior wall
l ll• Lateral walls (ML 0.5)
• Tonsils and adenoidsS C
• Lateral walls (ML 0.5)
• Tonsils and adenoidsS C• SMCP• SMCP
1.0At RestAt Rest
0.50.0 1.0
0.0
1 0Partial Closure
1.0
S l 0.3
1.00.0
Scales run in both direc
0.3
1.0direc-tions
0.0
llProtocolProtocol
• Modified superiorly based pharyngeal flap• Staged adenotonsillectomy 4months prior to
PF
• Modified superiorly based pharyngeal flap• Staged adenotonsillectomy 4months prior to
PFPF• Posterior nasopharyngeal mucosa available for
high PF after adenoidectomy
PF• Posterior nasopharyngeal mucosa available for
high PF after adenoidectomyhigh PF after adenoidectomy• Tonsillectomy to prevent lateral port and
oropharyngeal obstructionFl i d t b b th l l f
high PF after adenoidectomy• Tonsillectomy to prevent lateral port and
oropharyngeal obstructionFl i d t b b th l l f • Flap raised at or above above the level of velum
• Donor site closed with superior advancement
• Flap raised at or above above the level of velum
• Donor site closed with superior advancement• Donor site closed with superior advancement• Donor site closed with superior advancement
hhTechniqueTechnique
• Short, high, wide flap
• Short, high, wide flap
• Limited to naso-and upper
h
• Limited to naso-and upper
horopharynxoropharynx
TechniqueTechniqueTechniqueTechniqueShort FlapConventional Flap
Soft Palate Soft Palate
Donor Site
DONNOR
Traditional
SITE
CLO M difi dOSU
Modified
RE
Donor Site ClosureDonor Site Closure
Modified TraditionalModified Traditional
l fl fClosure of Donor SiteClosure of Donor SiteLateral Closure V ti l ClLateral Closure Vertical Closure
Lateral pharyngeal wall
d lld llMeasures and Follow-upMeasures and Follow-up
• Immediate postoperative • Cardiac/apnea monitors
C i i
• Immediate postoperative • Cardiac/apnea monitors
C i i• Continuous oximetry• Follow up at 10 – 14 days, 3 - 6 months,
annually
• Continuous oximetry• Follow up at 10 – 14 days, 3 - 6 months,
annuallyannually• Clinical screening for OSA – modified Epworth• Polysomnogram if symptoms and signs of
annually• Clinical screening for OSA – modified Epworth• Polysomnogram if symptoms and signs of
obstruction• Nasopharyngoscopy• Speech assessment
obstruction• Nasopharyngoscopy• Speech assessmentSpeech assessmentSpeech assessment
bbObstructive SymptomsObstructive Symptoms
• Snoring• Snoring • Exercise intolerance• Exercise intolerance
• Restlessness\movement
• Nasal dyspnea
• Restlessness\movement
• Nasal dyspnea
• Sinusitis
• Otitis media
• Sinusitis
• Otitis media
• Chronic rhinorrhea
• Mouth breathing
• Chronic rhinorrhea
• Mouth breathing
• Hypo\Denasality• Hypo\Denasality
• Sleep disordered breathing
• Sleep disordered breathing
ResultsResults• 100 pharyngeal flaps – 88 wide or very wide
3 t t OR f bl di
• 100 pharyngeal flaps – 88 wide or very wide
3 t t OR f bl di• 3 returns to OR for bleeding
• 4 surgical revisions2 f b t ti
• 3 returns to OR for bleeding
• 4 surgical revisions2 f b t ti• 2 for obstruction
• 2 for partial dehiscence
• 92 of 100 with normalization of resonance
• 2 for obstruction
• 2 for partial dehiscence
• 92 of 100 with normalization of resonance92 of 100 with normalization of resonance
• 3 with marked improvement but persistent hypernasality
92 of 100 with normalization of resonance
• 3 with marked improvement but persistent hypernasalityyp y
• 5 with moderate hyponasality
• 6 with persistent obstructive symptoms
yp y
• 5 with moderate hyponasality
• 6 with persistent obstructive symptomsp y p• negative PSGs – RDI < 5
p y p• negative PSGs – RDI < 5
SummarySummary
• Small gap VPI can be managed successfully multiple ways
• Small gap VPI can be managed successfully multiple ways
• Large gap VPI can be managed successfully with tailored wide pharyngeal flaps
• Large gap VPI can be managed successfully with tailored wide pharyngeal flaps
• Preoperative tonsillectomy and short flaps with vertical donor site closure reduce the b t ti t i t d ith id
• Preoperative tonsillectomy and short flaps with vertical donor site closure reduce the b t ti t i t d ith id obstructive symptoms associated with wide
flapsobstructive symptoms associated with wide flaps
Pharyngeal Flap Pre and PostPharyngeal Flap Pre and Post
Thank YouThank YouThank YouThank You
Flap with Carotid in the WayFlap with Carotid in the Way
b l l fb l l fSubmucosal CleftSubmucosal Cleft
• Result of some palate repair techniquesMi li d l
• Result of some palate repair techniquesMi li d l• Misaligned muscles• Furlow, IVV
• Short soft palate
• Misaligned muscles• Furlow, IVV
• Short soft palateShort soft palate• Furlow, push back
• Hypomobility
Short soft palate• Furlow, push back
• Hypomobility• Does palate surgery
help?• Does palate surgery
help?
l l hl l hPalatal LengtheningPalatal Lengthening• No muscle realignment• No muscle realignmentNo muscle realignment• Scarring
• Bare bone
No muscle realignment• Scarring
• Bare bone• Relapse
• Downward lengthening?• Relapse
• Downward lengthening?
l l ll l lIntravelar VeloplastyIntravelar Veloplasty
• Realigns muscle• No added length• Realigns muscle• No added lengthg• Scarring
g• Scarring
b d hb d hCombined TechniquesCombined Techniques
• IVV – muscle realignment• V – Y pushback – palatal lengthening• IVV – muscle realignment• V – Y pushback – palatal lengtheningV Y pushback palatal lengthening• Scarring
V Y pushback palatal lengthening• Scarring
Furlow PalatoplastyFurlow PalatoplastyFurlow PalatoplastyFurlow Palatoplasty
• Reorients muscle• Lengthens palate• Reorients muscle• Lengthens palateLengthens palate• Less scarring
Lengthens palate• Less scarring
h lh lPharyngoplastyPharyngoplasty• Hynes (1950)• Hynes (1950)Hynes (1950)• Orticochea (1968) “Dynamic sphincter”• Jackson (1977 1985)
Hynes (1950)• Orticochea (1968) “Dynamic sphincter”• Jackson (1977 1985)• Jackson (1977, 1985)• Jackson (1977, 1985)
h lh lPharyngoplastyPharyngoplasty
• Sphincter• Dynamic?• Sphincter• Dynamic?y• Peripheral
VP gap d ti
y• Peripheral
VP gap d tireduction
• Central Portreduction
• Central Port
Multiview Video fluoroscopy Multiview Video fluoroscopy Multiview Video fluoroscopy Images
Multiview Video fluoroscopy Images
Skolnick, 1969, 1970
Complete Closure (sagittal)Complete Closure (sagittal)
LW 0.5LW 0.5 LW 0.5LW 0.5