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