Artículo Clínico

---

Secondary functional veloplasty: a non-obstructive approach to valopharyngeal insufficiency
Veloplastia funcional secundaria: Una alternativa no obstructiva en el tratamiento de la insuficiencia velofaríngea

 

J. Cortés Araya^1,2, A.Y. Niño Duarte³, H.H. Sung Hsieh⁴, B. Gómez Sánchez⁵

---

1 Profesor Asociado de Cirugía Máxilofacial, Facultad de Odontología, Universidad de Chile, Chile.
2 Cirujano de la Unidad de Fisurados, Hospital Dr. Félix Bulnes Cerda. Santiago de Chile, Chile.
3 Cirujana Máxilofacial, Venezuela.
4 Instructora ad-honorem, Facultad de Odontología, Universidad de Chile, Chile.
5 Fonoaudiólogo, Facultad de Odontología, Universidad de Chile, Chile.

Correspondencia:
Juan Cortés Araya.
C/ Cruz del Sur 24 depto 201-Las Condes, Santiago de Chile.
E-mail:jcortes@uchile.cl

 

Introduction

It is common to observe the presence of sequels in patients born with velar or velomaxillary clefts, who have received veloplasties as primary treatment (Fig. 1). These sequels are expressed as velar dysfunctions, affecting the voice and audition of the patients suffering it. Clinically, they are known as open rhinolalia as the voice is affected, it becoming nasal, and on the other hand, we find hypoacusis, secondary to chronic otitis media, that affects middle ear ventilation.

The disorders caused by velar dysfunction are grouped under the term of "Velopharyngeal insufficiencies." We define velopharyngeal insufficiency as the incapacity of occlusion of the velopharyngeal sphincter, permitting the air to escape towards the nasal cavity during the emission of vocalic and consonant phonomes, except for m, n and ñ which are, by nature, nasal. In these cases, the velum is, to a greater or lesser degree, shortened, atrophic and its muscular fibers are displaced from their normal insertion site, and are incapable of moving in order to contact with the pharyngeal wall as normally occurs. Generally, in these cases, the phonoaudiological therapy is limited and its results are often unsatisfactory.

The pharyngoplasty classically presents as the procedure of choice in these cases, many techniques having been described (Fig. 2).¹ These procedures, whatever they are, aim to displace the mucosa and soft palate backwards, in a socalled posterior palate displacement or push back, that approaches the posterior border of the velum to the pharyngeal wall. It is then sutured to a flap that is cut in its posterior wall, either with the superior or inferior base. The result is that, in fact, air escape toward the nasal pits can be prevented, improving the rhinolalia but with the biological cost of a reduction in the diameter of the upper airway with the consequent respiratory reduction. Several studies show that this deterioration in respiratory capacity affects children more seriously than adults.² We presently know that a reduction in the upper airway not only means converting a patient who did not snore before the surgical act into one who does but also running the risk of generating a sleep obstructive disorder that produces a serious circadian rhythm alteration that is expressed, for example, in an I.U.A.R.S. (Increased Upper Airway Resistance Syndrome) ³ or in a S.A.S. (Sleep Apnea Syndrome).

Based on our preliminary experience of 15 cases, this article aims to present an original surgical treatment that corrects velopharyngeal insufficiency without affecting the upper airway diameter and achieving an appropriate velar morphology, that subsequently permits the emission of adequate voice and audition.

Material and method

From January 2000 to June 2002, we treated a series of 15 cases of patients having velar cleft sequels, characterized by moderate or severe velopharyngeal insufficiency, residual bucconasal clefts or fistulas and adherences due to mucosa scaring. At the time of surgery, the patients were between 8 and 22 years of age and all were evaluated, prior to the surgical treatment by the same phonoaudiologists, the surgical decision being made jointly by the phonoaudiologist and the surgeon.

For practical reasons, we have classified velopharyngeal insufficiencies into three types: mild, that we correct based on phonoaudiological reeducation; moderate and severe that we treat with phonoaudiological reeducation and surgical reconstruction. In the decision to perform this surgical procedure or not, we have defined Inclusion Criteria, considering those patients who, in spite of velar shortening, have a morphologically adequate velar muscular tissue and as Exclusion Criteria, those patients with previous marked asymmetric muscular reparations or in whom severe tissue loss is verified or in whom there is some neurological incapacity or alteration.

A surgical technique has been designed that aims to make the anatomical reconstruction of the soft palate based on the muscular elements available and that can be identified, dissected and functionally recovered.⁴ This technique makes it possible to simultaneously recover velopharyngeal competence, improving the morphological and functional conditions of the soft palate, eliminating rhinolalia and trying to achieve improvement in middle ear ventilation.

The procedure is based on the empiric verification that there is an anatomic substrate available in many velopharyngeal incompetences, whose functionality can be rescued and reestablished although it does not function adequately since the muscles are often displaced, atrophic and deformed. Thus, this operation is a secondary functional reconstruction of the soft palete or secondary functional veloplasty, inspired by the functional principles of Delaire.⁵ The patients were studied with aerophonoscopic registries performed prior to and after the surgical repair.

The surgical objective is to identify, dissect and adequately reinsert the tissues. With the help of a mouth opener that allows us to have an adequate operative field, we should first perform a total opening of the palate, sectioning it sagitally in the middle line. To completely expose the region, we incise from the retrouvular region at the height in which the posterior pillars should be found behind until the mucosa that lines the hard palate in front, searching for the bone reference of the posterior nasal spine. In this way, we expose both hemivelums, the borders remaining reverted towards the middle line. Once this is done, we have sufficient access to dissect from the palate vault to the region of the posterior pillars (Figs. 3 and 4). At this time, we dissect the muscular plane, searching for the elevator muscle of the soft palate or elevator muscle of the velum that should be uninserted from the bone palate and carried backwards, to then be joined in the middle line.

We do the same with the posterior pillar or palatopharyngeal muscle of each side. We dissect it to join one with the contralateral side and thus establish an arrangement between them that is as similar as possible to normal anatomy. We place special emphasis on the preservation of the pterygoid hooks and of their muscular insertions (Figs. 5 and 6), since they are important for the preservation of the tensor function together with the elevator of the soft palate.

Then the mucosa of the nasal side of the hard palate is identified and sutured with its contralateral side, thus establishing a clear separation between the nasal and buccal cavities. Suturing is continued, from front to back, thus moving the previously dissected soft palate musculature to a more posterior position than it previously had. The closure of this muscular plane is completed with the reconstruction of the posterior pillars, that are searched for behind the uvula region. Once this nasal and muscular (functional) plane is closed, the buccal plane is closed. It is started by closing the inferior side of the posterior pillars, the uvula, the soft palate area itself until reaching the hard palate area. At this time, the possible fistulas are corrected or the adherences or folds existing are eliminated.

A phonoaudiological examination was performed in each patient to evaluate the results. This examination was performed by the same specialist in all the cases. In order to make the study of the results objective, the examination included an instrumental evaluation using an aerophonoscope. Both this evaluation and the phonoaudiological examination were performed in the preoperative as well as postoperative period of each patient. The aerophonoscopic studies were performed with an apparatus " " and the operation was done by the same phonoaudiologist in all the cases.

Results

Figures 7 to 12 show the aerophonoscopic registries referring to the prolonged, pretreatment and postsurgical phonemas "CHI – LLA", "I", "U", and "I" of the case illustrated.

In the upper half of the figure, an improper air escape through the nose due to failure in the occlusion of the velar sphincter can be seen and the intensity of the phoneme emission can be seen in the lower half. We can verify how, after the surgical correction, the air escape is almost imperceptible and the intensity of the voice increases considerably.

Discussion

Valopharyngeal insufficiency is a usual condition observed in those born with soft palate fissures and treated surgically, regardless of the technique used. Although there are clinical backgrounds that verify that an early velum reconstruction is associated to better long term results regarding the quality of voice and audition,^6-8 velopharyngeal insufficiency may occur as a sequel of any technique. Treatment dependent factors would thus not only be important among the factors to be considered in its appearance, but also constitutional factors, such as width and depth of the pharynx and quality of the tissues involved, among others.

For the treatment of velopharyngeal insufficiency, several treatments have been tested, as, for example, phonoaudiological reeducation, which is really the base of any therapy, by itself, or as a complement to another procedure. The use or orthesis or other prosthesic additions that help to improve the velopharyngeal competence and surgical techniques, as the reoperation of the velum or the pharyngoplasty techniques, have been tested.

The latter may be the surgical technique used by the greatest number of surgeon who deal with the management and treatment of this condition.

From a practical point of view, however, if we compare the pharyngoplasty surgical techniques versus the secondary functional reconstruction of the velum proposed, we see how the velar reoperation offers certain advantages regarding the former, especially because of its surgical simplicity.

In fact, performing a secondary functional veloplasty not only implies reduction of the operative time but also economy in the means necessary to obtain the objective: functional velar lengthening. This antero-posterior lengthening is achieved on freeing the palatine aponeurosis with its tensor muscles and elevator of the soft palate from its insertions in the palate vault and once dissected, this is carried to a more posterior position, preserving the essential structures for its mobility, such as the pterygoid hooks.

If both surgical techniques are compared in regards to anatomic territory operated, we see that the operative site in the secondary reconstruction is the palate and the incisions are performed in the velar or maxillary area exclusively, without going into neighboring anatomic sectors.

On the contrary, when other topographic territories such as the posterior or lateral wall of the pharynx, rich in vessels such as ascending and descending pharyngeal vessels are affected by the pharyngoplasties, there is a potential risk of excessive bleeding and even more so in the cases that present anatomic variations, as for example, the Shprintzen Syndrome or Velocardiofacial Syndrome, that does not occur in secondary functional veloplasty since it has a different anatomic substrate.

In the immediate postoperative period, the discomfort caused by the exposure and manipulation of the pharyngeal tissues determined by the pharyngoplasty techniques are obviated when a secondary functional veloplasty is performed for the same reason detailed in the previous point. This period is easier, there not only being less breathing difficulty, since there is no type of airway restriction, but also fewer eating and speaking restrictions, since there are no invasive zones exposed, as occurs, on the contrary, in the postoperative of the pharyngoplasties.

When the mechanisms by which one technique and another improve the velopharyngeal insufficiency are analyzed, we see that these are completely different. While the secondary veloplasty improves the morphofunctional conditions to obtain a «normal» or «physiological» velopharyngeal competence, that is, active, due to a recovered contractile muscular function, the velopharyngeal competence obtained after a pharyngoplasty is passive in most of the cases, due to simple mechanical blockade of the airflow towards the nasal cavity.

From the functional point of view, a pharyngoplasty produces different changes. On the one hand, it can treat the velopharyngeal insufficiency, improving the voice, an aspect that has some unanimity⁹ since a flap shifted from the pharynx mechanically prevents air passage to the nasal pits. However, this beneficial characteristic is also the origin of its greatest disadvantage: blockage of the air passage from the nasal pits, that causes a significant decrease in the air volume that should pass from the nasal pits to the lungs. Although there have been efforts to improve the ventilatory aspects associated to the pharyngoplasty techniques, ¹⁰ there is documented evidence of airway obstruction due to surgical treatments that use the pharynx lumen, as the Furlow technique itself,^2,11,12 appearance of cardiovascular disorders and even post-operative death in patients having syndromes such as the Velocardiofacial or Pierre Robin ones.^13,14

Until recently, snoring was not considered as a pathological clinical sign and Sleep Medicine had not appeared in the clinical discipline spectrum. Nowadays, however, we know that snoring during sleep is a clinical sign that may be relevant within the sleep obstructive disease and that sleep diseases have a high prevalence in society, affecting between 5% to 10% of the populations according to some calculations in developed countries.^15-18 These diseases generate deterioration in quality of life, memory and concentration disorders and therefore learning disorders, cardiovascular complications, increase the number of traffic accidents and significantly influence work accidents. On the other hand, there are deformities in the facial skeleton in relationship to the frequent structural characteristics observed in cleft patients. We should remember that the most frequently observed is the lack of saggital advance and decrease of superior maxillary and a lower saggital length of this same maxillary, whether considered as a characteristics of the maxillary and cranial base of this population¹⁹ or simply sequels of surgical techniques of non-functional velar and/or maxillary closure.^20,21 In practice, this means that an important number of cleft patients present class III dentofacial deformity with inverted bite due to maxillary retrognathia. We know that a retrognathia, whatever its origin, is an adverse respiratory anatomical factor due to reduction of air space of the nasopharynx and/or due to inadequate location of the tongue within the buccal cavity. In this situation, the maxillary occupies a more posterior and higher anatomic site in the upper floor of the face, impacted in an area that normally should be available for air passage towards the bronchi.

Thus, it is doubly serious to use operative techniques that restrict the air passage by the upper airway and thus facilitate the appearance of obstructive respiratory disorders to a population that presents intrinsic characteristics of obstructive risk.

The greatest advantage of the technique proposed is precisely that it returns the normal velar morphology and thus the capacity to the velopharyngeal structures to obtain competence, leaving this sector in conditions of being reeducated phonoaudiologically and thus achieving a correct voice free of nasalizations, preserving the caliber and functionality of the upper airway.

Perhaps the greatest disadvantage of this technique is its limited indication. In fact, it is not useful in all the cases of velopharyingeal insufficiency (VFI). There is VFI having neurological etiology, as certain velar paralysis or others idiopathic ones, such as some malformations that are expressed with agenesis or hypoplasy of the velopalatine sectors. They do not respond to surgical treatment as that proposed since the indispensable substrate is not available: the duly innervated muscle tissue, necessary for velar contraction.

The challenge of the prevention and treatment of velopharyngeal insufficiency continues to exist. We believe that the search for solutions to this old problem should be oriented towards treatments in general and to the design of surgical techniques in particular that manage to correct velopharyngeal insufficiency without altering other structures, such as the pharynx, functions, such as respiratory or biological rhythms, such as circadian.

Along this reflexive line, our proposal is oriented to the recovery of the forms and function, searching for the recovery of normal anatomy and physiology of the zone with our technique.

Conclusions

• In selected cases, Secondary Functional Veloplasty improves velopharyngeal competence.

• In these cases, this improvement is seen by means of an aerophonoscope.

• This velopharyngeal correction preserves the upper respiratory space.

References

1. Sloan G. Posterior pharyngeal flap and sphincter pharyngoplasty: The state of the art. Cleft Palate. Craniofa J 2000;37:2112-22.         [ Links ]

2. Liao YF, Chuang ML, Chen PK, Chen NH, Yun C, Huang CS.Incidence and severity of obstructive sleep apnea following pharyngeal flap surgery in patients with cleft palate. Cleft Palate Craniofac J 2002;39:312-6.         [ Links ]

3. Puertas Cuesta FJ. El síndrome de aumento de resistencia de la vía aérea superior. Vigilia-Sueño 2000;12:S57-S64.         [ Links ]

4. Cortés J. Secondary funtional repair of the velar cleft. A non-obstructive approach in velopharingeal incompetence». CLEFT 2002. Munich 2002.         [ Links ]

5. Delaire J. Considérations sur la reconstitution de la luette et de la partie postérieure des palais congénitalement divisé. J Ann Chir Plast 1972;17:99-105.         [ Links ]

6. Too-Chung M A. The assessment of middle ear function and hearing by tympanometry in children before and after early cleft palate repair. British Journal of Plastic Surgery 1983;36:295-9.         [ Links ]

7. Psaume J. Brièveté de la période d’acquisition des phonèmes. Arguments pour le traitemente précoce des fentes maxillo-palatines. Rev Stomatol Chir Maxillofac 1992;93:349-50.         [ Links ]

8. Paradise JL, Elster BA, Tan L. Evidence in infants with cleft palate that breast milk protects against otitis media. Pediatrics 1994;94:853-60.         [ Links ]

9. Huang MH, Riski JE, Cohen SR, Simms CA, Burstein FD. An anatomic evaluation of the furlow double opposing Z-plasty technique of cleft palate repair. Ann Acad Med Singapore 1999;28:672-6.         [ Links ]

10. Hogan VM. A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft Palate J 1973;10:331-45.         [ Links ]

11. Yu-Fang Liao, Yun C, Chiung-Shing H, Chen PKT, Ning-Hung C, Kai-Fong H, Ming-Lung Chuang. Longitudinal Follow-Up of Obstructive Sleep Apnea Following Furlow Palatoplasty in Children With Cleft Palate: A Preliminary Report. The Cleft Palate-Craniofacial Journal 2003;40.         [ Links ]

12. Robson MC, Stankiewicz JA, Mendelsohn JS. Cor pulmonale secondary to cleft palate repair. Plast Reconstr Surg 1977;59:754-7.         [ Links ]

13. Kravath RE, Pollak CP, Borowiecki B, Weitzman ED. Obstructive sleep apnea and deathassociated with surgical correction of velopharyngeal incompetence. The Journal of Pediatrics 1980;96:645:8.         [ Links ]

14. Jackson P, Whitaker LA, Randall P. Airway hazards associated with pharyngeal flaps in patients who have the Pierre Robin syndrome. Plast Reconstr Surg 1976; 58:184-6.         [ Links ]

15. Lugaresi E, Zucconi M, Bixler EO. Epidemiology of sleep disorders. Psychiatric Annals 1987;17:446-53.         [ Links ]

16. Marín JM, Gascón JM, Carrizo S, Gispert J. Prevalence of sleep apnoea syndrome in the Spanish adult population. Int J Epidemiol 1997;26:381-6.         [ Links ]

17. Bixler EO, Kales A, Soldatos Cr, Kales JD, Healey S. Prevalence of Sleep Disorders in the Los Angeles Metropolitan Area. Am J Psych 1979;136:1257-62.         [ Links ]

18. Vela-Bueno A. de Iceta M. Fernández C. Prevalencia de los trastornos del sueño en la ciudad de Madrid. Gaceta Sanitaria 1999;13:441-8.         [ Links ]

19. Granic X. Análisis arquitectural y estructural de la base craneal anterior en sujetos fisurados labio-maxilo-palatinos. Tesis, Facultad de Odontología. Universidad de Chile 2002.         [ Links ]

20. Joos, U. Skeletal growth after muscular reconstruction for cleft lip, alveolous and palate. Br J Oral Maxillofac Surg1995;33:139-44.         [ Links ]

21. Markus AF, Precious DS. Effect of primary surgery for cleft lip and palate on midfacial growth. Br J Oral Maxillofac Surg 1997;35:6-10.         [ Links ]