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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_33_библиотеки_им_акад_М_И_Перельмана
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FIGURE 10-3 The pharyngeal flap is a midline tissue bridge
extending from the flap's reattachment at the posterior
pharyngeal wall to its point of insertion in the soft palate. Two
open spaces on either side of the flap permit nasal
respiration, drainage, and resonance for nasal consonant
production. (From Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft
palate speech [4th ed]. St. Louis: Mosby, 2010.)
Pharyngeal flaps are essentially tissue obturators, not structures
that are active in closing the VP port. A good speech result from a
flap depends on mesial movement of the lateral pharyngeal walls,
superoposterior movement of the velum, or both. Individuals who
have mesial movement of the lateral pharyngeal walls observed
during speech production before surgery are generally considered
the best candidates for the operation.
Endoscopic and multiview videofluorographic speech studies
have revolutionized treatment planning and assessment of
outcomes. When used preoperatively, endoscopy and
videofluoroscopy provide a view of the movements of the velum,
lateral pharyngeal walls, posterior pharyngeal walls, and associated
pharyngeal tissues while the patient produces speech. These studies
can help the surgeon determine whether a pharyngeal flap is likely
to be helpful and, to some extent, choose how to customize the flap
to fit the observed deficiency. For example, if good lateral wall
movement is observed endoscopically during speech in a child with
a large midline VP gap, the surgeon could be relatively confident
that a moderately wide pharyngeal flap would improve speech.
Although higher-cost assessment procedures such as magnetic
resonance imaging have been proposed for preoperative speech
assessment, they have not become commonly used.
Sphincter Pharyngoplasty
Surgeons are understandably very cautious about using surgical
procedures to improve speech if those procedures may affect nasal
respiration. The pharyngeal flap places a midline tissue obstruction
squarely in the middle of the VP port, where it can have an impact
on nasal respiration. What has become known as sphincter
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pharyngoplasty received considerable aention from surgeons who
were intrigued by the prospect of a more physiological alternative to
the pharyngeal flap.
The procedure involves raising two flaps, one from each of the
posterior pharyngeal pillars, elevating them superiorly and
posteriorly, and inserting them into a posterior pharyngeal wall
incision created at or near the level of the hard palate. The two flaps
may overlap one another to create some posterior pharyngeal wall
augmentation. The result is a smaller midline VP port (Fig. 10-4).
Valving the residual port for speech requires movement of the
velum. Narrowing of the lateral edges of the residual port during
speech has been observed in some patients, resulting in what
appears to be a sphincter-like closing paern (Video 10-2
).
FIGURE 10-4 The sphincter pharyngoplasty involves raising
two flaps from the posterior pharyngeal pillars, elevating them
superiorly and posteriorly, and inserting them into an incision
created at or near the level of the hard palate. The result is a
smaller midline velopharyngeal port. (From Peterson-Falzone SJ,
Hardin-Jones MA, Karnell MP: Cleft palate speech [4th ed]. St. Louis: Mosby,
2010.)
Current versions of sphincter pharyngoplasties remain popular
and can be an important part of the team's or surgeon's repertoire of
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techniques, particularly when patients are carefully selected with
regard to the size of the VP deficit and the behavior of the velar and
pharyngeal musculature as seen on radiographic and endoscopic
views. Patients who have active velar movements for speech but
who have lile or no lateral wall movement may be considered by
some surgeons as good candidates for sphincter pharyngoplasty.
This view is based on the theory that a smaller midline gap should
be easily valved by the midline action of the soft palate during
speech. Postoperative nasal airway obstruction is uncommon
(Kilpatrick et al., 2010). As with all other surgical approaches to
secondary management of VPI, the success of sphincter
pharyngoplasty first and foremost depends on accurate diagnosis of
the problem.
Augmentation Pharyngoplasty
Augmenting the posterior pharyngeal wall to reduce the size of the
VP port has been described as creating a permanent adenoid pad.
The techniques that have been used include (1) rearranging adjacent
soft tissue, (2) implanting cartilage or rib, and (3) injecting or
implanting various types of biocompatible materials.
Implants of various kinds (rib, cartilage, fat, and synthetic
materials) have been used to create an anterior projection or pad on
the pharyngeal wall. The reports were initially optimistic, but results
were ultimately inconsistent even when limiting the procedure to
patients with small VP gaps. Most of these techniques have been
abandoned because of unpredictable results, postoperative
complications, or restrictions imposed by the Food and Drug
Administration. More recent reports indicate that fat and calcium
hydroxyapatite are among the injectable substances remaining in use
for posterior wall augmentation to treat VPI.
Comparison Studies of Surgical Approaches to
Management of Velopharyngeal Inadequacy
The findings from two prospective trials (Abyholm et al., 2005;
Ysunza et al., 2002) seem to confirm Sloan's (2000) earlier opinion
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that pharyngeal flap and sphincter pharyngoplasty are equally
effective for managing VPI. A more recent meta-analysis (Collins et
al., 2012) compared the findings of Ysunza et al. (2004) and Abyholm
et al. (2005). Collins et al. found a possible trend favoring the
pharyngeal flap over sphincter pharyngoplasty for VPI resolution,
with no significant difference in complication rates (p. 868).
Approximately 20% of those who received either procedure did not
benefit or did not benefit completely from either procedure. This
finding may lead to further consideration of whether some criteria if
properly applied could lead to surgical choices or modifications that
would improve success rates further. Given that a success rate of
80% is frequently reported in the literature, it appears that surgical
management of VPI does not benefit every patient. For those who
need additional help, other options are available.
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Prosthodontic Management of
Velopharyngeal Inadequacy
There are times when surgical management of VPI cannot be
considered. Some patients have persistent health concerns that leave
them too fragile to undergo the stress associated with surgery. Some
families do not wish to undergo surgery for cultural, religious,
financial, or other personal reasons. As discussed earlier, we have
seen that surgery does not work equally well for everyone. Some of
these patients may be fied with a speech prosthesis. Speech
prostheses designed to address VPI consist of (1) an oral plate that
clasps firmly to the teeth and (2) an extension directed posteriorly to
the velopharynx (Delgado et al., 1992).
Patients with a history of good oral hygiene and healthy
permanent maxillary dentition to which the oral plate is aached are
the best candidates, given the need for a firm anchor. When a
prosthesis is needed to help a young one, it is important that the
child is mature enough to cooperate and tolerate some temporary
discomfort while the prosthesis is being designed. A supportive
family is critical to the success of prosthetic management in children.
Several days of consistent use of the prosthesis are usually necessary
for a typical child to become acclimated to the prosthesis.
Considerable family encouragement and persistence are needed to
get through that initial period successfully. Perhaps the most
important requirement for success is a prosthodontist who is skilled
and experienced in the fabrication of well-fiing, comfortable
prostheses for children.
Two prosthesis types that differ with regard to the posterior
extension are usually considered. The palatal obturator, sometimes
referred to as a speech bulb, includes a posterior extension designed
to fill the VP gap that exists during speech. The palatal lift includes a
posterior extension that lifts the soft palate so the palatal tissue, and
not the prosthesis, fills the gap.
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Palatal Obturator
The speech bulb or palatal obturator may be the best prosthetic
approach for patients whose soft palate is mobile but too short to
adequately close the VP port completely. When used for a patient
with a repaired cleft, an obturator typically has an under-and-up
design (Fig. 10-5). The posterior extension from the anterior oral
plate is directed inferiorly and posteriorly beneath the velum and
upward into the velopharynx. The pharyngeal bulb is placed at the
end of the extension behind the velum to fill the space that cannot be
closed by the velum and lateral walls during speech. In this manner,
the obturator functions the same as a pharyngeal flap in that it
makes the VP port smaller and, one hopes, easier to close. The
anterior oral portion of the device clasps to the teeth.
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FIGURE 10-5 The speech bulb or palatal obturator typically
has an under-and-up design.
The success of treatment depends primarily on the correct design
and placement of the bulb, which in turn depends on adequate
visualization of the VP port at rest and during speech and
swallowing. The prosthodontist on the cleft palate-craniofacial team
may look to endoscopic or videofluoroscopic speech studies to
determine the optimum size, vertical height, and shape of the speech
bulb. As with a pharyngeal flap, the movement of the pharyngeal
walls is also important for success. In fact, some clinicians have used
temporary speech bulbs to help identify the best size and placement
for planned pharyngeal flaps. Speech bulbs and other types of
obturators are also used to manage VPI or oronasal openings
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occurring in some patients who have lost palatal pharyngeal tissue
due to management of head and neck cancer.
Palatal Lift
In contrast to speech bulbs that fill the VP space, palatal lifts are
essentially horizontal, rigid arms designed to lift the velum into a
position from which VP closure can be more easily obtained (Fig. 10-
6). Palatal lifts are most frequently used for patients with
neurological impairment of velar movement.
FIGURE 10-6 A palatal lift extends posteriorly from its oral
foundation to lift the velum into an elevated position from
which velopharyngeal closure can be more easily obtained.
In practical terms, an optimum effect on speech with the use of a
palatal lift still depends on having at least some degree of movement
in either the velum itself or in portions of the pharyngeal
musculature. When there is absolutely no movement, speech
outcome is necessarily a compromise, falling somewhere along the
continuum between (1) complete obstruction of the VP port by
pushing the velum backward and upward to the posterior
pharyngeal wall and making the device wide enough to also push
the velum laterally or posterolaterally against the lateral pharyngeal
walls and (2) incomplete closure of the VP system, leaving some
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degree of opening that does not vary with the speech task. As with
speech bulbs, in cases when the optimum result cannot be achieved,
a middle of the road compromise is reached in which the VP port is
neither sufficiently closed for completely nonnasal production of
pressure consonants nor adequately open for normal nasal
resonance on nasal consonants and vocalic segments.
Role of the SLP in Prosthetic Management of VPI
Because the goal of prosthetic management for VPI is to provide
normal oral-nasal resonance and control of airflow for speech, the
SLP is the prosthodontist's most important professional partner in
designing a device that accomplishes this goal. Successful treatment
depends on these two partners working together throughout the
initial assessment, the fiing of the prosthesis, and the follow-up
process. In the initial assessment, it is the SLP (not the
prosthodontist) who will know how to differentiate, for example,
nasal airflow (which should be amenable to this type of physical
management) from habituated maladaptive compensatory
articulations (which will most likely not be treatable by such
management). Decisions regarding whether a lift or speech bulb
would be best are ideally made only after complete physiologic
speech testing has been performed, preferably including endoscopic
assessment of VP closure for speech. The SLP who performs and
records endoscopic examinations is also in a unique position to help
the prosthodontist understand the anatomical and physiological
nature of the problem the prosthesis should be designed to address.
The process of creating the portion of the VP portion of the lift or
bulb begins after the prosthodontist has created the oral portion
necessary for retention. The prosthodontist gradually adds dental
compound to the VP portion of the device in a stepwise fashion. The
goal is to add just enough compound in just the right places until the
patient is able to achieve completely oral speech while maintaining
nasal respiration (Box 10-1). The SLP should be present during each
of these add-on sessions, while prompting the patient to produce
oral speech sounds and listening for the intended changes in
resonance and airflow. It is the SLP who can finally say, “That's it!”
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