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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4578_Библиотеки_им_академика_М_И_Перельмана
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Supplemental Readings
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Physical Management of
Velopharyngeal Inadequacy
When the initial or primary palatoplasty does not provide adequate
velopharyngeal (VP) closure, when closure appears adequate for
speech in early childhood but then changes to inadequate closure as
a result of natural growth or adenoid involution, or when VP closure
is inadequate because of a neuromotor disorder, the team needs to
consider how best to reestablish good VP function. The available
choices are either surgical or prosthetic. The surgical approaches
involve either (1) repositioning the muscles of the velum to increase
velar length and improve the effectiveness of the velar motion or (2)
repositioning the muscles and tissues of the pharyngeal walls or
faucial pillars to change the size and shape of the VP port. The choice
of surgical procedure is usually based on the surgeon's preference.
One hopes that the surgeon's preference is based, in part, on the
appearance and movements of the structures that define the VP port
as seen on nasopharyngoscopic or radiographic speech studies. The
nonsurgical prosthetic approaches to this problem consist of acrylic
plates to cover palatal defects, palatal lifts, and obturators or speech
bulbs to close the VP port during speech.
Individuals whose speech is affected by submucous clefts are also
likely to require physical management. Because the physical signs
are subtle and do not always result in a clinically significant speech
disorder, it is critical that patients who do show the physical signs be
assessed by a speech-language pathologist (SLP) to determine
whether they are actually exhibiting VP inadequacy (VPI). In other
words, submucous clefts do not have to be operated on simply
because they are there. Surgical intervention for these patients may
be considered a primary procedure because typically no previous
palatal surgery was performed. Surgery is usually performed to
reconstruct the levator muscle. Both Cho et al. (2004) and Sullivan et
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al. (2011) reported that the Furlow double opposing Z-plasty was
effective for reconstructing submucous cleft palates.
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Surgical Management of
Velopharyngeal Inadequacy
Levator Muscle Reconstruction Procedures
Many of the surgical procedures used in initial (primary)
palatoplasties to produce a soft palate with the closest
approximation to normal muscle orientation and adequate length
are also used for those same purposes in older individuals with cleft
palate for whom the first surgery did not produce the optimum
result. These procedures have included intravelar veloplasty, Furlow
double opposing Z-plasty, and various modifications of the V-Y
pushback.
Levator reconstruction procedures have essentially replaced
pushback surgical procedures intended to improve velopharyngeal
closure for speech.
Intravelar veloplasty was originally advocated for primary closure
of the soft palate by Kriens (1969, 1970). It is based on findings that
fibers from the left and right levator muscle bundles do not join
normally within the soft palate in children with unrepaired cleft
palate. Intravelar veloplasty involves dissecting the levator bundles
from their abnormal insertions along the margins of the palatal cleft
and repositioning them to approximate a normal levator sling.
Surgeons subsequently experimented with its use not only during
primary palatoplasty but also as a secondary approach to improving
residual VPI.
The Furlow double opposing Z-plasty procedure has received
aention as a levator reconstruction method to improve speech in
select individuals after primary cleft palate repair (Randall et al.,
1986) and in secondary management of VPI (D'Antonio, 1997; Chim
et al., 2015; Dailey et al., 2006). Like intravelar veloplasty, this
procedure reorients the levator muscles to create a functioning
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palatal muscle sling (Fig. 10-1). It also adds some palatal length and
thickness.
FIGURE 10-1 Furlow double opposing Z-plasty. (From Furlow
LT: Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 78:724-
736, 1986.)
It has yet to be clearly demonstrated how best to identify patients
who could benefit from muscle repositioning. Findings from several
studies have suggested that patients with a smaller VP gap size or
with milder degrees of VPI may benefit from velar muscle
reconstruction and repositioning (Chen et al., 1994; Dailey et al.,
2006; D'Antonio et al., 2000; Hudson et al., 1995; Sie et al., 2001). The
presence of a notch or trough on the nasal surface of the repaired
soft palate is interpreted by some surgeons as evidence of a muscle
diastasis or separation of the left and right levator muscle bundles. If
the two bundles are separated, it is assumed that velar movement
will be less than adequate for speech in a manner typically found in
children with submucous cleft palate.
The advantage of all the levator reconstruction procedures is that
when they work, they do so by approximating or reproducing the
VP physiology that would have been in place if the cleft had not
occurred. In contrast, most forms of pharyngoplasty, particularly
centrally placed pharyngeal flaps, aempt to achieve closure by
mechanisms that are not as physiologically natural.
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Pharyngeal Flap
A pharyngeal flap is typically accomplished surgically by making a
U-shaped incision at the midline of the posterior pharyngeal wall.
The tissue within the U-shaped outline is carefully raised, brought
forward, and inserted into an incision created on the nasal surface of
the soft palate (Fig. 10-2). The ideal result is a midline tissue bridge
extending from the flap's remaining aachment 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 (Fig. 10-3). The ability
to create a flap that adequately strikes the delicate balance among all
these demands defines the challenge for the surgeon and the art of
the procedure (Video 10-1 ).
FIGURE 10-2 A pharyngeal flap is typically accomplished
surgically by making a U-shaped incision at the midline of the
posterior pharyngeal wall, carefully raising the resulting
unipedicled superiorly based flap, and suturing it into an
incision created on the nasal surface of the soft palate. (From
Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft palate speech [4th ed].
St. Louis: Mosby, 2010.)
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