- Email: [email protected]
Endoscopic-assisted sphincter pharyngoplasty (EASP)
International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Endoscopic-assisted sphincter pharyngoplasty (EASP) Sherif Mohammad Askar * Department of ORL-HN Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Sharkia Governorate, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 August 2012 Received in revised form 11 October 2012 Accepted 12 October 2012 Available online 8 November 2012
Objectives: Sphincter pharyngoplasty operation was designed for the treatment of velopharyngeal insufficiency via a transoral route. Few investigators used palatal stretching sutures or palatal splitting procedures (which may affect the performance of the palate) to overcome the problem of difficult visualization. The purpose of this study is to present and evaluate the role of intraoperative nasoendoscopy during sphincter pharyngoplasty. Although Vadodaria et al. (2004) (in a cadaver study) used the endoscope to perform SP operation, this study (to our knowledge) is the first report of intraoperative nasoendoscopy in sphincter pharyngoplasty. Subjects and methods: This prospective study was conducted at ORL-HN Department, Zagazig University Hospitals, Zagazig University, Egypt. Seven patients with persistent postoperative hypernasality were enrolled in this work. They were prepared by head and neck physical examination and phonetic evaluation. Patients were subjected to treatment by endoscopic-assisted sphincter pharyngoplasty, a procedure that was designed to combine both a transoral and a transnasal routes via the aid of nasoendoscope. Postoperative nasoendoscopic and phonetic assessment was done for all of the patients. Results: The procedure is easily conducted, done by available instruments with no extra burden over patients or hospitals. The procedure insured an under vision and well controlled steps. No major complications were recorded. Good speech outcome results were reported. Conclusion: Endoscopic-assisted sphincter pharyngoplasty is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Sphincter pharyngoplasty Endoscopic Velopharyngeal insufficiency
1. Introduction Sphincter pharyngoplasty (SP) is a commonly performed procedure for the treatment of velopharyngeal insufficiency (VPI) [1]. As the procedure is performed through the transoral route, surgeon may face the problem of inadequate visualization and assessment during the steps in the nasopharynx [2]. Few transpalatal procedures were described to overcome such problems e.g. palatopharyngeal sling [3], but they require palatal dissection which, if experience is not adequate, will interrupt palatal performance. Nasoendoscopy (NE) plays an important role in the pre and postoperative assessment of patients with VPI, but its use intraoperatively is not discussed in the literature, according to
* Corresponding author at: Department of ENT-HN Surgery, Faculty of Medicine, Zagazig University, Egypt./Address (8) Kamal Abaza Street, Zagazig City, Sharkia Governorate, Egypt. Tel.: +20 55 233 255 8; mobile: +20 122 44 56 780. E-mail address: [email protected]. 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.10.011
our knowledge, although Vadodaria et al. [2] used the endoscope to perform SP operation but in a cadaver study. We proposed that the use of nasoendoscopy could potentially provide improved direct visualization during the procedure aiming at creation of a bulge ‘‘high’’ in the posterior pharyngeal wall at the optimal level. This work presents the first report of intraoperative use of the nasoendoscopy in sphincter pharyngoplasty operation (EASP) to achieve under vision and controlled procedure. 2. Patients and methods 2.1. Patients This study was carried out on seven Arabic speaking patients who were referred to the Phoniatric Unit, ORL-HN Department, Zagazig University Hospitals with persistent hypernasality after traditional curettage adenoidectomy (5 patients) and cleft palate repair (2 patients) procedures in the period between February 2008 and September 2010. Patients were two males and five females with ages ranging between 11 and 17 years (mean age = 14
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
171
Table 1 Descriptive data of fiberoptic endoscopic evaluations of the VP port of the studied patients (n = 7). Fiberoptic endoscopic evaluations (a) Degree of velar movement
Normal Mild impairment Moderate impairment Normal Mild impairment Moderate impairment
(b) Lateral pharyngeal wall motion
years and 3 months). The period of hypernasality after primary surgery ranged between 11 and 37 months (mean = 23 months). Patients with identified risk factors e.g. syndromic cleft palate or myopathy were excluded from the study. Other exclusion criteria included patients who were in need for palatal procedures e.g. residual gaps or fistulae, persistent (or recurrent) adenoids, patients with hyperactive airways, children with delayed speech/language developments or associated neurologic disorders. The study was approved by the Ethics Committee of the Zagazig University Hospitals, Faculty of Medicine Zagazig University, Egypt. 2.2. Methods Thorough history taking, complete general and head and neck physical examination (including upper airway endoscopy) were done for all patients. Then, every patient was subjected to the protocol of assessment that is applied in Phoniatric Unit, ORL Department Zagazig University Hospitals that includes subjective as well as quasi-objective measures of evaluation [4]. It comprises assessment for cases of VPI as follows: (A) Elementary diagnostic procedures (i) Patient’s and parents’ interview It includes personal data; developmental milestones and detailed history of operative intervention and its outcome. (ii) Auditory perceptual assessment (APA) of the patient’s speech The subjective evaluation of patients’ speech in a free conversation included type and degree of nasality, consonant precision, the compensatory articulatory mechanisms (glottal and pharyngeal articulation), facial grimace, audible nasal emission of air, and the overall intelligibility of speech (Table 2). Table 2 Results of pre- versus post-operative APA of the patients’ speech (n = 7). APA
Pre-operative n
Normal resonance Degree of hypernasality Mild Moderate Hyponasality Pharyngeal articulation Present Absent Facial grimacing Present Absent Audible nasal emission Present Absent Overall speech intelligibility Normal Mild impairment Moderate impairment
%
Post-operative n
%
0
0
5
71.4
1 6 0
14.3 85.7 0
2 0 0
28.6 0 0
2 5
28.6 71.4
0 7
0 100
3 4
42.9 57.1
0 7
0 100
2 5
28.6 71.4
0 7
0 100
0 1 6
0 14.3 85.7
5 2 0
71.4 28.6 0
Number of patients
Percentage (%)
4 1 2 5 1 1
57.1 14.3 28.6 71.4 14.3 14.3
(B) Clinical diagnostic aids (i) Documentation of APA (audio-recording) A standard Arabic speech samples were recorded digitally in the computer and then assessed by giving scores for every APA item in speech and voice assessment. (ii) Documentation of visual assessment All the 7 patients were examined using a fiberoptic nasopharyngeal endoscopy connected to a video camera and A TV tuner of a PC. The velopharyngeal (VP) valve movement was recorded (Table 1) while the subject was repeating the speech samples that have been recommended by an International Working Group [5]: - Repetition of at least four different consonant–vowel combinations, including both nasal and non-nasal utterances. Both high and low vowels were used. An example would be/ma-ma-ma/, /pa-pa-pa/, /ta-ta-ta/, /ka-kaka/, /mi-mi-mi/, /pi-pi-pi/, /ti-ti-ti/ and /ki-ki-ki/. - Production of at least two sustained fricatives (preferably both voiceless and voiced) such as /sssss/, /fffff/, /zzzzz/ and /vvvvv/. - Production of the nasal–oral blend in the word /ambar/ - Arabic phrases involving connected speech with varying phonemic contexts: 1. Nasal sentence (/mama betnajem manal/). 2. Oral sentence (/ali rah jel’ab korah/). R 3. Combined oral–nasal sentence (/sami af fostan semsem/). - Connected speech: counting from 1 to 10 in Arabic to get a varied phonemic sample with nasal to non-nasal transitions and voiced–voiceless transitions. The movement of each component of VP sphincter namely: velum and lateral pharyngeal walls was traced on the monitor and given a score from 0 to 4 as follows: [0 = the resting (breathing) position or no movement; 2 = half the distance to the corresponding wall; 4 = the maximum movement reaching and touching the opposite wall]. Pattern of closure of the VPS was specified. All patients in this work show coronal pattern with a moving palate. According to the results of preoperative phonetics evaluation, seven patients who demonstrated predominantly coronal closure pattern of the VP valve were managed by endoscopic-assisted sphincter pharyngoplasty (EASP). A clear written informative consent was obtained for all patients after few sessions of clarification of the procedure in details to patients and parents (caregivers). Routine preoperative laboratory and radiological evaluations were requested. 2.3. Surgical technique General anesthesia was conducted with oral endotracheal intubation and a Boyle–Davis mouth gag is in place. The posterior tonsillar pillars as well as the posterior wall of the nasopharynx were injected with adrenaline in saline solution
172
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
Fig. 1. Preoperative fiberoptic nasopharyngoscopy of the velopharyngeal sphincter showing the movement of the velum: (A) at rest and (B) during phonation of/a/sound. The arrow refers to the velopharyngeal gap.
(1:200,000). The nasopharynx was injected transnasally under endoscopic view. Bilateral superiorly based myomucosal flaps, 1–1.5 cm in width, were elevated in the usual way through the transoral route extending from below the Eustachian tubes, orifices to the level of the lower pole of tonsils. The flaps included parts of the palatopharyngeus and superior constrictor muscles. The 08 rigid endoscope (Storz 20 cm long, 5 mm diameter connected to a camera – Storz and video system – Sony) was introduced (in the wider side of the nose) to the nasopharynx. The surgeon remained seated at the head of the patient. Anatomy of the nasopharynx was clarified especially the arch of atlas and both Eustachian orifices. The endoscope was held in position by the left hand of the surgeon. A transverse incision was made with a curved knife on the posterior pharyngeal wall, under endoscopic visualization, in the site preoperatively determined, which the site of the maximal palate excursion is. It is located at the level of the arch of atlas. The knife itself may pass through a transoral or a transnasal routes. A raw area was then created in the posterior wall of the nasopharynx as a bed for the coming flaps (Fig. 4). Then, the two myomucosal flaps were rotated and delivered to the nasopharyngeal raw area. Flaps were sutured to the inferior lip of the transverse incision and also sutured together with overlap using vicryl 4–0 sutures with a transoral needle holder, under endoscopic visualization (Fig. 5). During suturing, the endoscope is held in place by an assistant. Final check of the overlap of flaps and degree of obturation and hemostasis was done (Fig. 6). The lateral ports’ catheters were not used during the procedure. Lastly, the donor raw areas of both flaps in the lateral wall of the oropharynx are sutured transorally with vicryl 4–0.
2.4. Postoperative follow up In the early postoperative period, no significant airway problems were recorded. Nasal obstruction was recorded in 5 patients, which was improved within 2–3 weeks. Also the postoperative pain was easily controlled. All patients were sent home in the following morning. No infection was recorded. Patients were sent to the speech unit after 1 month (after the complete healing). The velopharyngeal function and speech were assessed again at the end of the follow up period. Period of follow up ranged from 9 to 12 months. 3. Statistics The data were collected, tabulated and analyzed using SPSS statistical package Version 15 for windows. Qualitative data were presented as numbers and corresponding percentages. 4. Results 4.1. Preoperative evaluation of the patients Preoperative evaluation of the patients by nasoendoscopy (Fig. 1) revealed that all patients had symmetric velar movement. 57.1% of the patients had normal degree of velar movement, 14.3% had mildly impaired mobility and 28.6% had moderately impaired velar mobility. All patients (100%) had coronal pattern of VP closure. Lateral pharyngeal wall movement was assessed and revealed that 71.4% of the patients had normal lateral pharyngeal wall movement and 28.6% of them had diminished mobility. The fiber optic endoscopic evaluations of the velopharyngeal port are
Fig. 2. Postoperative nasopharyngoscopy (9 months) of the velopharyngeal sphincter: (A) resting position and (B) during phonation.
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
173
Fig. 3. Postoperative nasopharyngoscopy (9 months) of the velopharyngeal sphincter: (A) resting position and (B) during phonation.
summarized in Table 1. The results of auditory perceptual assessments of the patients’ speech are summarized in Table 2. 4.2. Post-operative evaluation of the patients Five out of the seven patients who were managed by endoscopic-assisted sphincter pharyngoplasty demonstrated symptoms of nasal obstruction which improved within 2–3 weeks. Postoperatively five patients demonstrated normal degree of nasal resonance and two patients demonstrated improvement from moderate degree to mild degree of hypernasality. No patient demonstrated any degree of hyponasality. Five patients demonstrated normal degree of speech intelligibility and two patients demonstrated mild degree of impairment of speech intelligibility. No pharyngalizations of fricatives, audible nasal emission or facial grimacing were detected in the seven patients postoperatively (Table 2). No flap downward migration was detected at the end of follow up period (Figs. 2 and 3). 5. Discussion Since its first description by Hynes in 1950, sphincter pharyngoplasty SP is used by many oropharyngeal surgeons for correction of velopharyngeal insufficiency especially when coronal or circular pattern of closure of the nasopharyngeal sphincter (VPS) predominates [6–8]. Many modifications were published in trials to optimize its outcome, and to deal with its difficulties e.g. obscured vision of the nasopharynx, improper incision site and difficult assessment of suturing of flaps, degree of overlap and obturation [2,9]. Although researchers prescribed the application
Fig. 4. The incision in the nasopharynx under nasoendoscopic view. Bed (B) is prepared to receive the flaps.
of retraction sutures, or malleable blades [10] but it does not provide a clear direct visualization of the operative site in the nasopharynx [2]. Recently, authors had turned their faces anteriorly toward the palate to overcome these problems by suturing flaps in the palate, or application of cerclage sutures [3,11]. Use of modern endoscopes is a cornerstone in the management of cases of VPI as it permits excellent visualization and assessment of the velopharyngeal sphincter (VPS) components during pre and postoperative work up. Also Raurell et al. [12] applied it in surgery of the palate. Vadodaria et al. [2] reported the feasibility of transnasal endoscopy in sphincter pharyngoplasty operation in 3 cadavers using a 308 rigid lens. In this work, the surgeon used the transnasal 08 rigid endoscope during sphincter pharyngoplasty operation in 7 patients. General anesthesia was delivered in the usual way for surgery in the upper airway. The use of the endoscope insured a properly positioned nasopharyngeal incision (which can be performed via a transnasal or an oropharyngeal routes) and a good raw area. Flap overlap and suturing was adequately controlled and directly assessed. Also, the degree of obturation of the nasopharynx was directly assessed under vision. No palatal dissection and no retraction sutures of the palate were needed. No special instrumentation was needed. The surgeon did not face a situation that necessitated shifting to a conventional stretching or splitting of the palate. The study reports more than 85% improvement in hypernasality which is matched with results of the classic transoral surgery in other reports [6,13]. No obstructive symptoms were recorded at the end of the study, a result that agrees with the assumption suggested by other workers [13,14]. The author performed the procedure in the usual position for oral surgery while the patient is supine and the surgeon is seated at the head of the patient. It means that the nasopharynx is seen upside down (palate is above and the vault of the nasopharynx is
Fig. 5. Suture placement as visualized from nasopharynx.
174
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
Funding None. Conflict of interest statement The author does not have any potential financial conflict of interest related to or could influence this work. Acknowledgement Thanks to all members at the Phoniatrics Unit, Zagazig University Hospitals who carried out the phonetics issues. References Fig. 6. Final check of overlap and degree of obturation by nasopharyngoscopy. N.B.: P: palate, F: flap, B: surgical bed and S: suction tip.
below). It took a very short time to adjust working with no need to shift to the usual standing position of nasoendoscopic procedures. This study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved direct visualization of a traditionally difficult-to-expose area. The 08 endoscope was used during the procedure for: (1) local injection of the posterior wall of the nasopharynx, (2) creation of posterior pharyngeal wall incision, (3) flap suturing, (4) flap positioning and (5) assessment of the degree of overlap and obturation. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used.
6. Conclusion EASP is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved direct visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure.
[1] J.L. Marsh, The evaluation and management of velopharyngeal dysfunction, Clin. Plast. Surg. 31 (2004) 261–269. [2] S. Vadodaria, D. Mowatt, V. Ramakrishnan, S. Jacob, E. Freedlander, Trans-nasal endo-assisted pharyngoplasty: a cadaver study, Br. Assoc. Plast. Surg. 57 (2004) 418–422. [3] M. Abdel-aziz, Palatopharyngeal sling, a new technique in treatment of velopharyngeal insufficiency, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 173–177. [4] M.N. Kotby, E.K. Abdel Haleem, M. Hegazi, E. Safe, M. Zaki, Aspects of assessment and management of velopharyngeal dysfunction in developing countries, Folia Phoniatr. Logop. 49 (1997) 139. [5] K.J. Golding-Kushner, Standardization for the reporting of nasopharyngoscopy and multi-view videofluoroscopy: a report from an international working group, Cleft Palate J. 27 (1990) 337. [6] J.L. Marsh, Management of velopharyngeal dysfunction: differential diagnosis for differential management, J. Craniofac. Surg. 14 (2003) 621–628. [7] L.L. Chiu, K.C.Y. Sie, Sphincter pharyngoplasty for management of velopharyngeal insufficiency, Oper. Tech. Otolaryngol. 20 (2009) 263–267. [8] M. Abdel-Aziz, H. Dewidar, H. El-Hoshy, A. Aziz, Treatment of persistent postadenoidectomy velopharyngeal insufficiency by sphincter pharyngoplasty, Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 1329–1333. [9] I.T. Jackson, J.S. Silverston, Sphincter pharyngoplasty as a secondary procedure in cleft palates, Plast. Reconstr. Surg. 59 (1977) 518–525. [10] J.K.G. Laitung, A modification of the Kilner–Dott mouth gag for improving exposure to the nasopharyngeal area, Br. J. Plast. Surg. 39 (1986) 268–269. [11] A. Ragab, Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency, Int. J. Pediatr. Otorhinolaryngol. 71 (2007) 793–800. [12] A. Raurell, S.J. Southern, O.M. Fenton, Perioperative use of nasoendoscopy in cleft surgery, Ann. Plast. Surg. 45 (2000) 627–628. [13] G.M. Sloan, Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art, Cleft Palate Craniofac. J. 37 (2) (2000) 112–122. [14] C.S. Raymond, G. Bettega, C. Deschaux, J. Lebeau, B. Raphael, P. Le´vy, et al., Sphincter pharyngoplasty as a treatment of velopharyngeal incompetence in young people: a prospective evaluation of effects on sleep structure and sleep respiratory disturbances, Chest 125 (2004) 864–871.
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Endoscopic-assisted sphincter pharyngoplasty (EASP) Sherif Mohammad Askar * Department of ORL-HN Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Sharkia Governorate, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 August 2012 Received in revised form 11 October 2012 Accepted 12 October 2012 Available online 8 November 2012
Objectives: Sphincter pharyngoplasty operation was designed for the treatment of velopharyngeal insufficiency via a transoral route. Few investigators used palatal stretching sutures or palatal splitting procedures (which may affect the performance of the palate) to overcome the problem of difficult visualization. The purpose of this study is to present and evaluate the role of intraoperative nasoendoscopy during sphincter pharyngoplasty. Although Vadodaria et al. (2004) (in a cadaver study) used the endoscope to perform SP operation, this study (to our knowledge) is the first report of intraoperative nasoendoscopy in sphincter pharyngoplasty. Subjects and methods: This prospective study was conducted at ORL-HN Department, Zagazig University Hospitals, Zagazig University, Egypt. Seven patients with persistent postoperative hypernasality were enrolled in this work. They were prepared by head and neck physical examination and phonetic evaluation. Patients were subjected to treatment by endoscopic-assisted sphincter pharyngoplasty, a procedure that was designed to combine both a transoral and a transnasal routes via the aid of nasoendoscope. Postoperative nasoendoscopic and phonetic assessment was done for all of the patients. Results: The procedure is easily conducted, done by available instruments with no extra burden over patients or hospitals. The procedure insured an under vision and well controlled steps. No major complications were recorded. Good speech outcome results were reported. Conclusion: Endoscopic-assisted sphincter pharyngoplasty is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Sphincter pharyngoplasty Endoscopic Velopharyngeal insufficiency
1. Introduction Sphincter pharyngoplasty (SP) is a commonly performed procedure for the treatment of velopharyngeal insufficiency (VPI) [1]. As the procedure is performed through the transoral route, surgeon may face the problem of inadequate visualization and assessment during the steps in the nasopharynx [2]. Few transpalatal procedures were described to overcome such problems e.g. palatopharyngeal sling [3], but they require palatal dissection which, if experience is not adequate, will interrupt palatal performance. Nasoendoscopy (NE) plays an important role in the pre and postoperative assessment of patients with VPI, but its use intraoperatively is not discussed in the literature, according to
* Corresponding author at: Department of ENT-HN Surgery, Faculty of Medicine, Zagazig University, Egypt./Address (8) Kamal Abaza Street, Zagazig City, Sharkia Governorate, Egypt. Tel.: +20 55 233 255 8; mobile: +20 122 44 56 780. E-mail address: [email protected]. 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.10.011
our knowledge, although Vadodaria et al. [2] used the endoscope to perform SP operation but in a cadaver study. We proposed that the use of nasoendoscopy could potentially provide improved direct visualization during the procedure aiming at creation of a bulge ‘‘high’’ in the posterior pharyngeal wall at the optimal level. This work presents the first report of intraoperative use of the nasoendoscopy in sphincter pharyngoplasty operation (EASP) to achieve under vision and controlled procedure. 2. Patients and methods 2.1. Patients This study was carried out on seven Arabic speaking patients who were referred to the Phoniatric Unit, ORL-HN Department, Zagazig University Hospitals with persistent hypernasality after traditional curettage adenoidectomy (5 patients) and cleft palate repair (2 patients) procedures in the period between February 2008 and September 2010. Patients were two males and five females with ages ranging between 11 and 17 years (mean age = 14
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
171
Table 1 Descriptive data of fiberoptic endoscopic evaluations of the VP port of the studied patients (n = 7). Fiberoptic endoscopic evaluations (a) Degree of velar movement
Normal Mild impairment Moderate impairment Normal Mild impairment Moderate impairment
(b) Lateral pharyngeal wall motion
years and 3 months). The period of hypernasality after primary surgery ranged between 11 and 37 months (mean = 23 months). Patients with identified risk factors e.g. syndromic cleft palate or myopathy were excluded from the study. Other exclusion criteria included patients who were in need for palatal procedures e.g. residual gaps or fistulae, persistent (or recurrent) adenoids, patients with hyperactive airways, children with delayed speech/language developments or associated neurologic disorders. The study was approved by the Ethics Committee of the Zagazig University Hospitals, Faculty of Medicine Zagazig University, Egypt. 2.2. Methods Thorough history taking, complete general and head and neck physical examination (including upper airway endoscopy) were done for all patients. Then, every patient was subjected to the protocol of assessment that is applied in Phoniatric Unit, ORL Department Zagazig University Hospitals that includes subjective as well as quasi-objective measures of evaluation [4]. It comprises assessment for cases of VPI as follows: (A) Elementary diagnostic procedures (i) Patient’s and parents’ interview It includes personal data; developmental milestones and detailed history of operative intervention and its outcome. (ii) Auditory perceptual assessment (APA) of the patient’s speech The subjective evaluation of patients’ speech in a free conversation included type and degree of nasality, consonant precision, the compensatory articulatory mechanisms (glottal and pharyngeal articulation), facial grimace, audible nasal emission of air, and the overall intelligibility of speech (Table 2). Table 2 Results of pre- versus post-operative APA of the patients’ speech (n = 7). APA
Pre-operative n
Normal resonance Degree of hypernasality Mild Moderate Hyponasality Pharyngeal articulation Present Absent Facial grimacing Present Absent Audible nasal emission Present Absent Overall speech intelligibility Normal Mild impairment Moderate impairment
%
Post-operative n
%
0
0
5
71.4
1 6 0
14.3 85.7 0
2 0 0
28.6 0 0
2 5
28.6 71.4
0 7
0 100
3 4
42.9 57.1
0 7
0 100
2 5
28.6 71.4
0 7
0 100
0 1 6
0 14.3 85.7
5 2 0
71.4 28.6 0
Number of patients
Percentage (%)
4 1 2 5 1 1
57.1 14.3 28.6 71.4 14.3 14.3
(B) Clinical diagnostic aids (i) Documentation of APA (audio-recording) A standard Arabic speech samples were recorded digitally in the computer and then assessed by giving scores for every APA item in speech and voice assessment. (ii) Documentation of visual assessment All the 7 patients were examined using a fiberoptic nasopharyngeal endoscopy connected to a video camera and A TV tuner of a PC. The velopharyngeal (VP) valve movement was recorded (Table 1) while the subject was repeating the speech samples that have been recommended by an International Working Group [5]: - Repetition of at least four different consonant–vowel combinations, including both nasal and non-nasal utterances. Both high and low vowels were used. An example would be/ma-ma-ma/, /pa-pa-pa/, /ta-ta-ta/, /ka-kaka/, /mi-mi-mi/, /pi-pi-pi/, /ti-ti-ti/ and /ki-ki-ki/. - Production of at least two sustained fricatives (preferably both voiceless and voiced) such as /sssss/, /fffff/, /zzzzz/ and /vvvvv/. - Production of the nasal–oral blend in the word /ambar/ - Arabic phrases involving connected speech with varying phonemic contexts: 1. Nasal sentence (/mama betnajem manal/). 2. Oral sentence (/ali rah jel’ab korah/). R 3. Combined oral–nasal sentence (/sami af fostan semsem/). - Connected speech: counting from 1 to 10 in Arabic to get a varied phonemic sample with nasal to non-nasal transitions and voiced–voiceless transitions. The movement of each component of VP sphincter namely: velum and lateral pharyngeal walls was traced on the monitor and given a score from 0 to 4 as follows: [0 = the resting (breathing) position or no movement; 2 = half the distance to the corresponding wall; 4 = the maximum movement reaching and touching the opposite wall]. Pattern of closure of the VPS was specified. All patients in this work show coronal pattern with a moving palate. According to the results of preoperative phonetics evaluation, seven patients who demonstrated predominantly coronal closure pattern of the VP valve were managed by endoscopic-assisted sphincter pharyngoplasty (EASP). A clear written informative consent was obtained for all patients after few sessions of clarification of the procedure in details to patients and parents (caregivers). Routine preoperative laboratory and radiological evaluations were requested. 2.3. Surgical technique General anesthesia was conducted with oral endotracheal intubation and a Boyle–Davis mouth gag is in place. The posterior tonsillar pillars as well as the posterior wall of the nasopharynx were injected with adrenaline in saline solution
172
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
Fig. 1. Preoperative fiberoptic nasopharyngoscopy of the velopharyngeal sphincter showing the movement of the velum: (A) at rest and (B) during phonation of/a/sound. The arrow refers to the velopharyngeal gap.
(1:200,000). The nasopharynx was injected transnasally under endoscopic view. Bilateral superiorly based myomucosal flaps, 1–1.5 cm in width, were elevated in the usual way through the transoral route extending from below the Eustachian tubes, orifices to the level of the lower pole of tonsils. The flaps included parts of the palatopharyngeus and superior constrictor muscles. The 08 rigid endoscope (Storz 20 cm long, 5 mm diameter connected to a camera – Storz and video system – Sony) was introduced (in the wider side of the nose) to the nasopharynx. The surgeon remained seated at the head of the patient. Anatomy of the nasopharynx was clarified especially the arch of atlas and both Eustachian orifices. The endoscope was held in position by the left hand of the surgeon. A transverse incision was made with a curved knife on the posterior pharyngeal wall, under endoscopic visualization, in the site preoperatively determined, which the site of the maximal palate excursion is. It is located at the level of the arch of atlas. The knife itself may pass through a transoral or a transnasal routes. A raw area was then created in the posterior wall of the nasopharynx as a bed for the coming flaps (Fig. 4). Then, the two myomucosal flaps were rotated and delivered to the nasopharyngeal raw area. Flaps were sutured to the inferior lip of the transverse incision and also sutured together with overlap using vicryl 4–0 sutures with a transoral needle holder, under endoscopic visualization (Fig. 5). During suturing, the endoscope is held in place by an assistant. Final check of the overlap of flaps and degree of obturation and hemostasis was done (Fig. 6). The lateral ports’ catheters were not used during the procedure. Lastly, the donor raw areas of both flaps in the lateral wall of the oropharynx are sutured transorally with vicryl 4–0.
2.4. Postoperative follow up In the early postoperative period, no significant airway problems were recorded. Nasal obstruction was recorded in 5 patients, which was improved within 2–3 weeks. Also the postoperative pain was easily controlled. All patients were sent home in the following morning. No infection was recorded. Patients were sent to the speech unit after 1 month (after the complete healing). The velopharyngeal function and speech were assessed again at the end of the follow up period. Period of follow up ranged from 9 to 12 months. 3. Statistics The data were collected, tabulated and analyzed using SPSS statistical package Version 15 for windows. Qualitative data were presented as numbers and corresponding percentages. 4. Results 4.1. Preoperative evaluation of the patients Preoperative evaluation of the patients by nasoendoscopy (Fig. 1) revealed that all patients had symmetric velar movement. 57.1% of the patients had normal degree of velar movement, 14.3% had mildly impaired mobility and 28.6% had moderately impaired velar mobility. All patients (100%) had coronal pattern of VP closure. Lateral pharyngeal wall movement was assessed and revealed that 71.4% of the patients had normal lateral pharyngeal wall movement and 28.6% of them had diminished mobility. The fiber optic endoscopic evaluations of the velopharyngeal port are
Fig. 2. Postoperative nasopharyngoscopy (9 months) of the velopharyngeal sphincter: (A) resting position and (B) during phonation.
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
173
Fig. 3. Postoperative nasopharyngoscopy (9 months) of the velopharyngeal sphincter: (A) resting position and (B) during phonation.
summarized in Table 1. The results of auditory perceptual assessments of the patients’ speech are summarized in Table 2. 4.2. Post-operative evaluation of the patients Five out of the seven patients who were managed by endoscopic-assisted sphincter pharyngoplasty demonstrated symptoms of nasal obstruction which improved within 2–3 weeks. Postoperatively five patients demonstrated normal degree of nasal resonance and two patients demonstrated improvement from moderate degree to mild degree of hypernasality. No patient demonstrated any degree of hyponasality. Five patients demonstrated normal degree of speech intelligibility and two patients demonstrated mild degree of impairment of speech intelligibility. No pharyngalizations of fricatives, audible nasal emission or facial grimacing were detected in the seven patients postoperatively (Table 2). No flap downward migration was detected at the end of follow up period (Figs. 2 and 3). 5. Discussion Since its first description by Hynes in 1950, sphincter pharyngoplasty SP is used by many oropharyngeal surgeons for correction of velopharyngeal insufficiency especially when coronal or circular pattern of closure of the nasopharyngeal sphincter (VPS) predominates [6–8]. Many modifications were published in trials to optimize its outcome, and to deal with its difficulties e.g. obscured vision of the nasopharynx, improper incision site and difficult assessment of suturing of flaps, degree of overlap and obturation [2,9]. Although researchers prescribed the application
Fig. 4. The incision in the nasopharynx under nasoendoscopic view. Bed (B) is prepared to receive the flaps.
of retraction sutures, or malleable blades [10] but it does not provide a clear direct visualization of the operative site in the nasopharynx [2]. Recently, authors had turned their faces anteriorly toward the palate to overcome these problems by suturing flaps in the palate, or application of cerclage sutures [3,11]. Use of modern endoscopes is a cornerstone in the management of cases of VPI as it permits excellent visualization and assessment of the velopharyngeal sphincter (VPS) components during pre and postoperative work up. Also Raurell et al. [12] applied it in surgery of the palate. Vadodaria et al. [2] reported the feasibility of transnasal endoscopy in sphincter pharyngoplasty operation in 3 cadavers using a 308 rigid lens. In this work, the surgeon used the transnasal 08 rigid endoscope during sphincter pharyngoplasty operation in 7 patients. General anesthesia was delivered in the usual way for surgery in the upper airway. The use of the endoscope insured a properly positioned nasopharyngeal incision (which can be performed via a transnasal or an oropharyngeal routes) and a good raw area. Flap overlap and suturing was adequately controlled and directly assessed. Also, the degree of obturation of the nasopharynx was directly assessed under vision. No palatal dissection and no retraction sutures of the palate were needed. No special instrumentation was needed. The surgeon did not face a situation that necessitated shifting to a conventional stretching or splitting of the palate. The study reports more than 85% improvement in hypernasality which is matched with results of the classic transoral surgery in other reports [6,13]. No obstructive symptoms were recorded at the end of the study, a result that agrees with the assumption suggested by other workers [13,14]. The author performed the procedure in the usual position for oral surgery while the patient is supine and the surgeon is seated at the head of the patient. It means that the nasopharynx is seen upside down (palate is above and the vault of the nasopharynx is
Fig. 5. Suture placement as visualized from nasopharynx.
174
S.M. Askar / International Journal of Pediatric Otorhinolaryngology 77 (2013) 170–174
Funding None. Conflict of interest statement The author does not have any potential financial conflict of interest related to or could influence this work. Acknowledgement Thanks to all members at the Phoniatrics Unit, Zagazig University Hospitals who carried out the phonetics issues. References Fig. 6. Final check of overlap and degree of obturation by nasopharyngoscopy. N.B.: P: palate, F: flap, B: surgical bed and S: suction tip.
below). It took a very short time to adjust working with no need to shift to the usual standing position of nasoendoscopic procedures. This study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved direct visualization of a traditionally difficult-to-expose area. The 08 endoscope was used during the procedure for: (1) local injection of the posterior wall of the nasopharynx, (2) creation of posterior pharyngeal wall incision, (3) flap suturing, (4) flap positioning and (5) assessment of the degree of overlap and obturation. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used.
6. Conclusion EASP is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved direct visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure.
[1] J.L. Marsh, The evaluation and management of velopharyngeal dysfunction, Clin. Plast. Surg. 31 (2004) 261–269. [2] S. Vadodaria, D. Mowatt, V. Ramakrishnan, S. Jacob, E. Freedlander, Trans-nasal endo-assisted pharyngoplasty: a cadaver study, Br. Assoc. Plast. Surg. 57 (2004) 418–422. [3] M. Abdel-aziz, Palatopharyngeal sling, a new technique in treatment of velopharyngeal insufficiency, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 173–177. [4] M.N. Kotby, E.K. Abdel Haleem, M. Hegazi, E. Safe, M. Zaki, Aspects of assessment and management of velopharyngeal dysfunction in developing countries, Folia Phoniatr. Logop. 49 (1997) 139. [5] K.J. Golding-Kushner, Standardization for the reporting of nasopharyngoscopy and multi-view videofluoroscopy: a report from an international working group, Cleft Palate J. 27 (1990) 337. [6] J.L. Marsh, Management of velopharyngeal dysfunction: differential diagnosis for differential management, J. Craniofac. Surg. 14 (2003) 621–628. [7] L.L. Chiu, K.C.Y. Sie, Sphincter pharyngoplasty for management of velopharyngeal insufficiency, Oper. Tech. Otolaryngol. 20 (2009) 263–267. [8] M. Abdel-Aziz, H. Dewidar, H. El-Hoshy, A. Aziz, Treatment of persistent postadenoidectomy velopharyngeal insufficiency by sphincter pharyngoplasty, Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 1329–1333. [9] I.T. Jackson, J.S. Silverston, Sphincter pharyngoplasty as a secondary procedure in cleft palates, Plast. Reconstr. Surg. 59 (1977) 518–525. [10] J.K.G. Laitung, A modification of the Kilner–Dott mouth gag for improving exposure to the nasopharyngeal area, Br. J. Plast. Surg. 39 (1986) 268–269. [11] A. Ragab, Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency, Int. J. Pediatr. Otorhinolaryngol. 71 (2007) 793–800. [12] A. Raurell, S.J. Southern, O.M. Fenton, Perioperative use of nasoendoscopy in cleft surgery, Ann. Plast. Surg. 45 (2000) 627–628. [13] G.M. Sloan, Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art, Cleft Palate Craniofac. J. 37 (2) (2000) 112–122. [14] C.S. Raymond, G. Bettega, C. Deschaux, J. Lebeau, B. Raphael, P. Le´vy, et al., Sphincter pharyngoplasty as a treatment of velopharyngeal incompetence in young people: a prospective evaluation of effects on sleep structure and sleep respiratory disturbances, Chest 125 (2004) 864–871.