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Observations on pharyngoplasty
OBSERVATIONS ON PHARYNGOPLASTY
By WILFREDHYNES, F.R.C.S.
The Plastic and Jaw Department, United SheffieM Hospitals THE writer has practised pharyngoplasty by muscle transplantation for twenty years and feels that some of the observations he has made during this period may be of interest. He has come to the conclusion, for example, that it is difficult to assess the results of pharyngoplasty, or for that matter of any other secondary cleft palate operation, except in the most general terms. Primary cleft palate results are difficult enough to assess and this is evidenced by the fact that good speech following the same or similar primary operation varies from 5o per cent. to 90 per cent. of cases in different hands. One of the difficulties in assessing the results in primary cases is the number of variables which are present in the palatopharyngeal region--some of these variables are anatomical and concern the length and position of the cleft ; but others are physiological and are much more important as they involve the degree of development and the mobility of the palatal elements. These variables are not all covered by the classifications in common use by which cases are grouped for assessment. Assessment of the result of secondary palate operations is even more difficult because the number of variables in the palato-pharyngeal region is greater--in addition to the variations seen in primary cases, there are variations in the number and type of operations already carried out on the patient, variations in the degree of development in the palate and pharynx since these operations were done and variations in the ability of the patients to compensate for any residual post-operative palato-pharyngeal imperfections. There is, therefore, a need for a more effective classification against which to assess the results of cleft palate operations--so that, when new patients are seen, a reasoned decision can be taken as to which operation should be carried out in any particular case according to its group and, further, so that the outcome of this treatment can be foretold. This classification should have a physiological rather than an anatomical basis; it should cover all the common variables seen in the palato-pharyngeal region in cleft palate cases ; it should be objective and should be capable of standardisation. Classifications in common use are unsatisfactory. The older Veau and Ritchie classifications and the more recent classifications of Kernahan and Stark (I958), for example, have an anatomical basis against which it seems almost impossible to assess speech results which depend on the physiology of the parts. In addition, they deal with the palate and ignore the pharynxmas if the soft palate, which, after all, is merely one of the walls of the pharnyx, can be considered in isolation. Radiography would seem to offer a more rational basis for a classification as it demonstrates the physiology of the palato-pharyngeal area and it is objective. In its present form, however, radiography does not provide all the information we require. The soft palate moves in the antero-posterior plane whereas the oropharynx moves principally in the transverse planemthe lateral X-ray view of the palato-pharyngeal region may, therefore, demonstrate the movement of the palate well enough, but it tells us little of the activity of the pharynx. It takes a number of years to collect enough cleft palate material to make a follow-up worth while. It can be a little sad if, at the end of this period, the collector finds that 244
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he has largely wasted his time because his cases are grouped anatomically whereas his results can only be measured physiologically.
PHARYNGOPLASTY BY MUSCLE TRANSPLANTATION This operation was described by the writer in I95o and again in I953 (Hynes, I95o, I953). It is felt that a short description of the operation at this stage will clarify the rest of the discussion. The operation is based on two accepted principles--one surgical and the other physiological. It is surgically correct to use a transposition flap to cover a defect ; and, when replacing one muscle by another in a muscle transplant operation, it is physiologically correct that the two muscles should normally be synergic so that massive postoperative re-education will be unnecessary. The lateral walls of the oropharynx, each of which lies at the bottom of a lateral pharyngeal recess behind the corresponding posterior pillar of the fauces, must be fully exposed (Fig. IA). This is easy if there is a residual cleft of the soft palate ; if, however, the velum is in one piece, it must be divided in the middle line as the first step in the operation. With the posterior faucial pillar and the corresponding soft palatal element retracted by hooks and with the head then turned to one side, the lateral pharyngeal wall on that side is raised in its whole length and width as a flap based above, its pedicle lying just below the level of the Eustachian region ; this flap must include the whole thickness of the muscle in the lateral pharyngeal wall together with its overlying mucosa (Fig. I, B). The secondary defects on the lateral pharyngeal walls are closed by suture (Fig. I, c) and this reduces the transverse diameter of the oropharynx by an amount which depends on the width of the flaps--the wider the flaps the greater the narrowing; in addition, it has the effect of drawing the pedicles of the two flaps towards the mid-line and permanently obliterates the pharyngeal recesses which extend laterally behind the posterior pillar of the fauces on each side--the significance of this will be discussed later. T h e two lateral pharyngeal flaps are then transposed upwards and inwards and are inset into a defect high across the posterior pharyngeal wall made by a transverse mucosal incision just below the level of the Eustachian region (Fig. I, c). This produces a considerable muscle ridge across the upper part of the posterior pharyngeal wall and reduces the anterio-posterior diameter of the pharynx in the palato-pharyngeal region. The pharyngoplasty is now complete and its effect is therefore to reduce all the diameters of the oropharynx very considerably and to produce high on its posterior wall a muscle ridge which should move with the palate (Fig. 2). The palate is now dealt with. If the velum was divided to provide access as the first step in the operation, it is simply brought together in two layers without attempting to lengthen it. If there was a residual cleft of the palate at the beginning of the operation, it is repaired by any suitable method favoured by the surgeon, either as the last step in the operation or at a second operation two or three months after the pharnygoplasty. The writer uses the simplest method to get the palate in one piece and makes no effort to lengthen it. When the palate has been brought together a muscle sphincter will result ; it will consist of two synergic elements which work smoothly together--a posterior element formed by the posterior pharyngeal ridge of the pharyngoplasty and an anterior element formed by the repaired velum (Fig. 3).
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A
B
FIG.
I
Pharyngoplasty by muscle transplantation. A, Incisions. B, Lateral pharyngeal flaps raised and transverse defect established. C, Secondary defects closed and flaps transposed.
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FIG. 2 The posterior pharyngeal ridge six months after pharyngoplasty.
Fro. 3 Palato-pharyngeal sphincter resulting from pharyngoplasty. A. Sphincter open in repose. ]3. Sphincter closed during phonation.
Fro. 4
Cross section of the oropharynx showing the pharyngeal recesses extending laterally behind the posterior pillars of the fauces during repose. The dotted lines represent the position of the lateral pharyngeal walls during phonation with consequent obliteration of the lateral pharyngeal recesses.
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BRITISH JOURNAL OF PLASTIC SURGERY T H E LATERAL PHARYNGEAL RECESSES
Examination of the lateral pharyngeal wall shows that air can pass between the larynx and the nose without having to negotiate the palato-pharyngeal space--a simple fact that explains the post-operative persistence of cleft palate speech stigmata in some cases. The width of the oropharynx is greater than appears on inspection of the back of the throat through the mouth because the pharynx extends laterally as a recess on each side behind the posterior faucial pillars for a distance which varies from patient to patient. Each lateral pharyngeal recess communicates below with the lower pharynx
FIO. 5 Enlarged, static pharynx in a " failed palate " aged 13 years.
and thence with the larynx and, above, it passes upwards behind the palato-pharyngeal fold and joins the fossa of Rosenmtiller on the lateral wall of the nasopharynx behind the Eustachian region. These lateral pharyngeal recesses can be obliterated during speech (and swallowing) in a normal person by the contraction of the muscles lying in the lateral walls of the oropharynx (Fig. 4). When the pharynx is in repose, the lateral pharyngeal recesses are open and air can therefore pass from larynx to nose behind the posterior pillars of the fauces and so bypass the palato-pharyngeal region. During speech the lateral pharyngeal recesses are obliterated and all the air from the larynx is compelled to ascend the central part of the pharynx and is therefore directed to the region controlled by the soft palate. Unfortunately, in cleft palate patients, the pharynx is not always normal. A considerable number o f " failed cleft palate "patients show the condition o f " enlarged static pharynx "--where the oropharynx is abnormally large and the pharyngeal movements during speech are poor or seem to be absent so that the cavernous lateral pharyngeal recesses cannot be obliterated during phonation (Fig. 5). Laryngeal air, as it ascends the pharynx to the nose, can therefore by-pass the palato-pharyngeal region during speech. After a secondary operation in such a failed cleft palate case, air will continue to " leak" into the nose during speech however successful the operation may have
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been in controlling the palato-pharyngeal region, and cleft palate speech stigmata will therefore persist. Pharyngoplasty by muscle transplantation, however, can influence this state of affairs. It will be recalled that, in this operation, after raising the two lateral pharyngeal flaps, the closure of the secondary defects on the lateral pharyngeal walls permanently obliterates the two lateral pharyngeal recesses in all cases, i.e., when the pharynx is normal and also in those " failed cleft palate " patients who possess an " enlarged, static pharynx ". Both in repose and during speech, laryngeal air is therefore compelled to ascend the central part of the pharynx where it encounters, and comes under the influence of, the palato-pharyngeal apparatus. It would seem to the writer that the Rosenthal pharyngoplasty concentrates on the palato-pharyngeal area but does not deal with the lateral pharyngeal recesses ; as a consequence, the "failed cleft palate" patient with an enlarged static pharynx who is treated in this way will show cleft palate speech stigmata after operation because laryngeal air will still be able to by-pass the pharyngeal flap however effective it might otherwise be. The above considerations provide a guide as to which type of pharyngoplasty should be done in any particular " f a i l e d cleft palate" case. As the pharyngoplasty by muscle transplantation obliterates the lateral pharyngeal recesses in all cases, the writer, perhaps not unnaturally, recommends its use for all patients. The Rosenthal operation, also, may well be satisfactory for those "failed " cases in whom the pharynx moves normally during speech. However, even if the surgeon favours the pharyngeal flap operation under these normal pharyngeal circumstances, the writer feels that he should hesitate to use it if the movement of the pharynx is insufficient to obliterate the lateral pharyngeal recesses during speech.
CONDITIONS NECESSARY FOR SUCCESSFUL PHARYNGOPLASTY
I. Choice o f case.--Some surgeons are perhaps too critical and are prepared to carry out a pharyngoplasty or some other secondary palate operation for relatively trivial reasons. The results are naturally good whichever operation is done and this success encourages the surgeon to operate more and more readily. Other surgeons are not critical enough and are satisfied if the patient is easily intelligible, even though cleft palate speech stigmata are present. Thus, in a recent publication on the results of the pharyngeal flap operation, a surgeon claims " acceptable intelligibility " in a very considerable proportion of the patients in certain age groups ; this unusual way of measuring success implies the persistence, and admits the acceptance, of some degree of imperfect speech after operation. Briefly, the writer is prepared to carry out a pharyngoplasty if the patient's speech shows cleft palate stigmata--weak consonants, nasalised vowels and nasal escape--with or without additional speech faults of a compensatory nature. 2. O p e r a t i o n details.--These are far simpler to carry out than they are to describe. (a) The soft palate may or may not be in one piece before the pharyngoplasty. Free access to the pharynx, ensuring an effective, high posterior pharyngeal ridge, is possible only if an intact soft palate is divided in the mid-line as the first step in the operation. It is possible to carry out a pharyngoplasty with the soft palate in one piece but this makes the operation more difficult and results in a posterior pharyngeal ridge which is too low for the short soft palate to contact during speech. There need be no hesitation about dividing the palate as any tension on its suture line, when its two halves are brought together at the end of the operation, is effectively relieved by the closure of
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the secondary defects on the lateral pharyngeal walls resulting from the raising of the two lateral pharyngeal flaps. (b) The lateral pharyngeal flaps.--The r~haryngeal muscles (superior constrictor, palato-pharyngeus and salpingo-pharyngeus) form a mass of considerable thickness in the lateral walls of the pharynx but are reduced to a thin aponeurotic layer as they pass downwards and inwards across the posterior wall of the pharynx to be inserted in the median raphe. To ensure both movement and bulk in the posterior pharygneal ridge, the lateral pharyngeal flaps which form it must contain as much active muscle as possible.
Fzo. 6 The pharyngeal flaps advised in a recent publication. They are~ incorrectly~ outlined on the posterior pharyngeal wall.
For this reason each of the two flaps must be raised from the whole width and thickness of the lateral pharyngeal wall, and not from the lateral part of the posterior pharyngeal wall as described in a recent publication (Fig. 6); this incorrect use of the posterior wall produces flaps which have no bulk and which cannot produce movement as they contain aponeurosis instead of muscle. The velum having been divided, free exposure of each lateral wall, as it lies at the bottom of the lateral pharyngeal recess, is obtained by turning the head on one side after retracting the posterior faucial pillar and the corresponding soft palatal element by means of hooks (Fig. 7). This enables the surgeon to see as high as the Eustachian region on the lateral wall of the nasopharynx while, below, the lower reaches of the pharynx can be exposed if the assistant raises the lower end of the cleft palate gag from the chest wall as required (Fig. 8 ) . With the mucosa and underlying sub-mucosa of the lateral wall of the oropharynx
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FIG. 7 Exposure of the lateral walls of the pharynx by hook retraction. At operation, of course, only one side is exposed at a time.
J
FIG. 8 Manoeuvre to expose the lower reaches of the pharynx.
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raised as a prominent fold by another hook placed at its centre, two parallel mucosa! incisions are made, one immediately behind and parallel to the posterior pillar of the fauces and the other at the junction of the posterior and lateral pharyngeal walls (Fig. !
A
FIG. 9
The raising of the left lateral pharyngeal flap. A, Outline of the flap together with the transverse incision across the posterior pharyngeal wall just below the Eustachian region. B, Traction exerted on the lower pedicle prior to its division. C, Mucosa at the lower pedicle divided.
9, A). Each incision extends from a level just below the Eustachian cushion above to the lower pharynx below, and each incision is deepened laterally by a blunt dissector through the full thickness of the lateral pharyngeal muscles until the resistance of the pharyngeal fascia, which protects the carotid sheath, is felt.
OBSERVATIONS
ON
253
PItARYNGOPLASTY
With the hooks still in position, it is convenient at this stage to make the transverse mucosal incision high up across the posterior wall of the pharynx just below the Eustachian level (Fig. 9, A) and to widen it by spreading the mucosal edges by blunt dissection ; this transverse incision, about 2 cm. long in an average adult, joins the upper ends of the two lateral pharyngeal secondary defects, when, at the next step, the second lateral pharyngeal flap is raised (Fig. i, B). The lower end of the flap is then divided to ensure the inclusion of the full thickness
,.
D FIG. 9 E D, Inward retraction of the lower pedicle as the full thickness of the muscle in the lateral pharyngeal wall is divided. E, Lateral pharyngeal flap raised exposing the white pharyngeal fascia.
of the lateral pharyngeal muscles. To do this, the hook at the centre of the flap is removed and a hook is inserted on each margin of the flap just above its lower end (Fig. 9, n) ; upward traction on these hooks puts the lower pharynx on the stretch so that the mucosa and sub-mucosa can be divided across the lower pedicle with long scissors (Fig. 9, c). This exposes the underlying pharyngeal muscle which is, in turn, divided with .scissors in a lateral direction until the white pharyngeal fascia is seen. As he is dividing the muscle in this way, the surgeon may feel a little worried as to the safety of the carotid sheath which lies beyond the pharyngeal fascia, and caution may well result in some of the muscle being left behind. This anxiety can be overcome, however, by the manoeuvre illustrated (Fig. 9, D). When the mucosa at the lower pedicle has been divided, the two hooks now retract inwards towards the centre of the pharynx so as to expose more and more of the lateral pharyngeal muscle as it is progressively divided with long scissors ; as long as muscle can be seen in the lateral pharyngeal wall, it can safely be divided until the point is reached where the white pharyngeal fascia is exposed. The whole thickness of the lateral pharyngeal wall is now dissected up as a flap pedicled above by scissor dissection in this natural plane between pharyngeal muscle and fascia (Fig. 9, E). This ensures the inclusion of all the muscle in the flap and the minimum of bleeding ; the occasional spurting vessel can easily be controlled by long forceps and it has usually stopped bleeding when the forceps are removed. (c) The inset of the bulky lateral pharyngeal flaps into the relatively narrow trans-
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J O U R N A L OF P L A S T I C S U R G E R Y
verse defect made by the mucosal incision across the upper part of the posterior pharyngeal wall may, at first sight, appear technically difficult. It is accomplished quite easily by attaching only the left flap to the defect and then insetting the raw surface of the right
/ A FIG. IO B I n s e t o f t h e two lateral p h a r y n g e a l flaps into t h e transverse p h a r y n g e a l defect. A, T h e a t t a c h m e n t o f t h e lower border of t h e left flap to t h e lower b o r d e r of t h e transverse defect. Be T h e a t t a c h m e n t o f t h e lower b o r d e r of t h e right flap to t h e u p p e r border o f t h e left flap.
FIG.
II
~-circle needle m o u n t e d on needle holder in reversed position.
flap to that of the left (Fig. IO). To do this the anterior border (when transposed, the lower border) of the left flap is attached to the lower edge of the transverse mucosal incision by two sutures which, when tied, draw the flap across the back of the upper
OBSERVATIONS ON PHARYNGOPLASTY
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pharynx (Fig. IO, A). The anterior border (when transposed, the lower border) of the left flap is then attached to the upper border of the inset flap by two sutures (Fig. Io, B) and any exposed raw surfaces that remain are covered by a tacking suture where required. The two flaps form a sort of tubed pedicle split longitudinally and attached to the lower edge of the transverse mucosal incision. These deep stitches are easy to insert if the suture material is threaded on a small a-circle needle mounted in the reversed position through a hole on the business end of an ordinary long needle holder (Fig. 1i). 3. P o s t - o p e r a t i v e f o l l o w - u p . - - T h e definitive assessment of the speech result is made nine to twelve months after the operation, when the scars in the palate and
A Fm. iz B Transposition of posterior pillars across the front of the posterior pharyngeal ridge. A, Outline of flaps and the transverse defect made across the front of the ridge. B, Secondary defects closed and flaps transposed.
pharynx have matured. The writer uses his syllabic speech test which not only demonstrates the presence of a speech defect but also locates its cause (Hynes, I957). If, after pharyngoplasty, speech still shows cleft palate stigmata which are the result of faults in the palato-pharyngeal region, the posterior pharyngeal ridge can be deepened or the palate can be lengthened. The writer has found that some form of further operation of this kind has been required in 2o per cent. of his pharyngoplasty patients-there is, after all, a limit to what any operation can achieve and this is determined by the condition of the parts with which he is dealing. Deepening of the posterior pharyngeal ridge, which is reserved for the less severe cases, is carried out by an operation which in principle resembles the pharyngoplasty operation (Fig. I2) : each posterior faucial pillar is raised as a flap based above (Fig. I2, A) and, after its secondary defect has been closed, it is transposed upwards and inwards and inset into a defect made by a transverse mucosal incision across the anterior surface of the existing posterior pharyngeal ridge (Fig. i2, B). For more severe residual palato-pharyngeal defects, the palate must be lengthened. The writer favours the method (Fig. I3) first described by Cuthbert (I95I) for primary palate repair and later used by Gibson (I959) for secondary palate lengthening.
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After pharyngoplasty, the syllabic test may show that the cause of the faulty speech lies outside the palato-pharyngeal region. If this is so, the affected area is treated surgically or dentally if this is possible. As a general rule, however, it will be found that
t'7/~, } /
i
\ ">z.v~X
'YJ '
FIG. 13 The use of the transposition flap from the mucosa of the hard palate to lengthen a short soft palate (after Gibson).
this kind of faulty speech is due to faulty tongue movements of a compensatory nature (Hynes, 1957); such cases are referred for speech therapy which will be successful only if the surgeon has succeeded in producing an effective palato-pharyngeal apparatus by his pharyngoplasty. REFERENCES CIJTHBERT, J. (1951). Br. J. plast. Surg., 4, 185. GIBSON, T. (1959). Br. J. plast. Sure., 12, 223. HYNES, W. (195o). Br. J. plast. Surg., 3, 128. HYNES, W. (1953). Ann. R. Coll. Surg., 13, 17. HYNES, W. (1957). Br. J. plast. Surg., Io, 1I 4. KERNAHAN, m. A., and STARK, R. B. (1958). Plastic reconstr. Surg., 22, 435.
By WILFREDHYNES, F.R.C.S.
The Plastic and Jaw Department, United SheffieM Hospitals THE writer has practised pharyngoplasty by muscle transplantation for twenty years and feels that some of the observations he has made during this period may be of interest. He has come to the conclusion, for example, that it is difficult to assess the results of pharyngoplasty, or for that matter of any other secondary cleft palate operation, except in the most general terms. Primary cleft palate results are difficult enough to assess and this is evidenced by the fact that good speech following the same or similar primary operation varies from 5o per cent. to 90 per cent. of cases in different hands. One of the difficulties in assessing the results in primary cases is the number of variables which are present in the palatopharyngeal region--some of these variables are anatomical and concern the length and position of the cleft ; but others are physiological and are much more important as they involve the degree of development and the mobility of the palatal elements. These variables are not all covered by the classifications in common use by which cases are grouped for assessment. Assessment of the result of secondary palate operations is even more difficult because the number of variables in the palato-pharyngeal region is greater--in addition to the variations seen in primary cases, there are variations in the number and type of operations already carried out on the patient, variations in the degree of development in the palate and pharynx since these operations were done and variations in the ability of the patients to compensate for any residual post-operative palato-pharyngeal imperfections. There is, therefore, a need for a more effective classification against which to assess the results of cleft palate operations--so that, when new patients are seen, a reasoned decision can be taken as to which operation should be carried out in any particular case according to its group and, further, so that the outcome of this treatment can be foretold. This classification should have a physiological rather than an anatomical basis; it should cover all the common variables seen in the palato-pharyngeal region in cleft palate cases ; it should be objective and should be capable of standardisation. Classifications in common use are unsatisfactory. The older Veau and Ritchie classifications and the more recent classifications of Kernahan and Stark (I958), for example, have an anatomical basis against which it seems almost impossible to assess speech results which depend on the physiology of the parts. In addition, they deal with the palate and ignore the pharynxmas if the soft palate, which, after all, is merely one of the walls of the pharnyx, can be considered in isolation. Radiography would seem to offer a more rational basis for a classification as it demonstrates the physiology of the palato-pharyngeal area and it is objective. In its present form, however, radiography does not provide all the information we require. The soft palate moves in the antero-posterior plane whereas the oropharynx moves principally in the transverse planemthe lateral X-ray view of the palato-pharyngeal region may, therefore, demonstrate the movement of the palate well enough, but it tells us little of the activity of the pharynx. It takes a number of years to collect enough cleft palate material to make a follow-up worth while. It can be a little sad if, at the end of this period, the collector finds that 244
OBSERVATIONS ON PHARYNGOPLASTY
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he has largely wasted his time because his cases are grouped anatomically whereas his results can only be measured physiologically.
PHARYNGOPLASTY BY MUSCLE TRANSPLANTATION This operation was described by the writer in I95o and again in I953 (Hynes, I95o, I953). It is felt that a short description of the operation at this stage will clarify the rest of the discussion. The operation is based on two accepted principles--one surgical and the other physiological. It is surgically correct to use a transposition flap to cover a defect ; and, when replacing one muscle by another in a muscle transplant operation, it is physiologically correct that the two muscles should normally be synergic so that massive postoperative re-education will be unnecessary. The lateral walls of the oropharynx, each of which lies at the bottom of a lateral pharyngeal recess behind the corresponding posterior pillar of the fauces, must be fully exposed (Fig. IA). This is easy if there is a residual cleft of the soft palate ; if, however, the velum is in one piece, it must be divided in the middle line as the first step in the operation. With the posterior faucial pillar and the corresponding soft palatal element retracted by hooks and with the head then turned to one side, the lateral pharyngeal wall on that side is raised in its whole length and width as a flap based above, its pedicle lying just below the level of the Eustachian region ; this flap must include the whole thickness of the muscle in the lateral pharyngeal wall together with its overlying mucosa (Fig. I, B). The secondary defects on the lateral pharyngeal walls are closed by suture (Fig. I, c) and this reduces the transverse diameter of the oropharynx by an amount which depends on the width of the flaps--the wider the flaps the greater the narrowing; in addition, it has the effect of drawing the pedicles of the two flaps towards the mid-line and permanently obliterates the pharyngeal recesses which extend laterally behind the posterior pillar of the fauces on each side--the significance of this will be discussed later. T h e two lateral pharyngeal flaps are then transposed upwards and inwards and are inset into a defect high across the posterior pharyngeal wall made by a transverse mucosal incision just below the level of the Eustachian region (Fig. I, c). This produces a considerable muscle ridge across the upper part of the posterior pharyngeal wall and reduces the anterio-posterior diameter of the pharynx in the palato-pharyngeal region. The pharyngoplasty is now complete and its effect is therefore to reduce all the diameters of the oropharynx very considerably and to produce high on its posterior wall a muscle ridge which should move with the palate (Fig. 2). The palate is now dealt with. If the velum was divided to provide access as the first step in the operation, it is simply brought together in two layers without attempting to lengthen it. If there was a residual cleft of the palate at the beginning of the operation, it is repaired by any suitable method favoured by the surgeon, either as the last step in the operation or at a second operation two or three months after the pharnygoplasty. The writer uses the simplest method to get the palate in one piece and makes no effort to lengthen it. When the palate has been brought together a muscle sphincter will result ; it will consist of two synergic elements which work smoothly together--a posterior element formed by the posterior pharyngeal ridge of the pharyngoplasty and an anterior element formed by the repaired velum (Fig. 3).
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BRITISH JOURNAL OF PLASTIC SURGERY
A
B
FIG.
I
Pharyngoplasty by muscle transplantation. A, Incisions. B, Lateral pharyngeal flaps raised and transverse defect established. C, Secondary defects closed and flaps transposed.
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247
FIG. 2 The posterior pharyngeal ridge six months after pharyngoplasty.
Fro. 3 Palato-pharyngeal sphincter resulting from pharyngoplasty. A. Sphincter open in repose. ]3. Sphincter closed during phonation.
Fro. 4
Cross section of the oropharynx showing the pharyngeal recesses extending laterally behind the posterior pillars of the fauces during repose. The dotted lines represent the position of the lateral pharyngeal walls during phonation with consequent obliteration of the lateral pharyngeal recesses.
248
BRITISH JOURNAL OF PLASTIC SURGERY T H E LATERAL PHARYNGEAL RECESSES
Examination of the lateral pharyngeal wall shows that air can pass between the larynx and the nose without having to negotiate the palato-pharyngeal space--a simple fact that explains the post-operative persistence of cleft palate speech stigmata in some cases. The width of the oropharynx is greater than appears on inspection of the back of the throat through the mouth because the pharynx extends laterally as a recess on each side behind the posterior faucial pillars for a distance which varies from patient to patient. Each lateral pharyngeal recess communicates below with the lower pharynx
FIO. 5 Enlarged, static pharynx in a " failed palate " aged 13 years.
and thence with the larynx and, above, it passes upwards behind the palato-pharyngeal fold and joins the fossa of Rosenmtiller on the lateral wall of the nasopharynx behind the Eustachian region. These lateral pharyngeal recesses can be obliterated during speech (and swallowing) in a normal person by the contraction of the muscles lying in the lateral walls of the oropharynx (Fig. 4). When the pharynx is in repose, the lateral pharyngeal recesses are open and air can therefore pass from larynx to nose behind the posterior pillars of the fauces and so bypass the palato-pharyngeal region. During speech the lateral pharyngeal recesses are obliterated and all the air from the larynx is compelled to ascend the central part of the pharynx and is therefore directed to the region controlled by the soft palate. Unfortunately, in cleft palate patients, the pharynx is not always normal. A considerable number o f " failed cleft palate "patients show the condition o f " enlarged static pharynx "--where the oropharynx is abnormally large and the pharyngeal movements during speech are poor or seem to be absent so that the cavernous lateral pharyngeal recesses cannot be obliterated during phonation (Fig. 5). Laryngeal air, as it ascends the pharynx to the nose, can therefore by-pass the palato-pharyngeal region during speech. After a secondary operation in such a failed cleft palate case, air will continue to " leak" into the nose during speech however successful the operation may have
OBSERVATIONS ON PHARYNGOPLASTY
249
been in controlling the palato-pharyngeal region, and cleft palate speech stigmata will therefore persist. Pharyngoplasty by muscle transplantation, however, can influence this state of affairs. It will be recalled that, in this operation, after raising the two lateral pharyngeal flaps, the closure of the secondary defects on the lateral pharyngeal walls permanently obliterates the two lateral pharyngeal recesses in all cases, i.e., when the pharynx is normal and also in those " failed cleft palate " patients who possess an " enlarged, static pharynx ". Both in repose and during speech, laryngeal air is therefore compelled to ascend the central part of the pharynx where it encounters, and comes under the influence of, the palato-pharyngeal apparatus. It would seem to the writer that the Rosenthal pharyngoplasty concentrates on the palato-pharyngeal area but does not deal with the lateral pharyngeal recesses ; as a consequence, the "failed cleft palate" patient with an enlarged static pharynx who is treated in this way will show cleft palate speech stigmata after operation because laryngeal air will still be able to by-pass the pharyngeal flap however effective it might otherwise be. The above considerations provide a guide as to which type of pharyngoplasty should be done in any particular " f a i l e d cleft palate" case. As the pharyngoplasty by muscle transplantation obliterates the lateral pharyngeal recesses in all cases, the writer, perhaps not unnaturally, recommends its use for all patients. The Rosenthal operation, also, may well be satisfactory for those "failed " cases in whom the pharynx moves normally during speech. However, even if the surgeon favours the pharyngeal flap operation under these normal pharyngeal circumstances, the writer feels that he should hesitate to use it if the movement of the pharynx is insufficient to obliterate the lateral pharyngeal recesses during speech.
CONDITIONS NECESSARY FOR SUCCESSFUL PHARYNGOPLASTY
I. Choice o f case.--Some surgeons are perhaps too critical and are prepared to carry out a pharyngoplasty or some other secondary palate operation for relatively trivial reasons. The results are naturally good whichever operation is done and this success encourages the surgeon to operate more and more readily. Other surgeons are not critical enough and are satisfied if the patient is easily intelligible, even though cleft palate speech stigmata are present. Thus, in a recent publication on the results of the pharyngeal flap operation, a surgeon claims " acceptable intelligibility " in a very considerable proportion of the patients in certain age groups ; this unusual way of measuring success implies the persistence, and admits the acceptance, of some degree of imperfect speech after operation. Briefly, the writer is prepared to carry out a pharyngoplasty if the patient's speech shows cleft palate stigmata--weak consonants, nasalised vowels and nasal escape--with or without additional speech faults of a compensatory nature. 2. O p e r a t i o n details.--These are far simpler to carry out than they are to describe. (a) The soft palate may or may not be in one piece before the pharyngoplasty. Free access to the pharynx, ensuring an effective, high posterior pharyngeal ridge, is possible only if an intact soft palate is divided in the mid-line as the first step in the operation. It is possible to carry out a pharyngoplasty with the soft palate in one piece but this makes the operation more difficult and results in a posterior pharyngeal ridge which is too low for the short soft palate to contact during speech. There need be no hesitation about dividing the palate as any tension on its suture line, when its two halves are brought together at the end of the operation, is effectively relieved by the closure of
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the secondary defects on the lateral pharyngeal walls resulting from the raising of the two lateral pharyngeal flaps. (b) The lateral pharyngeal flaps.--The r~haryngeal muscles (superior constrictor, palato-pharyngeus and salpingo-pharyngeus) form a mass of considerable thickness in the lateral walls of the pharynx but are reduced to a thin aponeurotic layer as they pass downwards and inwards across the posterior wall of the pharynx to be inserted in the median raphe. To ensure both movement and bulk in the posterior pharygneal ridge, the lateral pharyngeal flaps which form it must contain as much active muscle as possible.
Fzo. 6 The pharyngeal flaps advised in a recent publication. They are~ incorrectly~ outlined on the posterior pharyngeal wall.
For this reason each of the two flaps must be raised from the whole width and thickness of the lateral pharyngeal wall, and not from the lateral part of the posterior pharyngeal wall as described in a recent publication (Fig. 6); this incorrect use of the posterior wall produces flaps which have no bulk and which cannot produce movement as they contain aponeurosis instead of muscle. The velum having been divided, free exposure of each lateral wall, as it lies at the bottom of the lateral pharyngeal recess, is obtained by turning the head on one side after retracting the posterior faucial pillar and the corresponding soft palatal element by means of hooks (Fig. 7). This enables the surgeon to see as high as the Eustachian region on the lateral wall of the nasopharynx while, below, the lower reaches of the pharynx can be exposed if the assistant raises the lower end of the cleft palate gag from the chest wall as required (Fig. 8 ) . With the mucosa and underlying sub-mucosa of the lateral wall of the oropharynx
OBSERVATIONS ON PHARYNGOPLASTY
251
FIG. 7 Exposure of the lateral walls of the pharynx by hook retraction. At operation, of course, only one side is exposed at a time.
J
FIG. 8 Manoeuvre to expose the lower reaches of the pharynx.
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252
raised as a prominent fold by another hook placed at its centre, two parallel mucosa! incisions are made, one immediately behind and parallel to the posterior pillar of the fauces and the other at the junction of the posterior and lateral pharyngeal walls (Fig. !
A
FIG. 9
The raising of the left lateral pharyngeal flap. A, Outline of the flap together with the transverse incision across the posterior pharyngeal wall just below the Eustachian region. B, Traction exerted on the lower pedicle prior to its division. C, Mucosa at the lower pedicle divided.
9, A). Each incision extends from a level just below the Eustachian cushion above to the lower pharynx below, and each incision is deepened laterally by a blunt dissector through the full thickness of the lateral pharyngeal muscles until the resistance of the pharyngeal fascia, which protects the carotid sheath, is felt.
OBSERVATIONS
ON
253
PItARYNGOPLASTY
With the hooks still in position, it is convenient at this stage to make the transverse mucosal incision high up across the posterior wall of the pharynx just below the Eustachian level (Fig. 9, A) and to widen it by spreading the mucosal edges by blunt dissection ; this transverse incision, about 2 cm. long in an average adult, joins the upper ends of the two lateral pharyngeal secondary defects, when, at the next step, the second lateral pharyngeal flap is raised (Fig. i, B). The lower end of the flap is then divided to ensure the inclusion of the full thickness
,.
D FIG. 9 E D, Inward retraction of the lower pedicle as the full thickness of the muscle in the lateral pharyngeal wall is divided. E, Lateral pharyngeal flap raised exposing the white pharyngeal fascia.
of the lateral pharyngeal muscles. To do this, the hook at the centre of the flap is removed and a hook is inserted on each margin of the flap just above its lower end (Fig. 9, n) ; upward traction on these hooks puts the lower pharynx on the stretch so that the mucosa and sub-mucosa can be divided across the lower pedicle with long scissors (Fig. 9, c). This exposes the underlying pharyngeal muscle which is, in turn, divided with .scissors in a lateral direction until the white pharyngeal fascia is seen. As he is dividing the muscle in this way, the surgeon may feel a little worried as to the safety of the carotid sheath which lies beyond the pharyngeal fascia, and caution may well result in some of the muscle being left behind. This anxiety can be overcome, however, by the manoeuvre illustrated (Fig. 9, D). When the mucosa at the lower pedicle has been divided, the two hooks now retract inwards towards the centre of the pharynx so as to expose more and more of the lateral pharyngeal muscle as it is progressively divided with long scissors ; as long as muscle can be seen in the lateral pharyngeal wall, it can safely be divided until the point is reached where the white pharyngeal fascia is exposed. The whole thickness of the lateral pharyngeal wall is now dissected up as a flap pedicled above by scissor dissection in this natural plane between pharyngeal muscle and fascia (Fig. 9, E). This ensures the inclusion of all the muscle in the flap and the minimum of bleeding ; the occasional spurting vessel can easily be controlled by long forceps and it has usually stopped bleeding when the forceps are removed. (c) The inset of the bulky lateral pharyngeal flaps into the relatively narrow trans-
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verse defect made by the mucosal incision across the upper part of the posterior pharyngeal wall may, at first sight, appear technically difficult. It is accomplished quite easily by attaching only the left flap to the defect and then insetting the raw surface of the right
/ A FIG. IO B I n s e t o f t h e two lateral p h a r y n g e a l flaps into t h e transverse p h a r y n g e a l defect. A, T h e a t t a c h m e n t o f t h e lower border of t h e left flap to t h e lower b o r d e r of t h e transverse defect. Be T h e a t t a c h m e n t o f t h e lower b o r d e r of t h e right flap to t h e u p p e r border o f t h e left flap.
FIG.
II
~-circle needle m o u n t e d on needle holder in reversed position.
flap to that of the left (Fig. IO). To do this the anterior border (when transposed, the lower border) of the left flap is attached to the lower edge of the transverse mucosal incision by two sutures which, when tied, draw the flap across the back of the upper
OBSERVATIONS ON PHARYNGOPLASTY
255
pharynx (Fig. IO, A). The anterior border (when transposed, the lower border) of the left flap is then attached to the upper border of the inset flap by two sutures (Fig. Io, B) and any exposed raw surfaces that remain are covered by a tacking suture where required. The two flaps form a sort of tubed pedicle split longitudinally and attached to the lower edge of the transverse mucosal incision. These deep stitches are easy to insert if the suture material is threaded on a small a-circle needle mounted in the reversed position through a hole on the business end of an ordinary long needle holder (Fig. 1i). 3. P o s t - o p e r a t i v e f o l l o w - u p . - - T h e definitive assessment of the speech result is made nine to twelve months after the operation, when the scars in the palate and
A Fm. iz B Transposition of posterior pillars across the front of the posterior pharyngeal ridge. A, Outline of flaps and the transverse defect made across the front of the ridge. B, Secondary defects closed and flaps transposed.
pharynx have matured. The writer uses his syllabic speech test which not only demonstrates the presence of a speech defect but also locates its cause (Hynes, I957). If, after pharyngoplasty, speech still shows cleft palate stigmata which are the result of faults in the palato-pharyngeal region, the posterior pharyngeal ridge can be deepened or the palate can be lengthened. The writer has found that some form of further operation of this kind has been required in 2o per cent. of his pharyngoplasty patients-there is, after all, a limit to what any operation can achieve and this is determined by the condition of the parts with which he is dealing. Deepening of the posterior pharyngeal ridge, which is reserved for the less severe cases, is carried out by an operation which in principle resembles the pharyngoplasty operation (Fig. I2) : each posterior faucial pillar is raised as a flap based above (Fig. I2, A) and, after its secondary defect has been closed, it is transposed upwards and inwards and inset into a defect made by a transverse mucosal incision across the anterior surface of the existing posterior pharyngeal ridge (Fig. i2, B). For more severe residual palato-pharyngeal defects, the palate must be lengthened. The writer favours the method (Fig. I3) first described by Cuthbert (I95I) for primary palate repair and later used by Gibson (I959) for secondary palate lengthening.
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After pharyngoplasty, the syllabic test may show that the cause of the faulty speech lies outside the palato-pharyngeal region. If this is so, the affected area is treated surgically or dentally if this is possible. As a general rule, however, it will be found that
t'7/~, } /
i
\ ">z.v~X
'YJ '
FIG. 13 The use of the transposition flap from the mucosa of the hard palate to lengthen a short soft palate (after Gibson).
this kind of faulty speech is due to faulty tongue movements of a compensatory nature (Hynes, 1957); such cases are referred for speech therapy which will be successful only if the surgeon has succeeded in producing an effective palato-pharyngeal apparatus by his pharyngoplasty. REFERENCES CIJTHBERT, J. (1951). Br. J. plast. Surg., 4, 185. GIBSON, T. (1959). Br. J. plast. Sure., 12, 223. HYNES, W. (195o). Br. J. plast. Surg., 3, 128. HYNES, W. (1953). Ann. R. Coll. Surg., 13, 17. HYNES, W. (1957). Br. J. plast. Surg., Io, 1I 4. KERNAHAN, m. A., and STARK, R. B. (1958). Plastic reconstr. Surg., 22, 435.