Surgical treatment of adenoidectomy complications: Velopharyngeal inadequacy and nasopharyngeal stenosis

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SURGICAL TREATMENT OF ADENOIDECTOMY COMPLICATIONS: VELOPHARYNGEAL INADEQUACY AND NASOPHARYNGEAL STENOSIS MARSHALL E. SMITH, MD, STEVEN D. GRAY, MD, HARLAN R. MUNTZ, MD

Complications of adenoidectomy include velopharyngeal inadequacy and nasopharyngeal stenosis. The evaluation of velopharyngeal inadequacy requires the participation of speech pathology in assessing the problem and formulating a treatment plan. Nasal endoscopy findings are crucial in this process, and a decision tree based on these findings is given. The surgical treatment options for velopharyngeal inadequacy after adenoidectomy are discussed. The less common problem of nasopharyngeal stenosis and an approach to its treatment is also presented.

Long-term complications of aden0idectomy are uncommon, but they can cause significant problems when they occur. These problems involve an alteration in the dimension of nasopharynx and its opening into the oropharynx. If an excessive opening is created, then symptoms of hypernasal speech and nasopharyngeal regurgitation during swallowing can result. If excessive scar tissue develops in the location of the adenoid, it may narrow the nasopharyngeal inlet and obstructive nasal breathing develops. Patients may develop significant difficulty with nasal obstruction, sleep apnea, inability to clear nasal secretions, and dry mouth. We will discuss our surgical approach in treatment of postadenoidectomy velopharyngeal inadequacy (VPI) and pharyngeal stenosis. A comprehensive evaluation of VPI and its management is detailed in other reviews. 1-3

VPI AND INCOMPETENCE When a patient develops hypernasal speech after an adenoidectomy, the evaluation of the problem is crucial to determine indications for surgical treatment. The patient is examined to confirm the presence of hypernasality; this is done with perceptual assessment and mirror testing to see if nasal emission fogs a dental mirror during repetition of nonnasal sounds. Speech and language status of the child is reviewed. A child who is developmentally delayed may From the Division of Otolaryngology/Head and Neck Surgery, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City, UT. Address reprint requests to Marshall E. Smith, MD, Division of Otolaryngology, University of Utah Medical Center, 50 N. Medical Drive, #3C120, Salt Lake City, UT 84132. Copyright 2002, Elsevier Science (USA). All rights reserved. 1043-1810/02/1301-0021 $35.00/0 doi:10.1053/otot.2002.30534 98

be at higher risk of showing underlying velopharyngeal dysfunction, that may have been present to a small degree preoperatively and has been worsened by the adenoidectomy. Some of these children may have velocardiofacial syndrome. 4 A phenotypic examination for this is indicated. High-resolution chromosome testing for 22qll deletion may be positive, but its absence does not rule out velocardiofacial syndrome. Physical examination of the child is closely performed to look for a submucous cleft palate that may have not been recognized preoperatively. Some patients with large adenoids may exhibit transient hypernasality or nasal emission immediately postoperatively. If the speech development is normal and no other abnormalities are found, we will wait 2 to 3 months to see if the problem resolves on its own. If it has not resolved, then referral to a speech-language pathologist is made. This individual is preferably someone with experience in working with resonance disorders, and who has access to and familiarity in use of a NasometerU (Kay Elemetrics, Lincoln Park, NJ). Nasalance measures with the NasometerU should confirm the presence and severity of hypernasality. The next step in evaluation is nasal endoscopy. This is preferably performed in a setting where the speech pathologist is in attendance, and video recording equipment is available for the surgeon, speech pathologist, parent, and patient to view the study together. Based on these findings, the indication for surgical management is determined. It is important to ascertain the cause of the velopharyngeal dysfunction. With speech dysfunction after adenoidectomy, any of the following can be present. When referring to any type of abnormal velopharyngeal function, the term velopharyngealinadequacyis used. This can be separated into 3 etiologic categories: (1) velopharyngeal insufficiency, (2) velopharyngeal incompetence, and (3) velopharyngeal mislearning. Insufficiency includes structural defects that result in insufficient tissue to accomplish closure. Incompetence describes impairment of motor con-

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 13, NO 1 (MAR), 2002: PP 98-102

NasalEndoscopy Findings I LargeGap Flaccidorpareticpalate

ModerateGap(2-10mm) goodpalatallift

Small(1.2 mm) CentralGap irregularposteriorwall'

Submucouscleftpalate

palatoplasty Loosesphincter palatalliftprosthesis Sphincterpharygoplasty Double,opposingZ.plasty pharyngoplasty tightsphincterpharygoplasty Foldedflappharyngoplasty superior.based Revisionadenoidectomy* [ pharyngeaflap

I Tonsilherniation causingVPI

tonsillectomy

FIGURE 1. Decision tree for management of hypernasality after adenoidectomy, based on nasal endoscopy findings. For explanation of "*" see reference5.

trol caused by neurologic dysfunction, such as paresis/ paralysis. Causes include skull base surgery or tumors around the jugular foramen and vagus nerve, or central nervous system impairment caused by stroke, especially involving the brainstem. Mislearning includes etiologies not caused by structural defects or neuromotor pathologies (ie, functional) for which surgery is not indicated. If a structural or physical abnormality (ie, insufficiency) is identified, then surgical management is usually indicated. In incompetence (ie, flaccid or paretic palate) surgery or palatal lift prosthesis may be used. A decision tree and options for treatment are outlined in Figure 1. Details of all surgical options will not be discussed here and are available elsewhere. 1-3 TREATMENT

OF THE SMALL GAP

We would like to highlight treatment of the small gap, which is commonly found in postadenoidectomy VPI. The first condition to identify is irregular posterior wall caused by incomplete adenoid removal. In a review of 16 patients with postadenoidectomy VPI, 10 were found to have incomplete closure caused by residual adenoid tissue at the plane of palatal closure that interfered with complete closure? This condition can be remedied by a revision adenoidectomy. When this type of small gap is excluded, then the small central gap is caused by velopharyngeal disproportion, ie, the distance between the palate and posterior pharyngeal wall is too great to be completely closed by the velopharyngeal valve. In this case, augmentation of the posterior pharyngeal wall is considered. The concept of augmenting the posterior pharyngeal wall in an effort to improve velopharyngeal competence has received and will continue to receive attention for a number of reasons: (1) the risk of inducing hyponasality and nasal obstruction is lower, (2) it is relatively easy to perform the procedures, (3) the majority of persistent velopharyngeal gaps are continuous with the posterior pharyngeal wall, and (4) the velum or soft palate has relatively good motion in many patients with VPI. The concept of simply bringing the posterior pharyngeal wall forward to correct the gap in many patients with VPI is appealing. In practice, many posterior pharyngeal wall augmentation techniques have failed to meet expectations. Currently, one of the best SMITH, GRAY, AND MUNTZ

techniques to augment the posterior pharyngeal wall is a sphincter pharyngoplasty, because a large shelf of tissue is placed across the posterior pharyngeal wall. Various materials have been used to augment the posterior wall, either by injection or implantation. Tissue implants, such as cartilage, fascia, and fat, have been used. 6 Other bioimplants for this indication may become available in the future. Because of the theoretical advantages of posterior wall augmentation, renewed interest has occurred in using posterior wall tissue to create a shelf or ledge along the posterior wall. In this procedure, a superiorly based pharyngeal flap is lifted up and buckled or folded, to create a ridge across the posterior wall. Folded-flap pharyngoplasty may be selected when there is a small central midline gap and velopharyngeal closure could be completed by simply bringing the posterior wall forward. Occasionally, because patients may achieve velopharyngeal closure, but because the closure is not tight enough, pressure causes leakage of the air to occur through the velopharyngeal port. This condition is referred to as a touch closure problem because the pharyngeal walls touch together but do not achieve competent closure. Under these conditions, a small augmentation of the posterior pharyngeal wall is enough to provide a competent seal. If significant augmentation of the posterior pharyngeal wall is required, then a sphincter pharyngoplasty is usually a better technique. Posterior wall augmentation works best for small, central, or off-center gaps in the area of 1 to 3 mm or for touch closure problems. FOLDED-FLAP

PHARYNGOPLASTY

TECHNIQUE

Folded pharyngeal flap pharyngoplasty is relatively simple and easy to perform. A superiorly based pharyngeal flap is raised and then folded on itself at the level of maximum pharyngeal wall motion in the area of the velopharyngeal port. A superiorly based pharyngeal flap is elevated to prevertebral fascia, so that the constrictor muscle is present within the flap. The width of the flap is decided by ascertaining the width of the gap to be obturated and making the flap slightly larger. The flap shrinks once it is elevated; therefore, a wider flap than anticipated is usually required (Fig 2). 99

A

i=

FIGURE 2. Folded flap pharyngoplasty; surgical technique. (A) Superiorly based pharyngeal flap elevated from the posterior pharyngeal wall. (B) Fold in the flap, which is then sutured back to the pharyngeal wall. Reprinted with permission. 7

The lateral incisions are made first and carried through the constrictor muscle until the white fascia is encountered posteriorly. At this point, a right-angle elevator can be used to elevate the remaining muscle off the fascia. The flap is detached inferiorly at about the level of the inferior

A

pole of the tonsil. The flap is elevated superiorly to slightly above the level of the desired augmentation. When the flap is elevated above the level of augmentation, the buckle of the flap will be correctly positioned. The flap can then be sutured on itself or to the posterior wall so that the

B

Ster

FIGURE 3. Pharyngeal stenosis: surgical technique (A) When using inferiorly based sternocleidomastoid myocutaneous flap, skin paddle is placed over superior portion of muscle. (B) Blood supply to flap comes from thyrocervical trunk and branches off either superior thyroid or inferior thyroid artery. Reprinted with permission. 1~ 100

TREATMENT OF ADENOIDECTOMYCOMPLICATIONS

FI

t'naryngeal stenosis

:: :

.... Musculocutaneous flap transfer

FIGURE 4. Pharyngeal stenosis: surgical technique. (A) Severe pharyngeal stenosis with dotted line depicting superior incision where scar was released. (B) Myocutaneous transfer of sternocleidomastoid flap through lateral pharyngotomy into posterior and lateral pharyngeal walls after release of scar. Reprinted with permission. 1~

fold is in the desired location vertically. Usually 3 or 4 sutures are placed across the inferior edge of the flap to hold it in proper position, and then 1 or 2 sutures are placed on the lateral aspects of the folded flap for stability and to close any dead space between the 2 layers of the flap. Drawbacks to this procedure include (1) variability in flap atrophy; and (2) although large buckles can be created, they are functionally not very useful because a large buckle has a tendency to move up and down, depending on the amount of air pressure. For this reason, small gaps of 1 to 3 mm can be closed successfully, but large gaps are inconsistently closed because a large folded flap is not vertically stable in its position.

RESULTS Gray et al reported on a retrospective review of 12 patients who underwent folded-flap pharyngoplasty for small-gap VPI. 7 This included 7 patients who had postdenoidectomy VPI. Perceptual ratings of nasality improved in most patients, especially those without an underlying syndrome. Nasometry scores improved most in patients age 8 years and younger. This study is contrasted with a report from Witt et al on 14 patients who underwent the same procedure. 8 In this study, patients with a gap up to 5 mm were included. Results were determined by independent ratings of preoperative and 3-month postoperative-recorded (audio-videotape) perceptual, nasoendoscopic, and fluoroscopic standardized speech, and airway evaluations. No difference was found in these ratings, suggesting the sur|MITH, GRAY, AND MUNTZ

gical procedure did not improve VPI in these patients. In these reports, differing surgical techniques, nonidentical patient populations, and variations in listener assessment of hypernasality, which can be difficult to judge on recorded samples, may explain differences. Nonsyndromic younger patients with small-gap (1 to 2 mm) or touch closure VPI seem to be good candidates for posterior wall augmentation by folded-flap pharyngoplasty.

NASOPHARYNGEALSTENOSIS Nasopharyngeal stenosis may develop after adenoidectomy, tonsillectomy, or both. It refers to the development of scar tissue in the nasopharynx a n d / o r soft palate that obstructs the posterior nasal airway into the oropharynx. This problem can also develop if a uvulopalatopharyngoplasty is performed at the same time as an adenoidectomy. A key symptom of this condition is nasal obstruction and anterior nasal discharge. 9 The obstruction of the airway at this level may cause hyponasal speech a n d / o r obstructive sleep apnea. If the scarring extends down into the oropharynx, symptoms of dysphagia may develop. If the palate is tethered in the oropharynx, then hypernasal speech may be seen. 1~ As in the assessment of velopharyngeal incompetence, the most useful assessment tool is fiberoptic nasoendoscopy. This examination, combined with the transoral view, allows the best determination of the location and extent of the narrowing. Because of the concentric scarring that develops in this location, this problem can be difficult to treat. Surgical treatment options include dilation, laser, excision, local flaps, and re101

flap g i reconstruction. o n In thea mildest l cases dilation 9 m a y be used. 9 Local flap reconstruction w i-t h Z-plasty 1 1 or laterally b a s e d p h a r y n g e a l flaps 12 m a y be used. W h e n these are unsuccessful, or if the scarring is severe, then regional flap reconstruction or free flap reconstruction options are available. 9'13 Regional flap reconstruction w i t h a sternocleidomastoid (SCM) m y o c u t a n e o u s flap has b e e n u s e d w i t h success in treating severe p h a r y n g e a l stenosis. The flap m a y be pedicled inferiorly or superiorly. It is believed that an inferiorly pedicled flap uses thinner skin in the u p p e r neck that has a less precarious perforating b l o o d s u p p l y to the skin p a d d l e (Fig 3 A,B). The inferiorly b a s e d SCM flap is pedicled off the thyrocervical t r u n k a n d the superior thyroid artery a n d vein. The p r o c e d u r e is described as follows. 1~ The SCM flap is outlined externally on the neck skin, a c u t a n e o u s skin p a d d l e is designed to reconstruct the desired defect, and an incision is designed that incorporates the skin p a d d l e and skin creases. S u b p l a t y s m a l flaps are elevated superiorly a n d inferiorly. The SCM flap is skeletonized circumferentially. The spinal accessory nerve is identified and preserved. Care is t a k e n to protect the b l o o d s u p p l y to the m i d d l e a n d inferior portions of the flap. The majority of the b l o o d s u p p l y comes f r o m inferior, f r o m the thyrocervical trunk. A second b r a n c h c o m e s off the superior thyroid artery. Once the flap is elevated, a tunnel is then created b y dissecting to the lateral p h a r y n g e a l wall. Once the lateral p h a r y n g e a l wall is reached, a p h a r y n g o t o m y is u s e d for e x p o s u r e a n d to deliver the flap into the desired area of the pharynx. The scars h a v e b e e n released transorally, and a specific b e d for the flap has b e e n created. The flap is then s e w n into place b y incorporating sutures t h r o u g h b o t h the skin a n d muscle (Fig 4). The skin is then closed externally; the external incision heals well with v e r y little defect n o t e d in the n o r m a l neck contour.

CONCLUSION P o s t a d e n o i d e c t o m y complications of VPI or p h a r y n g e a l stenosis are u n c o m m o n . W h e n they h a p p e n , the p r o b l e m is carefully evaluated. W h e n surgical repair is indicated, a variety of surgical tecl-miques are available. We h a v e de-

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scribed a few of these techniques, which m a y be helpful for the occasional situation in w h i c h they are needed.

REFERENCES 1. D'Antonio LL, Crockett DM: Evaluation and management of velopharyngeal inadequacy, in (Smith JD, Bumsted R, eds): Pediatric Facial Plastic and Reconstructive Surgery. New York, NY, Raven Press, 1993, pp 173-196 2. Gray SD, Pinborough-Zimmerman J: Velopharyngeal incompetence, in Cummings CW, Frederickson JM, Harker LA, et al (eds): Pediatric Otolaryngology-Head and Neck Surgery, (ed 3). St. Louis, Mo, Mosby, 1998, pp 174-187 3. Smith ME, Gray SD, Pinborough-Zimmerman J: Velopharyngeal insufficiency, in Papel I, Nachlas N, Sykes J, et al (eds): Facial Plastic and Reconstructive Surgery, ed 2. New York, NY, Thieme, 2001 (in press) 4. Perkins JA, Sie K, Gray S: Presence of 22qll deletion in postadenoidectomy velopharyngeal insufficiency. Arch Otolaryngol Head Neck Surg 126:645-648, 2000 5. Ren YF, Isberg A, Henningsson G: Velopharyngeal incompetence and persistent hypernasality after adenoidectomy in children without palatal defect. Cleft Palate Craniofac J 32:476-482, 1995 6. Dejonckere PH, van Wijngaarden HA: Retropharyngeal autologous fat transplantation for congenital short palate: a nasometric assessment of functional results. Ann Otol Rhinol Laryngot 110:168-172, 2001 7. Gray SD, Pinborough-Zimmerman J, Catten M: Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 121:107-112, 1999 8. Witt PD, O'Daniel TG, Marsh JL, et al: Surgical management of velopharyngeal dysfunction: Outcome analysis of autogenous posterior pharyngeal wall augmentation. Plast Reconstr Surg 99:1287-1296, 1997 9 , Pratt LW: Acquired nasopharyngeal stenosis. Laryngoscope 84:707713, 1974 10. Haller JR, Gray SD: Severe pharyngeal stenosis treated with inferiorly based sternocleidomastoid myocutaneous flap. Ann Otol Rhinol Laryngol 108:731-734, 1999 11. Woolf RM, Broadbent TR: Nasopharyngeal stenosis following tonsillectomy and adenoidectomy. Plast Reconstr Surg 45:352-355, 1970 12. Cotton RT: Nasopharyngeal stenosis. Arch Otolaryngol 111:146-148, 1985 13. McLaughlin KE, Jacobs IN, Todd NW, et al: Management of nasopharyngeal and oropharyngeal stenosis in children. Laryngoscope 107:1322-1331, 1997

TREATMENT OF ADENOIDECTOMYCOMPLICATIONS