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The other uses of the surgical glove
Letters to the Editor
Velopharyngeal incompetence the Orticochea pharyngoplasty
471
treated by
Sir, In their paper on “An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty”, James et al.’ did not explain why they undertook preoperative lateral videofluoroscopy. Presumably not to check on the need for operation, since one would have expected this to have been a clinical decision based on the assessment of a very experienced speech therapist. It seems that it was not to choose an operation since only one operation was used and a suitable resting orifice was assessed on the snug tit of a finger tip. If it was used to establish a baseline in the event of an unsatisfactory outcome, it would have been informative to know whether there was a correlation with preoperative gap size and residual hyper- or hyponasality. It would also be informative to know how many of the initially incompetent sphincters subsequently became competent within three years, which Lendrum and Dhar’ noted in their paper. Of the group of 63 modified Hynes operations reported by Peat et al.,’ only 2 patients had residual hypernasal resonance. Disappointingly 11 had hyponasal resonance. However, unlike Honig’s operation, where rather stenosed resting orifices were usually found in the hyponasal group, in the Hynes operation an adequate resting orifice was found in the majority and hyponasality was only noted in connected speech. This was found to be due to inability of the palate to descend rapidly in closed-open-closed sequences. Subsequently partial division of the pars thyroidea of palatopharyngeus was practised but the results have not yet been analysed to see whether partial sparing of the principal depressor helps to eliminate this problem.
We agree further analysis might have helped to assess whether there was any correlation between preoperative gap size and residual hyponasality but the numbers would have been so small that analysis would not have produced any results of statistical significance. It was also felt that an analysis of this type would not have been part of a routine audit. In trying to add to the information on the treatment of velopharyngeal incompetence, there is a fine line between clinical research and audit. We were not trying to set a new standard by clinical research but trying to see if we achieved that which was published. In many areas we have, but in any audit there will be deficiencies which can be acted upon or not. If acted upon, the audit cycle needs to be repeated to see if there is any improvement in outcome. The next stage would be to perform follow-up lateral videofluoroscopies to assess any postoperative gap and correlate pre- and postoperative videofluoroscopy results with clinical outcome. However, we are not sure whether this extra analysis would improve the surgical technique or the clinical outcome. Yours faithfully, N. K. James FRCS(Plast) Consultant Plastic Surgeon. Lister Hospital, Stevenage, Herts, UK. T. M. Milward MA, FRCS Consultant Plastic Surgeon, Leicester Royal Infirmary, Leicester, UK.
References I.
2.
Yours faithfully, R. W. Pigott FRCS, FRCS(1) Honorary Consultant in Plastic Surgery, Frenchay Hospital, Bristol, UK.
Riski JE, Ruff CL, Georgiade GS, Barick WJ, Edwards PD. Evaluation of the sphincter pharyngoplasty. Cleft Palate Craniofac J 1992; 29: 254-61. Peat BG, Albery GH, Jones K. Pigott RW. Tailoring velopharyngeal surgery: the influence of etiology and type of operation. Plast Reconstr Surg 1994; 93: 948-53.
The other uses of the surgical glove
References 1.
2. 3.
James NK, Twist M, Turner MM, Milward TM. An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty. Br J Plast Surg 1996; 49: 1977201. Lendrum J, Dhar BK. The Orticochea dynamic pharyngoplasty. Br J Plast Surg 1984; 37: 160-8. Peat BG, Albery EH, Jones K, Pigott RW. Tailoring velopharyngeal surgery: the influence of etiology and type of operation. Plast Reconstr Surg 1994; 93: 948-53.
Velopharyngeal incompetence the Orticochea pharyngoplasty
Sir, We read with interest the article ‘The extended role of the surgical glove’.’ The other uses of this commonly available surgical appliance that would merit mention are: As a sterile drape over the feet during lower leg and ankle surgery. The surgical glove can be used to prevent heel pressure sores as a miniwater mattress when immobilising patients after cross leg flaps.’ As a means of transporting amputated distal appendages to a replantation center. The amputated part can be wrapped in a moist gauze which is then inserted into a glove, whose end is then tied and immersed into an oversized glove containing iced water.
treated by - reply
Sir, We would like to thank Mr Pigott for his comments about our paper on the Orticochea pharyngoplasty. The initial lateral videofluoroscopy was undertaken as a baseline measurement to assess the preoperative gap size and movements of the palate. From this point, further analysis could have been performed along the lines suggested by Mr Pigott. However, this was not done as initial results seemed to be good and the paper set out to audit the technique of Orticochea pharyngoplasty. The aim of the paper was to assess the processes and outcome of the treatment of velopharyngeal incompetence and to assess whether the results achieved the published gold standard, as presented in the excellent papers of Riski et al.’ and Peat et al.’
Yours faithfully, A. Krishna MS, DNB, FRCSEd D. Mohan MS, MCh, FRCS Department of Plastic Surgery, Kingston General Hospital, Beverley Road, Hull HU3 1UR. UK
References I. 2.
Srinivasan J, Mathews RN. The extended role of the surgical glove (Letter). Br J Plast Surg 1997; 50(3): 218-19. Bhatnagar A. Plast Reconstr Surg 1997; 99:
Velopharyngeal incompetence the Orticochea pharyngoplasty
471
treated by
Sir, In their paper on “An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty”, James et al.’ did not explain why they undertook preoperative lateral videofluoroscopy. Presumably not to check on the need for operation, since one would have expected this to have been a clinical decision based on the assessment of a very experienced speech therapist. It seems that it was not to choose an operation since only one operation was used and a suitable resting orifice was assessed on the snug tit of a finger tip. If it was used to establish a baseline in the event of an unsatisfactory outcome, it would have been informative to know whether there was a correlation with preoperative gap size and residual hyper- or hyponasality. It would also be informative to know how many of the initially incompetent sphincters subsequently became competent within three years, which Lendrum and Dhar’ noted in their paper. Of the group of 63 modified Hynes operations reported by Peat et al.,’ only 2 patients had residual hypernasal resonance. Disappointingly 11 had hyponasal resonance. However, unlike Honig’s operation, where rather stenosed resting orifices were usually found in the hyponasal group, in the Hynes operation an adequate resting orifice was found in the majority and hyponasality was only noted in connected speech. This was found to be due to inability of the palate to descend rapidly in closed-open-closed sequences. Subsequently partial division of the pars thyroidea of palatopharyngeus was practised but the results have not yet been analysed to see whether partial sparing of the principal depressor helps to eliminate this problem.
We agree further analysis might have helped to assess whether there was any correlation between preoperative gap size and residual hyponasality but the numbers would have been so small that analysis would not have produced any results of statistical significance. It was also felt that an analysis of this type would not have been part of a routine audit. In trying to add to the information on the treatment of velopharyngeal incompetence, there is a fine line between clinical research and audit. We were not trying to set a new standard by clinical research but trying to see if we achieved that which was published. In many areas we have, but in any audit there will be deficiencies which can be acted upon or not. If acted upon, the audit cycle needs to be repeated to see if there is any improvement in outcome. The next stage would be to perform follow-up lateral videofluoroscopies to assess any postoperative gap and correlate pre- and postoperative videofluoroscopy results with clinical outcome. However, we are not sure whether this extra analysis would improve the surgical technique or the clinical outcome. Yours faithfully, N. K. James FRCS(Plast) Consultant Plastic Surgeon. Lister Hospital, Stevenage, Herts, UK. T. M. Milward MA, FRCS Consultant Plastic Surgeon, Leicester Royal Infirmary, Leicester, UK.
References I.
2.
Yours faithfully, R. W. Pigott FRCS, FRCS(1) Honorary Consultant in Plastic Surgery, Frenchay Hospital, Bristol, UK.
Riski JE, Ruff CL, Georgiade GS, Barick WJ, Edwards PD. Evaluation of the sphincter pharyngoplasty. Cleft Palate Craniofac J 1992; 29: 254-61. Peat BG, Albery GH, Jones K. Pigott RW. Tailoring velopharyngeal surgery: the influence of etiology and type of operation. Plast Reconstr Surg 1994; 93: 948-53.
The other uses of the surgical glove
References 1.
2. 3.
James NK, Twist M, Turner MM, Milward TM. An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty. Br J Plast Surg 1996; 49: 1977201. Lendrum J, Dhar BK. The Orticochea dynamic pharyngoplasty. Br J Plast Surg 1984; 37: 160-8. Peat BG, Albery EH, Jones K, Pigott RW. Tailoring velopharyngeal surgery: the influence of etiology and type of operation. Plast Reconstr Surg 1994; 93: 948-53.
Velopharyngeal incompetence the Orticochea pharyngoplasty
Sir, We read with interest the article ‘The extended role of the surgical glove’.’ The other uses of this commonly available surgical appliance that would merit mention are: As a sterile drape over the feet during lower leg and ankle surgery. The surgical glove can be used to prevent heel pressure sores as a miniwater mattress when immobilising patients after cross leg flaps.’ As a means of transporting amputated distal appendages to a replantation center. The amputated part can be wrapped in a moist gauze which is then inserted into a glove, whose end is then tied and immersed into an oversized glove containing iced water.
treated by - reply
Sir, We would like to thank Mr Pigott for his comments about our paper on the Orticochea pharyngoplasty. The initial lateral videofluoroscopy was undertaken as a baseline measurement to assess the preoperative gap size and movements of the palate. From this point, further analysis could have been performed along the lines suggested by Mr Pigott. However, this was not done as initial results seemed to be good and the paper set out to audit the technique of Orticochea pharyngoplasty. The aim of the paper was to assess the processes and outcome of the treatment of velopharyngeal incompetence and to assess whether the results achieved the published gold standard, as presented in the excellent papers of Riski et al.’ and Peat et al.’
Yours faithfully, A. Krishna MS, DNB, FRCSEd D. Mohan MS, MCh, FRCS Department of Plastic Surgery, Kingston General Hospital, Beverley Road, Hull HU3 1UR. UK
References I. 2.
Srinivasan J, Mathews RN. The extended role of the surgical glove (Letter). Br J Plast Surg 1997; 50(3): 218-19. Bhatnagar A. Plast Reconstr Surg 1997; 99: