Posterior Pharyngeal Flap and Sphincter Pharyngoplasty: The State of the Art

Abstract

Surgical management of velopharyngeal insufficiency by attachment of posterior pharyngeal flap or construction of sphincter pharyngoplasty is reviewed. Posterior pharyngeal flap surgery is well established, with a long history dating back to the 19th century. Flaps have been based superiorly, inferiorly, or laterally. There have been reports of airway obstruction and obstructive sleep apnea associated with posterior pharyngeal flap surgery. The concept of surgical creation of a dynamic sphincter pharyngoplasty to provide velopharyngeal closure was first introduced by Hynes in 1950. Hynes and others have proposed several subsequent anatomic modifications. Airway dysfunction has also been reported following sphincter pharyngoplasty, but may not be as frequent or severe as with posterior pharyngeal flap. While several studies have compared posterior pharyngeal flap and sphincter pharyngoplasty in terms of speech outcome or complications, there is not, as yet, a consensus regarding the specific choice of one versus the other for surgical management of velopharyngeal insufficiency.

Influence of anesthetics on pharyngeal flap surgery: a 23-year study

“…These proportions were higher than those observed by BEN-NUN et al 1 but lower than those observed in most other studies, which show frequency rates of airway obstruction ranging from 0.36% to 90% and those for bleeding ranging from 0.73% to 8% 7,15,17,18 .…”

“…This procedure excises, moves and sutures a posterior pharyngeal wall flap into the velum, creating a permanent tissue bridge in the airway. A high rate of success, considered as improvement or elimination of speech symptoms, has been reported 15 .…”

Submucous cleft palate: outcomes after primary repair with repositioning of the levator muscle in 51 consecutive patients

“…Others have also recommended a primary pharyngeal flap either in isolation 9 or combined with palatoplasty, 10,14 but the potential for hyponasality, obstruction of the nasal airway, and sleep apnoea is increasingly common after pharyngeal flap operations. [15][16][17][18] Liao et al 19 reported an incidence of obstructive sleep apnoea of over 90% after pharyngeal flap operations and, of the 28 children in that study, 15 (53%) had moderate to severe sleep apnoea postoperatively.…”

Revisional surgery following the superiorly based posterior pharyngeal wall flap. Historical perspectives and current considerations

“…According to current opinion, polysomnographic investigations should have been considered to rule out or confirm OSAS. Obstructive sleep symptoms are more frequently associated with posterior pharyngeal flap surgery 27 , but many authors consider this flap to be effective in reducing nasal resonance due to VPI, particularly in severe cases 32 .…”