Results with Furlow Palatoplasty in Management of Velopharyngeal Insufficiency

Abstract

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

Comparação entre duas abordagens diferentes de tratamento cirúrgico da insuficiência velofaríngea

“…For this reason, the literature has advocated surgical techniques that allow adequate velopharyngeal closure in a condition more similar to the normal anatomical conditions, i.e. without altering the anatomy of the velopharyngeal sphincter, thus reducing the morbidity risks (8,16,17,18) . One procedure used for that purpose is intravelar veloplasty (7,19,20,21) .…”

“…Since this is a muscular repositioning procedure, intravelar veloplasty may be incorporated to conventional techniques already used for secondary palatoplasty. The main criterion to be considered to select individuals for intravelar veloplasty should be the anteriorized attachment of the palatal musculature and presence of small velopharyngeal gap (7,17,22) . Several studies demonstrated good speech outcomes in individuals with VPI submitted to intravelar veloplasty (8,16,17,18,20,21) .…”

“…Conversely, intravelar veloplasty is more effective in cases of less severe VPI, individuals with small velopharyngeal gaps and/or marginal velopharyngeal function. However, intravelar veloplasty has been also shown as effective in the presence of severe VPI (17,20,21) . Even though intravelar veloplasty does not completely solve the speech symptoms in individuals with large gaps, some authors advocate the utilization of this procedure as first option for the treatment of VPI, since this is considered a more physiological procedure.…”

“…Even though intravelar veloplasty does not completely solve the speech symptoms in individuals with large gaps, some authors advocate the utilization of this procedure as first option for the treatment of VPI, since this is considered a more physiological procedure. Therefore, individuals requiring pharyngeal flap at a later moment, after veloplasty, may present a more favorable velopharyngeal condition, thus avoiding the indication of a broad flap and its undesirable effects on respiration (17,23) . Therefore, this study compared the results of pharyngeal flap surgery performed after palatoplasty with intravelar veloplasty (two-stage surgical approach) with the outcomes of pharyngeal flap surgery routinely performed at the hospital (single surgical stage), on speech nasality and respiration.…”

Resistência laríngea em indivíduos com fechamento velofaríngeo marginal

“…Nos pacientes com fissura labiopalatina, a anatomia e a fisiologia do esfíncter velofaríngeo estão alteradas e o objetivo principal da cirurgia primária do palato é estabelecer condições anatômicas para a adequada função velofaríngea (4)(5)(6) . Entretanto, mesmo após a palatoplastia primária, alguns pacientes podem permanecer com a função velofaríngea inadequada e apresentar alterações de fala, tais como: hipernasalidade, emissão de ar nasal (audível ou não), fraca pressão intra-oral e distúrbios articulatórios compensatórios, que caracterizam a disfunção velofaríngea (DVF) (7)(8) .…”