Witt P D, Marsh J L, Marty-Grames L, Muntz H R
Division of Plastic Surgery, Cleft Palate and Craniofacial Deformities Institute of St. Louis Children's Hospital, Mo., USA.
Plast Reconstr Surg. 1995 Jul;96(1):129-38. doi: 10.1097/00006534-199507000-00020.
This paper reports results of surgical management of failed sphincter pharyngoplasties that were performed for velopharyngeal dysfunction. Revisional surgery consisted of tightening of the sphincter pharyngoplasty port or reinsertion of sphincter pharyngoplasty flaps following dehiscence. We critique the anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following sphincter pharyngoplasty and analyze the effect of sphincter pharyngoplasty revision on ultimate speech outcome. The results of initial sphincter pharyngoplasty surgery were evaluated in 46 patients with velopharyngeal dysfunction. Nine (20 percent) of these patients were considered surgical failures because of persistent hypernasality and/or nasal turbulence on perceptual speech evaluation at least 3 months postoperatively. These patients underwent sphincter pharyngoplasty revision and form the basis of this report. All patients who failed sphincter pharyngoplasty initially underwent both preoperative and postoperative perceptual speech evaluations, lateral phonation radiographic studies with still reference views, and flexible nasendoscopic studies. Evaluations of upper airway status were conducted by the same experienced otolaryngologist. Following sphincter pharyngoplasty revision, 7 of 9 (78 percent) patients demonstrated resolution of velopharyngeal dysfunction, and to some degree, all patients managed with revision became hyponasal. The primary cause of failure was partial or complete flap dehiscence; a secondary cause was hypotonicity of the velopharyngeal mechanism. Failure was not correlated with the level of insertion of the pharyngoplasty flaps with respect to the point of attempted velopharyngeal contact. Sphincter pharyngoplasty is an effective means of management for velopharyngeal dysfunction in many patients. The objective of removing the stigmata of velopharyngeal dysfunction without causing upper airway obstruction may not be realistic in some patients with microretrognathia (i.e., Pierre Robin sequence), in whom anatomic constraints predispose to flap dehiscence. Problems with surgical technique contributing to failure appear to be related to experience of the surgeon, and improvement in outcome can be anticipated as the "learning curve" is overcome.
本文报告了针对腭咽功能障碍所施行的括约肌咽成形术失败后的外科治疗结果。修复手术包括收紧括约肌咽成形术端口或在裂开后重新植入括约肌咽成形术皮瓣。我们对括约肌咽成形术后与不可接受的语音共鸣和鼻腔漏气相关的解剖异常进行了批判，并分析了括约肌咽成形术修复对最终语音结果的影响。对46例腭咽功能障碍患者的初始括约肌咽成形术手术结果进行了评估。其中9例（20%）患者因术后至少3个月的感知语音评估中持续存在高鼻音和/或鼻腔紊乱而被视为手术失败。这些患者接受了括约肌咽成形术修复，并构成了本报告的基础。所有最初括约肌咽成形术失败的患者均接受了术前和术后的感知语音评估、带有静止参考视图的侧位发声影像学研究以及灵活的鼻内镜检查。上气道状况评估由同一位经验丰富的耳鼻喉科医生进行。在括约肌咽成形术修复后，9例患者中的7例（78%）显示腭咽功能障碍得到解决，并且在某种程度上，所有接受修复治疗的患者都出现了低鼻音。失败的主要原因是皮瓣部分或完全裂开；次要原因是腭咽机制张力过低。失败与咽成形术皮瓣相对于试图实现腭咽接触点的插入水平无关。括约肌咽成形术是许多患者腭咽功能障碍的有效治疗手段。对于一些小下颌后缩（即皮埃尔·罗宾序列）患者而言，在不引起上气道阻塞的情况下消除腭咽功能障碍特征的目标可能并不现实，因为解剖学限制易导致皮瓣裂开。导致失败的手术技术问题似乎与外科医生的经验有关，随着“学习曲线”被克服，结果有望得到改善。
