Witt P D, O'Daniel T G, Marsh J L, Grames L M, Muntz H R, Pilgram T K
Department of Plastic and Reconstructive Surgery, St. Louis Children's Hospital, MO, USA.
Plast Reconstr Surg. 1997 Apr;99(5):1287-96; discussion 1297-300. doi: 10.1097/00006534-199704001-00012.
Posterior pharyngeal wall augmentation has been advocated for patients having velopharyngeal dysfunction with a small coronal gap. Nonautogenous augmentation has not been accepted widely because of migration or extrusion of alloplastic implants and resorption of injected materials. Autogenous posterior pharyngeal wall augmentation has been performed for decades by Italian surgeons. A retrospective study was conducted to evaluate the efficacy of this procedure. Autogenous posterior pharyngeal wall augmentation, using a rolled superiorly based pharyngeal myomucosal flap, was performed on 14 patients, between November of 1989 and June of 1992, who fulfilled two criteria: velopharyngeal dysfunction unresponsive to speech therapy and a small (< 20 percent) coronal gap on velopharyngeal nasendoscopy. Of these, 3 patients had prior prosthetic velopharyngeal management, including 2 patients with Robin sequence. All patients were evaluated preoperatively and 3 months postoperatively with recorded (audio-videotape) perceptual, nasendoscopic, and fluoroscopic standardized speech and airway evaluations. The tapes were used for construction of a randomized master tape that was presented in blinded fashion and random order to three skilled raters for independent assessment of numerous perceptual and instrumental parameters of speech. The raters were uninvolved in the care of the patients or this study, and their intraobserver and interobserver reliabilities were known. Preoperatively, the majority of patients had nasal turbulence. All patients had variable degrees of hypernasality ranging from intermittent to pervasive. Parameters rated included (1) resonance (hypernasality, hyponasality, mixed), (2) auditory nasal emission (including nasal turbulence), and (3) visual characteristics regarding velopharyngeal closure. The visual parameters consisted of questions about whether a pharyngeal bulge was present or absent, descriptions of posterior pharyngeal wall movements with speech, level of closure, completeness of velopharyngeal closure, and quantitative descriptions of the percentage of velopharyngeal closure postoperatively. Examiners were instructed to look for a static and/or dynamic projection or bulge (i.e., Passavant's ridge) and, if a bulge was present, whether the level of velopharyngeal closure was on the same plane as the neoposterior pharyngeal bulge. Results of the extramural judgments of these parameters showed that there was no statistically significant tendency for patients' speech to be rated as more normal after the augmentation procedure than before it. We conclude that (1) autogenous posterior pharyngeal wall augmentation does not result in speech improvement and (2) autogenous posterior pharyngeal wall augmentation does not impair the nasal airway.
对于患有腭咽功能障碍且冠状间隙较小的患者，有人主张进行咽后壁增厚术。由于异体植入物的迁移或挤出以及注射材料的吸收，非自体增厚术尚未被广泛接受。意大利外科医生进行自体咽后壁增厚术已有数十年历史。进行了一项回顾性研究以评估该手术的疗效。在1989年11月至1992年6月期间，对14例符合以下两个标准的患者进行了自体咽后壁增厚术，即使用向上卷曲的带蒂咽肌黏膜瓣：对言语治疗无反应的腭咽功能障碍以及腭咽鼻内镜检查显示冠状间隙较小（<20%）。其中，3例患者曾接受过腭咽假体治疗，包括2例患有罗宾序列的患者。所有患者在术前和术后3个月均接受了记录（音频 - 视频磁带）的感知、鼻内镜和荧光镜标准化言语及气道评估。这些磁带用于构建一盘随机主磁带，以盲法和随机顺序呈现给三名技术熟练的评估者，以独立评估言语的众多感知和仪器参数。评估者未参与患者的护理或本研究，且已知其观察者内和观察者间的可靠性。术前，大多数患者存在鼻气流紊乱。所有患者均有不同程度的鼻音过重，从间歇性到普遍性。评估的参数包括：（1）共鸣（鼻音过重、鼻音不足、混合性），（2）听觉性鼻漏气（包括鼻气流紊乱），以及（3）关于腭咽闭合的视觉特征。视觉参数包括关于是否存在咽隆起的问题、言语时咽后壁运动的描述、闭合水平、腭咽闭合的完整性以及术后腭咽闭合百分比的定量描述。检查者被要求寻找静态和/或动态的突出或隆起（即帕萨万特嵴），如果存在隆起，还要判断腭咽闭合水平是否与新形成的咽后壁隆起在同一平面上。这些参数的壁外判断结果显示，与术前相比，增厚手术后患者言语被评为更正常的情况没有统计学上的显著趋势。我们得出结论：（1）自体咽后壁增厚术不能改善言语，（2）自体咽后壁增厚术不会损害鼻气道。
