Witt P D, Myckatyn T, Marsh J L
Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, Washington University School of Medicine, Missouri 63110, USA.
Cleft Palate Craniofac J. 1998 Sep;35(5):447-53. doi: 10.1597/1545-1569_1998_035_0447_stfpio_2.3.co_2.
This paper reports on the rates of failure of operations (pharyngeal flap and sphincter pharyngoplasty) performed for management of velopharyngeal dysfunction, and outcome following their revision.
Anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following pharyngeal flap and sphincter pharyngoplasty were critiqued. The results of primary pharyngeal flap were evaluated for 65 patients, and the results of primary sphincter pharyngoplasty were evaluated for 123 patients. All patients were treated for velopharyngeal dysfunction. The definition of surgical failure was based on persistent hypernasality and/or nasal turbulence on perceptual speech evaluation, and incomplete velopharyngeal closure on instrumental evaluation, at least 3 months postoperatively.
All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, a tertiary cleft care center.
PATIENTS, PARTICIPANTS: All patients had failed surgical management initially, either with pharyngeal flap or sphincter pharyngoplasty, and all underwent repeat preoperative and postoperative perceptual speech evaluations; real-time lateral phonation fluoroscopy including still reference views; and flexible nasendoscopy of the velopharynx using standard speech protocols.
Revisional surgery for both procedures consisted of either tightening of the sphincter pharyngoplasty or pharyngeal flap port(s) or reinsertion of the sphincter pharyngoplasty or pharyngeal flaps following dehiscence.
The main outcome measure was normalcy of velopharyngeal function, i.e., elimination of perceptual hypernasality and instrumental evidence of complete velopharyngeal closure. The rates of pharyngeal flap failure and sphincter pharyngoplasty failure were determined for those patients requiring surgical revision.
Thirteen of 65 patients (20%) who underwent primary pharyngeal flap required revisional surgery. Of these 13 patients, eight were managed successfully with a single revisional operation. The remaining five patients (38%) continued to exhibit velopharyngeal dysfunction and underwent a second revision consisting of tightening or augmentation of the lateral ports. Speech results were satisfactory in all patients so treated; however, hyponasality with no other airway morbidity occurred in all five. Twenty of 123 patients (16%) who underwent primary sphincter pharyngoplasty required surgical revision. Of these 20 patients, 17 were managed successfully. For both procedures, the principal cause of failure was partial or complete flap dehiscence.
Rates of primary pharyngeal flap failure are roughly equivalent to rates of primary sphincter pharyngoplasty failure. Pharyngeal flap and sphincter pharyngoplasty failures can be salvaged with revisional surgery, which can provide a velopharyngeal mechanism capable of complete closure. Revisional surgery is usually associated with denasal speech.
本文报告了针对腭咽功能障碍所施行手术（咽瓣术和括约肌咽成形术）的失败率，以及翻修后的结果。
对咽瓣术和括约肌咽成形术后出现不可接受的语音共鸣及鼻腔漏气相关的解剖学异常进行了分析。评估了65例接受初次咽瓣术患者的结果，以及123例接受初次括约肌咽成形术患者的结果。所有患者均接受腭咽功能障碍治疗。手术失败的定义基于术后至少3个月的感知语音评估中持续存在的高鼻音和/或鼻气流紊乱，以及仪器评估中腭咽闭合不全。
所有患者均在圣路易斯儿童医院腭裂与颅面畸形研究所（一家三级腭裂护理中心）接受评估和治疗。
患者、参与者：所有患者最初的手术治疗均失败，要么是咽瓣术，要么是括约肌咽成形术，且均接受了术前和术后重复的感知语音评估；包括静态参考视图的实时侧位发声荧光透视检查；以及使用标准语音方案对腭咽进行的纤维鼻咽喉镜检查。
两种手术的翻修手术包括收紧括约肌咽成形术或咽瓣端口，或在裂开后重新植入括约肌咽成形术或咽瓣。
主要结局指标是腭咽功能正常，即消除感知高鼻音和腭咽完全闭合的仪器证据。确定了那些需要手术翻修患者的咽瓣术失败率和括约肌咽成形术失败率。
65例接受初次咽瓣术的患者中有13例（20%）需要翻修手术。在这13例患者中，8例通过单次翻修手术成功治疗。其余5例患者（38%）继续表现出腭咽功能障碍，并接受了第二次翻修，包括收紧或扩大外侧端口。所有接受如此治疗的患者语音结果均令人满意；然而，这5例患者均出现了鼻通气不足且无其他气道并发症。123例接受初次括约肌咽成形术的患者中有20例（16%）需要手术翻修。在这20例患者中，17例成功治疗。对于这两种手术，失败的主要原因是部分或完全瓣裂开。
初次咽瓣术失败率与初次括约肌咽成形术失败率大致相当。咽瓣术和括约肌咽成形术失败可通过翻修手术挽救，翻修手术可提供能够完全闭合的腭咽机制。翻修手术通常与鼻音减轻的语音相关。
