Customized Surgical Treatment of VPI with Pharyngeal Flaps Using Flexible Video Nasopharyngoscopy and Multiplanar Video Fluoroscopy

Objective: Speech is achieved through velopharyngeal competence—described as the complete closure of the velopharyngeal sphincter (VPS). Failure of complete closure of the VPS results in velopharyngeal insufficiency (VPI), which may severely interfere with intelligibility and quality of speech. VPI correction is not a one-size-fits all procedure, and this warrants the importance of customization that suits the individual patient’s anatomic and functional pathology. The purpose of this study is to determine whether customization of pharyngeal flaps—using a dynamic pre-procedural assessment—can achieve reliable and successful outcomes in the surgical treatment of VPI, despite differences in surgeon approach and technique. Methods: A total of 171 cases of VPI with pharyngeal flap surgery were reviewed between the ages of four and eighteen years. Four surgeons performed four different surgical techniques. All cases were evaluated preoperatively by a multidisciplinary team and underwent speech pathology evaluation, nasometry, multiplanar videofluoroscopy (MPVF) and flexible video nasopharyngoscopy (FVNP). Individualized preoperative planning was performed based on the findings. Results: 158 patients (92%) demonstrated overall successful correction of VPI with mean nasalance within normal limits following the surgical procedure. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a non-significant association between surgical technique and unsuccessful corrections. Conclusion: The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing superior pedicle pharyngeal flaps, high rates of success can be achieved when adequate surgical planning is based on imaging findings. Corresponding Author: Kongkrit Chaiyasate, 3555 W 13 Mile Rd #120, Royal Oak, MI, 48073, [email protected], 248-890-2515