Pharyngeal Flap and Obstructive Apnea: Maximizing Speech Outcome While Limiting Complications

Objective To assess speech results and rate of obstructive sleep apnea using a modified, superiorly based pharyngeal flap performed after staged adenotonsillectomy in a group with velopharyngeal insufficiency. Methods In this nonrandomized, retrospective case series (July 1, 1996, through June 30, 2003), patients were mainly children referred to a multispecialty craniofacial clinic. Patients underwent staged adenotonsillectomy 2 months before width-customized pharyngeal flap surgery. Short flaps were created high above the level of the palate, just long enough to reach the nasal surface. Donor sites were closed by superior advancement of the inferior posterior pharyngeal wall tissue. Cardiopulmonary and oximetry data were analyzed for immediate obstructive apnea. Speech results and airway symptoms were assessed at 6-month and yearly follow-up examinations. Results In the 54 consecutive patients who underwent staged adenotonsillectomy, no apnea occurred immediately after surgery. Long-term clinical examination revealed 4 cases of loud snoring. Polysomnographic results were negative in all cases. Complications included 3 cases of bleeding, 1 requiring transfusion. Velopharyngeal insufficiency was eliminated in 94% of patients. Conclusion Complications related to obstructive sleep apnea have been significantly reduced while maintaining excellent speech results by a staged approach of removing tonsils and adenoids and by creating a short, high, wide, superiorly based pharyngeal flap with superior advancement of the inferior posterior wall to close the donor site. Velopharyngeal insufficiency (VPI) is a disorder associated with cleft palate that persists in approximately 10% to 30% of cases after primary palatoplasty. Philip Gustav Passavant is credited with first describing, in 1862, the surgical attachment of the soft palate to the posterior pharyngeal wall to improve the hypernasal intonation in such patients. Twenty-five years later, Karl Schoenborn, MD, introduced the first true pharyngeal flap, but it was not until 1930 that Earl C. Padgett popularized the procedure. He found that the superiorly based flap was best at providing the necessary length, even in situations of significant soft palate deficiency. Although it has been regarded as an “unphysiological” procedure, most surgeons have agreed that the pharyngeal flap is the most effective technique, especially for management of severe cases. Despite its success, the safety of the pharyngeal flap has been a concern. Since a reported case of death related to airway obstruction after a pharyngeal flap, the incidence of obstructive sleep apnea (OSA) after this procedure has been a matter of increased focus. The largest studies have found evidence of OSA ranging from 2% to 10%, whereas smaller case series have documented obstruction as high as 90%. Although many of these reports have shown that this problem is limited mostly to the immediate postoperative period, there does appear to be a small group of patients who will continue to experience long-term difficulties, necessitating flap revision or even flap takedown. As a result of these findings, other operations have been used for treatment of VPI based on the presumption that the pharyngeal flap has a higher incidence of postoperative sleep apnea. Sphincter pharyngoplasty is commonly used, but the effectiveness of this technique has been variable.Additionally, rates of postoperative OSA may be just as high with sphincter pharyngoplasty as they are with the pharyngeal flap.Results from recent prospective comparison studies have found that rates of sleep apnea after surgery are essentially no different using either type of procedure. Looking at ways of preventing OSA, several reportshave addressed the need to contain the risk of airway obstruction after performance of the pharyngeal flap. Most problems appear to be limited to the first 24 to 48 hours after surgery, so it is recommended that immediate postoperative care be administered in an enhanced care setting. Additional suggestions have included limiting the number of concurrent head and neck procedures, postoperative use of a nasopharyngeal airway, and avoidance of pharyngeal flap placement in syndromic patients with a predisposition for airway collapse. Despite some apparent success at reducing the overall morbidity and mortality, there has yet to be a well-accepted guideline for managing this feared complication. For the last 8 years at State University of New York–Upstate Medical University, a surgical protocol has been in place with the specific aim of limiting OSA after construction of the pharyngeal flap. This protocol has been particularly important because our patient population has required most flaps to be wide or very wide for the treatment of VPI. On the basis of previous observations of preventable sources of airway obstruction, the main focus has been on removal of the tonsils and adenoids before flap surgery, shortening the length of the flap (and subsequently the length of the donor site), and superior advancement of the inferior posterior pharyngeal wall for closure of the donor site