Long-Term Follow-Up after Division of a Pharyngeal Flap for Severe Nasal Obstruction

Abstract

Between 1965 and 1986, nine patients were noticed to have significant nasal airway obstruction following surgery for velopharyngeal incompetence (VPI). All had a superiorly based pharyngeal flap. Division of the flap was recommended to correct the posterior obstruction. A complete section of the flap was done in seven cases and lateral port enlargement was done in the remaining two. The interval between flap elevation and transection ranged from 5 months to 5 years. Three patients required more than one operation to fully correct the obstruction.

All the patients were evaluated 2 to 14 years later to assess nasal breathing and speech and to document velopharyngeal function by nasoendoscopy and videofluoroscopy. One patient presented major symptoms of nasal obstruction at follow-up, while others reported snoring and occasional mouth breathing, although their nasal respiration appeared subjectively adequate. Four patients had normal speech, three were mildly hyponasal, one was moderately hyponasal, and the other was severely hyponasal. Intelligibility was good in all cases but one, although three patients had some articulation errors: two with persistent errors related to early VPI and one from dental malocclusion and tongue protrusion. Videofluoroscopy and nasoendoscopy showed that despite complete transection at the base of the flap in eight cases, five still had evidence of residual tethering. In one patient, the obstruction was almost complete and repeat division of the flap was recommended. Seven patients showed increased thickness of the soft palate in the midline where the flap had been anchored. Velopharyngeal closure was adequate in five cases, marginal in three, and obstructed in one.

The review of our cases showed that the velopharyngeal opening in these patients is not large and incompetent, but rather is contracted and the flap often reattaches posteriorly after division. We recommend a closure of all raw surfaces to be done when the flap is sectioned, adding Z-plasties when needed to prevent further V-P obstruction. Even in the presence of recurrent obstruction, the resection of the extra tissue contributed by the flap on the soft palate is not felt to be indicated.