Velofaringeal Disfonksiyon Tedavisinde Uygulanan Superior Bazlı Posterior Faringeal Flep Cerrahisi Sonrası Flep Patensisinin, Konuşma Sonuçlarının ve Obstrüktif Uyku Apne Riskinin Değerlendirilmesi

Abstract

In this study, it was aimed to evaluate the results of speech after superior-based posterior pharyngeal flap, the risk of obstructive sleep apnea, the changes in the pharyngeal flap and velopharyngeal anatomy in individuals with velopharyngeal dysfunction (VFD) using objective methods. For this purpose, patients who applied to our clinic with speech disorder after cleft palate repair were evaluated, and individuals with VFD findings in perceptual evaluation, nasalance scores above 30, and velopharyngeal incompetence detected in dynamic magnetic resonance imaging (MRI) were included in the study. However, patients with submucous cleft palate, younger than 4 years of age, syndromic diagnosis, high risk for obstructive sleep apnea (OSA) and developing VFD after orthognathic surgery were excluded from the study. Seventy-two patients who met these criteria were included in our study. Perceptual speech assessment, nasometry, dynamic and volumetric MRI, and sleep questionnaire were applied to all patients preoperatively. Superiorly-based posterior pharyngeal flap was applied to the patients by the same surgical team. Volumetric MRI was performed on the 5th postoperative day. Additionally, perceptual speech assessment, nasometry, dynamic and volumetric MRI, sleep questionnaire and polysomnography (PSG) were performed 6 months after the surgery. 46% of the individuals participating in the study were female and 54% were male. According to the Veau classification, 9% of the patients were Veau I, 44% Veau II, 34% Veau III and 13% Veau IV. The median age of primary palatoplasty of the patients was 12 months, and 52% of the repairs were performed in another center and 48% in our clinic. Sixty patients are classified in the pediatric age group and 12 patients are classified in the adult age group. The median age of pharyngeal flap is 7 years old. According to the results of both perceptual speech and nasometric evaluation, a statistically significant improvement in speech was observed after surgery (p<0.001). With the dynamic MRI evaluation of the patients, the mean preoperative and postoperative velopharyngeal areas were measured as 172.09 mm2 and 17.39 mm2, respectively. The mean velopharyngeal areas of the patients were reduced by 154.71 mm2. This reduction was found to be statistically significant (p<0.001). The mean distance of the velum tip to the posterior pharyngeal wall was measured as 8.78 mm preoperatively and 1.71 mm postoperatively, and the difference of 7.08 mm was found to be statistically significant (p<0.001). The mean preoperative and postoperative velar angles of the patients were measured 43.84° and 32.3°, respectively and the difference was statistically significant (p<0.001). The mean flap volume of the patients was measured as 3262.14 mm3 with the volumetric MRI evaluation in the 5th postoperative day and 697.67 mm3 in the late postoperative period. It was observed that an average of 2564.47 mm3 of the flap atrophied, this result was found to be statistically significant (p<0.001). As a result of PSG evaluation, OSA was detected in 5 of 60 pediatric patients, while OSA was not detected in any of 12 adult patients. Our study is the first study in the literature to reveal the changes of the pharyngeal flap volume, velopharyngeal port area, velar angle and distance of the inferior tip of the velum to the posterior pharyngeal wall with objective parameters which is with pre- and postoperative MRI. As a result, the pharyngeal flap significantly improves speech outcomes as a result of changes in velopharyngeal anatomy, and successfully treats velopharyngeal dysfunction with a low incidence of OSA.