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Posterior Pharyngeal Flap for Large Gap Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) is a speech disorder characterized by inability for the palate (velum) to contact the posterior pharyngeal wall resulting in nasal air escape and subsequent speech abnormalities. All but the mildest cases are treated surgically, with technique chosen based on the closure pattern and gap size reserving the pharyngeal flap for the most severely affected patients. We present a 6-year old female with developmental delay and VPI with large (~60%) coronal pattern velopharyngeal gap subsequently deemed a candidate for posterior pharyngeal flap.

Following Dingman mouthgag placement, the posterior wall is inspected and palpated ensuring no carotid medialization. The flap is designed and marked as wide and long as possible to reduce tension. Local injection wis performed. Using an angled needle tip Bovie, the flap was then elevated in the plane the prevertebral fascia to the level of the nasopharynx. The donor site is closed with simple interrupted 4.0 chromic sutures. The palatal mucosa is divided in a T-shaped fashion, without violating palatal musculature. The flap is inset with horizontal mattress sutures using 4.0 chromic. The nasal ports are inspected frequently to ensure adequate nasal airway patency. The palatal mucosa is reapproximated and any residual donor site closed.  The patient is observed overnight, discharged home post-operative day 1, maintained on a soft diet for two weeks and abstains from speech therapy for 4 weeks to allow healing. Follow up demonstrated excellent healing well and VPI resolution on repeat speech sample.

Posterior pharyngeal flap remains an effective tool for the management of large gap velopharyngeal insufficiency (VPI). In the presence of an intact and mobile soft palate, it does not require division of the palatal muscles.
Severe moderate or worse velopharyngeal insufficiency with coronal gapping and inability to further stimulate speech through speech therapy exercises.
Patients with known severe obstructive sleep apnea, and/or patients with more laterally based gaps on speech assessment.
Supine, occasional shoulder roll, RAE endotracheal tube.
Perceptual speech evaluation including video nasopharyngoscopy. Consider polysomnogram if high suspicion for underlying obstructive sleep apnea.
Ensure no carotid medialization. Elevate the flap to the level of the nasopharynx. Raise flap in the prevertebral plane. Submucosal palatal flap elevation.
Does not violate an intact mobile palate, reducing the chances or scarring, or continued speech disorder.
May develop obstructive sleep disordered breathing symptoms that require port revision. Inadequate port tightening at the time of surgery may be associated with persistent VPI.
No conflicts/disclosures.
No acknowledgements.
Jefferson ND, Willging JP. Management of noncleft velopharyngeal insufficiency. Current Opinion in Otolaryngology & Head and Neck Surgery. 2021 Aug 1;29(4):283-8.

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