Pharyngeal Flap. Gregory C. Allen, MD

Transcription

1 Pharyngeal Flap Gregory C. Allen, MD Department of Pediatric Otolaryngology Associate Medical Director, Cleft Palate Team Children's Hospital Colorado Associate Professor Departments of Otolaryngology and Pediatrics University of Colorado, Denver

2 History Gustav Passavant (1865) generally credited with first attempting suturing posterior palate to posterior pharyngeal wall Karl Schoenborn (1875) Inferiorly-based PF sutured to palate of 17 y/o female with previously unrepaired cleft palate He eventually switched to superiorly-based because of difficulty in sutu ring friable adenoid tissue

3 History Wolfgang Rosenthal (1924) combined inferiorly-based pharyngeal flap with von Langenbeck Padgett (1930 s) popularized in US Hogan (1971) lateral port control and flap lining Cleft Craft by Ralph Millard Available Free Online d i d /Ralph_Millard/cleftcraft/index.htm l ft/i d ht

4 Classification of PPF Inferiorly-based Better vasculari ity Limitations Length Adenoids Low position of base Superiorly-based Longer Inset at level of soft palate closure

5 Indications and Timing Age Closure patter rn Defect size Tonsils and adenoids

6 Surgical Technique Patient preparation Supine, oral RAE Slight Trendelenburg position, good lighting Antibiotics, local anesthesia and vasoconstriction Dingman mouthgag Flap marking and ETT, shoulder roll, neck extended design Length & upper extent (adenoid, anterior body of C1) Make is higher than anticipated plane of palatal closure Inferior migration often occurs with healing Width (tailor for defect and mobility)

7 Surgical Technique Splitting the palate Improves visibil ity in flap elevation Improves height of flap elevation Aids elevation of Hogan lining flaps Aids closure of 4-0 silk used to donor defect retract t uvula Lining flaps incised and elevated

8 Surgical Technique Flap Elevation Incise one side Identify correct plane beneath superior constrictor and palatopharyngeus muscles at paravertebral fascia Elevated bipedicle and divide distal attachment t Elevate superiorly (slightly wider and deeper superiorly) Hemostasis

9 Surgical Technique Donor Closure 3-0 absorbable suture (3-0 Vicryl) Improves healin ng and comfort Facilitates closure of lateral ports Lower end for drainage and hematoma prevention Avoid constriction of flap base superiorly

10 Surgical Technique Flap Inset Mucosal edge sutures placed and tagged (usually 3-5, 5-0 Monocryl) Mucosal suturess tied sequentially Muscle inset wit th mattress sutures (usually 3-5, 4-0 PDS) Lining flaps are sutured together and to flap (and/or prevertebral fascia) Close midline palatal incision over muscle

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12 Surgical Technique Nasal trumpet or catheter placed under direct visualizati ion Held in place with steristrips to nose for 8-16 hours Aids airway control during extubation and recovery Impedes oral intake some

13 Surgical Technique - Tips Flap not visible when palate closed Don t try to repla ace trumpet if dislodged Plane of flap elevation relatively avascular Elevate higher than you think necessary Lining flaps help pprevent scarring, narrowing, and tubing of flap

14 Postoperative Care Humidified O 2 /RA, Monitor SaO 2 Pain control Diet pourable liquid Remove nasal trumpet 23 hr stay in most Discharge criteria Adequate PO inta ke Room air SaO 2 > 92% when sleeping Good pain control Follow-up 2 weeks, 6 weeks, 6 months Watch for OSA, most will snore

15 Results 63-98% success Canady (2003) N=87, 10 yrs, min 53 CLP, 8 CP, 26 78% near normal Peat (1994) 2 yr follow-up SMCP nasality PF with pushback equivalent to sphincter (81% acceptable) PF alone (63%) 51% snoring, 9% revision secondary to OSA Pensler and Reich (1991) No difference between PF and sphincter 4% OSA in PF group

16 Results Ysunza (2002) 25 PF, 25 sphincter Success 84-88%, no difference between No OSA Abyholm, et al (20 005) Multicenter, international, randomized 3 months PF better, 12 months no difference 85% success Closure pattern preop did not make difference Seyfer (1988) Better when age < 6 yrs Length of time VPI present not significant

17 Results Demark (1985) Age not critical Leanderson (1974), Riski (1979) Better results when age < 6.4 yrs Study problems Reviewer bias, lack of objective data, definition of success, speech therapy application

18 Complications Early Airway comprom mise Hemorrhage Infection Aspiration/pneumonia Flap dehiscencee Cervical subluxation Late OSA Hyponasality Residual VPI