OPERATIVE TREATMENT OF RHINOLALIA : A REVIEW OF 139 PHARYNGOPLASTIES By A. J. C. HUFFSTADT, J. M. H. M. BORGHOUTS, and Mrs A. J. MOOLENAAR-BiJL University Hospital, ~ Groningen, Holland THE number of methods in use for operative correction of rhinolalia and the controversial opinions held about them demonstrate clearly that the problem has not yet been solved and that no one method is completely satisfactory in all cases. The basic defects, which cause the insufficient velopharyngeal closing mechanism, are still not fully understood. Hynes (I95O, I967) pointed out, for example, the variation in the lateral pharyngeal recess. Calnan (I956, I96I) and Yules et al. (I968) have shown that in normal circumstances the naso-pharyngeal closure during speech is probably performed by a valve mechanism (palatal muscle function). When this system becomes insufficient, the sphincter activity will be encouraged and the pharyngeal muscles play a more important role during speech (Braithwaite, I964 ; Van Gelder, 1965). Nasendoscopy, as recently introduced by Pigott (1969), may be of great value in further studies of these cases. Three quite different principles are involved in present-day surgical techniques : (a) advancement of the dorsal pharyngeal wall (Eckstein, I9O2 ; Hagerty and Hill, 196I ; Huizing, I967 ; Hynes, I967), (b) " push back " of the soft palate with or without closure of the nasal mucosal defect (Dorrance, 1925 ; Sanvenero-RosseUi, 1955 ; Gibson, I959 ; Millard, r963), and (c) fixing a muco-muscular flap from the dorsal pharyngeal wall onto the soft palate (SchiSnborn, I876 ; Rosenthal, r924). In Groningen we favour a pharyngeal flap of the Rosenthal type for all cases of rhinolalia. We prefer this method because it is a straightforward surgical procedure, it is little dependent on the often diminished palatal function and it is hardly ever complicated by post-operative fistulm. Operative Technique.--The flap is outlined as high up in the naso-pharynx as possible so that the final position of the flap will be as horizontal as possible (Fig. I, A and B). For this reason few of the flaps are visible when looking into the oral cavity (Fig. 2, A and B). The mucosa and underlying muscle tissue form the thickness. The width of the flap is always the full width of the dorsal pharyngeal wall. The donor area is never closed as the width of the defect does not allow it. When the flap has been fashioned, it is pulled on to the soft palate and the area which is to receive it is estimated. The oral mucosa of the soft palate is incised and a thin mucosal flap dissected and turned over. The palatal defect should reach well back on each side in order to retain a reasonable width after healing (Fig. 3, A to C). The size of the lateral openings can be determined by the width of the mucosa between the base of the pharyngeal flap and the end of the incisions on the soft palate and pharyngeal folds. The pharyngeal flap is stitched on to the prepared defect in the soft palate with 4/o silk. These sutures should be put in with great care and in precisely the right position. The turned over mucosa of the velum lies loosely on the raw upper surface of the pharyngeal flap. At the end of the operation it appears that the oral and nasal cavities are completely separated (Fig. 3, c). This appearance, however, does not persist since the flap gradually becomes narrower from fibrosis. We have had only two cases in which the flap had to be narrowed six months after the original operation because of too complete closure. 1 From the centre for the study and treatment of patients with cleft lip and palate in which participate the departments of plastic surgery, E.N.T., speech therapy, audiology, pmdiatrics, anmsthesiology, clinical psychology, psychiatry, anthropogenetics, anatomy, orthodontics, oral surgery and prosthesiology. I5o
A B FIG. I A~ The Rosenthal-type flap is centrally based and is raised as high as possible including the whole width of the dorsal naso-pharyngeal wall. B~ When sutured to a prepared bed on the soft palate~ it lies almost horizontally. As the donor area heals and contracts~ the base is raised even higher. FIG. 2 A~ The soft palate of an Ig-year-old girl with a congenital short palate causing moderate rhinolalia. B, The pharyngoplasty cured the rhinolalia completely. The flap is situated so high in the nasopharynx that it cannot be seen when looking directly into the mouth.
152 BRITISH JOURNAL OF PLASTIC SURGERY Between 1956 and 1965, pharyngoplasties of this type were performed on 139 patients whose ages varied from 4 to 57 years. Thirty-eight have been lost to follow-up for various reasons, mostly change of address, leaving IOI for the present review. The primary deformities in these cases are listed in Table I. The interval between operation and fouow-up ranged from six months to nine years. All patients had been examined pre-operatively by a team consisting of an E.N.T. c FIG. 3 A, Very short soft palate in a 6o-year-old patient with a short repaired medial cleft (gap 2 to 3 cm.) who could no longer wear an obturator. B, The flap has been dissected from the dorsal pharyngeal wall. C, The flap stitched into position. specialist, a speech therapist and a plastic surgeon so that the speech was fully documented ; tape recordings were also available. The improvement in speech was assessed by independent speech therapists of the department of logopedics and not by the surgeons. The reliability of this jury was found to be 98 per cent. in preliminary tests. Rhinolalia was graded as absent, slight, moderate or severe. When the speech had been restored to normal, the result was recorded as good (52 cases) ; when a severe or moderate rhinolalia was corrected to a slight one, the result was called satisfactory (28 cases) ; when a severe rhinolalia had improved to no better than moderate, the result was said to be minimal (i 4 cases). In the remaining seven cases there was no change. In other words, 8o per cent. of the patients had a worthwhile improvement and more than half achieved normal speech.
OPERATIVE TREATMENT OF RHINOLALIA There was no indication that the age of the patient when operated on had any significant effect on the result; nor, as shown in Table I, had the type of primary deformity. TABLE I Speech Results after Pharyngoplasty related to Various Deformities I53 Medial cleft palate Unilateral cleft lip and palate Bilateral cleft lip and palate Submucous cleft palate Congenital short palate Functional rhinolalia (cause unkn~own) Total Good Satisfactory Minimal 28 3I I2 4 17 I2 5 9 6 IO 3 5 3 I Nil 4 i 5 4 2 I 2., I " " i L TABLE II Speech Results after Pharyngoplasty from Various Publications Present Smith et al. Honig Skoog Dijkstra authors (I963) (I963) (I965) (I968) Number of patients Iox I23 48 82 17 Normal speech 52 42 20 22 I I ~ Satisfactory I 28... 12 4 3 In an attempt to compare the results of our technique with those of others, we have listed in Table II some published results. Smith et al. (I963) and Skoog (I965) used a Rosenthal type of flap, Honig (I963) followed Sanvenero-Rosselli's principle and Dijkstra (I968) used the Millard island flap. While it is not possible to draw firm conclusions, the present results compare favourably with those previously published. DISCUSSION We feel that the results of this survey justify our views that the Rosenthal principle of pharyngoplasty, performed along the lines described, is a useful operation. The functional result depends largely on the sphincter mechanism of the pharynx around the flap and is less dependent on good palatal activity than in the" push back "procedures. We are well aware that we still cannot give the answer to the question which pharyngoplasty is the method of choice. We firmly believe that the experience of the surgeon in a particular method is very important. Most surgeons do not have enormously long series of patients and it would be a mistake to split up these series into two or three techniques. Because of all the above-mentioned reasons and considerations, it is obvious that the treatment of rhinolalia should be performed in cleft palate centres. Perhaps by acquiring more experience, in time a more detailed diagnosis and indication system can be developed which may lead to a more justified choice of certain operative methods. REFERENCES BRAITHWAITE, E. (I964). In" Modern Trends in Plastic Surgery I ", p. 30, ed. Gibson, T. London : Butterworths. CALNAN, J. (x956). Diagnosis, prognosis and treatment of palato " pharyngeal incompetence " with special reference to radiographic investigations. Br. ft. plast. Surg., 8, 265-282.
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