Traitement de l'Insiffisance vélopharyngée par pharyngoplastie à lambeau pharyngé postérieur à pédicule supérieur dans les séquelles des fentes palatines

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Dr. Boumediene ABOU-BEKR
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Objectives: Operated velopalatine slits account for 55% of the causes of VPI in children. The management of the VPI is far from being well codified, because it must call on a multidisciplinary team composed of a pediatric surgeon, a speech therapist, a radiologist and a psychologist. The aim of our work is to set up a system for screening, evaluation, and treatment of VPI’s, by introducing objective examinations such as aerophonoscopy and profile teleradiography, as well as by using of pharyngoplasty technique with posterior pharyngeal flap and supper pedicle as a surgical correction method (SPF). Materials and methods : Through our study of 146 cases of operated cleft palates in children aged from 4 to 15 years, spread over a period of 06 years, between January 2010 and January 2016, analyzed and evaluated clinically, aerophonoscopically and radiologically in the pre and postoperation, there are only 58 cases of VPI of organic cause and 07 cases of functional cause that were retained for our prospective study making a total of 65 cases, which have benefited from a SPF including 11 cases that had weak Pharyngeal walls have benefited from a modified SPF that is to say associated with a pushbuck. The other cases were excluded from our study because 24 cases had normal phonation, 52 cases head velar insufficiency and responded well to speech therapy, and finally 05 cases had a closed rhinolalia and were excluded from our study. Results: With sufficient follow-up ranging from 02 years to 06 years, the postoperative results of the PLS were favorable with 75% (49cases) of improvement, 71% (09cases) of wich presented with satisfactory phonation and when this SPF was associated with a pushbuck (11 cases) it became 81% of improvement. Our postoperative results, with reference to other published foreign series, were quite comparable: Vasquez Paris 2007 (84%), Sprintzen USA (78%), Bachy France 2014 (85%), Karling Sweden 1999 (65%). Among the immediate postoperative complications were: 47 cases of snoring that disappeared between the first and third months, and 05 cases of sleep apnea that regressed spontaneously in three to six months. The postoperative failure rate was 25% (16 cases), there were: 04 floppy flaps that were resumed surgically, 02 of which have evolved badly, and the 14 other cases also evolved badly due to either a technical defect or operative indication error, either underlying velopharyngeal hypotonia or an enormous lateral orifice. Conclusion: Posterior pharyngeal flap supper pedicle pharyngoplasty (SPF) remains an effective solution to correct and improvc postoperativc PVI outcomcs. In some cases this PLS may be associated with a pushbuck to adapt to the physiology of the velopharyngeal sphincter, particularly in case of dysfunction of the lateral pharyngeal walls. The contribution of radiotelegraphy and aerophonoscopy significantly improved the pre- and postoperative assessment of VPI. Currently it is advisable according to the authors to prevent VPI by introducing the technique of intravascular veloplasty (IVV) in the primary surgical treatment of velopalatine slots, to reduce the rate of VPI. Keywords: Cleft palate, VPI, profile telegraphy, aerophonoscopy, speech therapy, SPF