Outcomes
Pharyngeal flap surgery may be able to improve speech performance in children or adults with a cleft palate who have velopharyngeal insufficiency. In fact, there is a high success rate for improvement of speech following pharyngeal flap surgery. However, surgery does not guarantee perfect or 100% intelligible speech. In addition to speech improvements, pharyngeal flap surgery may help eliminate hypernasality, nasal turbulence, and facial grimacing (Tonz et al., 2002). Often, speech improvements are not obvious immediately following the surgery. Speech improvements are more prevalent after one year post surgery and usually continue for several years. The outcomes of pharyngeal flap surgery vary among each individual in regards to improvements in hyponasality, hypernasality, nasal turbulence, voice quality, articulation, and intelligibility (Tonz et al., 2002; Liedman-Boshki et al., 2005).
Patients who undergo pharyngeal flap surgery encounter the risk of never breathing through their nose again, which could create abnormal speech (i.e., denasal resonance) (Witt et al., 1998). It is estimated that around 20-30% of patients with clefts develop hypernasal speech after pharyngeal flap surgery (Heliovaara et al., 2003). The percentage reported for individuals developing hypernasal speech is debated by researchers. It is possible that hypernasality can be a side effect of pharyngeal flap surgery, however hyponasal speech occurs more frequently after a successful surgery (Liedman-Boshki et al., 2005).
It is also possible that pharyngeal flap surgery will be unsuccessful. Some patients may even require secondary surgery for velopharyngeal insufficiency. It is common that individuals who have to undergo a second surgery could develop secondary speech problems, more specifically compensatory articulation and resonance disorders. Problems occurring post secondary surgery are often more difficult to extinguish (Tonz et al., 2002).
As previously mentioned, one problem that may occur after surgery is hypernasality. This is caused when a narrow flap and inadequate lateral pharyngeal wall movement prohibit lateral port closure during phonation. There are several other reasons surgery may fail the first time, including a poorly designed flap such as one that is too narrow, postoperative scar (contracture of the flap), or inappropriate patient selection. Also, the flap may be too wide and occlude the lateral ports. There are higher rates of surgical failure in children with a history of perinatal upper airway obstruction, such as those with Robin sequence (Witt et al., 1998).
The type of cleft, as well as the type of flap used (superiorly or inferiorly-based) does not seem to make a difference in postoperative speech outcomes. It has been reported that different types of flaps give different speech configurations, however the results showed equally good outcomes for postoperative speech, regardless of the type of flap used. Therefore, it is imperative that the surgeon selects the right type of flap for each individual (Liedman-Boshki et al., 2005).
Overall, speech should improve after pharyngeal flap surgery. It is important to remember that improvement is variable and individuals react differently to surgery. Changes in speech do not always occur immediately after surgery, but this does not mean improvements will not be made. Lastly, speech problems such as compensatory articulation strategies do not often extinguish on their own. A speech language pathologist is usually involved both before and after pharyngeal flap surgery to monitor and help improve speech difficulties.
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