State of the Art in Tonsillectomy

However, when one of our plastic surgeons commented how much easier a sphincter pharyngoplasty was to perform after a fresh tonsillectomy, the seed was planted for our new protocol, Dr. Donaldson told ENT Today. It was also observed that the patient who had undergone tonsillectomy and sphincter palatoplasty ended up with normal speech, and a well-healed central port that was surrounded by muscle.

After that, the team undertook to perform tonsillectomy and sphincter pharyngoplasty as a combined procedure on all subsequent patients, irrespective of examination or age, he said.

At the recent annual meeting of ASPO at COSM, Dr. Donaldson presented observational findings of 22 patients with VPI who underwent the combined procedure. There was no control group for comparison. The children all had clefting of the soft palate with variations of hard palate clefting with or without lip involvement. They ranged in age from 3 to 7.5 years.

The patients all underwent tonsillectomy with a coblator, and an inferior based flap on the posterior pharyngeal wall was created. The flap was elevated to Passavant’s ridge. Two muscle pedicles were created from the posterior tonsil pillars, and these were used to make a mucosa-lined sphincter.

All the patients were discharged home the same day after demonstrating the ability to drink and breathe appropriately in the secondary recovery after removal of the nasopharyngeal airway. No child to date has been readmitted after the procedure. Every child has demonstrated some speech improvement in the recovery area, Dr. Donaldson said.

At two-year follow-up, all the children attained improvement in speech, with 20 of them having good to excellent speech with respect to decrease in hypernasaslity.

Two cases, both in children over age five, had short palates at the initial surgery, and achieved only minimal improvement. They then underwent a Furlow double Z-plasty, planned by the team. Within six months, three patients presented with increased snoring, mild sleep apnea and vocal hyponasality-all attributed to nasopharyngeal stenosis with heavy midline scarring. The cases were resolved with removing the scar tissue and injecting steroids.

This procedure has no unique elements. It combines a well-proven procedure, sphincter palatoplasty, with an adjunct tonsillectomy, which improves pharyngeal mobility. The procedure can be performed early and does not violate the palatal repair, facilitating secondary procedures of that structure, Dr. Donaldson said.

He noted that the procedure is best undertaken early after the palate is repaired and VPI is no longer improving with intensive speech therapy. Also, traditional testing beyond speech evaluation is of very limited value due to the young age, and is of dubious significance given the alterations in anatomical relationships created by this surgery, he said.