Phonosurgery (combined approach palatopharyngoplasty--CAP)

A new surgical approach (CAP--Combined Approach Palatopharyngoplasty) is described for the correction of speech defects in palatopharyngeal incompetence. In palatopharyngeal incompetence the spatial relationships between the various components of the palatopharyngeal mechanism are disturbed. This combined approach brings about near-normal relationships (viz. intrapalatal and palatopharyngeal), as well as providing a competent palatopharyngeal sphincter, thus offering a remarkable improvement in speech. The operation comprises a two-stage procedure: stage I:--(a) submucosal transplantation of the levator palati muscles posteriorly to the region of the uvula and (b) 'crossed' palatopharyngoplasty; isolation of the palatopharyngeus muscles (posterior pillars) with their bases superiorly placed at their junctions with the soft palate, and transplantation of the lower free ends into the transverse retropharyngeal musculo-fascial pockets on the opposite side, the flaps thus crossing each other in the midline: stage II:--'check-valve' palatopharyngoplasty; elevation of a superiorly based posterior pharyngeal flap with anastomosis to the soft palate. The dynamics which are responsible for the improvement in speech are: (a) elevation of the palate to about the level of the atlas; (b) statico-dynamic constriction of the pharyngeal phonetic passage at the following levels: (i) at the newly placed levator eminence, (ii) at the newly constructed dynamic sphincter situated between the above-mentioned crossing and the free margin of the soft palate, and (iii) at the junction of the check-valve flap with the posterior pharyngeal wall; (c) increase in the effective length of the soft palate. The phonetic stream is prevented from entering the nasal chambers during the utterance of non-nasal pressure sounds by the newly constructed three-tier protective mechanism. This is identical with, but a 'reverse' representation of, the normal three-tier protective mechanism of the larynx, which prevents food from entering the tracheo-broncheal tree during deglutition. The operation has been performed in eight cases and the results are satisfactory, in so far as improvement in the quality of speech is better than that observed following other operations. In conclusion, the principles of phonosurgery may well be diagrammatically represented in Fig. 7.