The Horizontal Split Technique for Posterior Pharyngeal Flap Surgery: Speech and Airway Outcomes in 220 Patients

ObjectiveThe purpose of this 10-year retrospective review was to report our single-center outcomes using the posterior pharyngeal flap (PPF) horizontal split technique to treat patients with syndromic and non-syndromic velopharyngeal dysfunction (VPD).DesignRetrospective review (2011-2021).SettingA tertiary pediatric institution.PatientsPatients with VPD (4-21 years old).InterventionsPPF surgery using the horizontal split inset technique by 2 surgeons.Main Outcome MeasuresEvaluated factors included demographics, VPD characteristics, and pre-operative speech evaluation. Evaluated outcomes included complications, revisional VPD surgery rates, post-operative resonance, nasometry scores, and the apnea-hypopnea index (AHI).ResultsTwo hundred and twenty children (median age: 6.9 years) underwent surgery. The median operative time was 47 min. Most patients (95%) achieved improved resonance, with 89% achieving mild or no hypernasality. Median nasalance scores significantly decreased (pre-operative: 42, post-operative: 18). Of 137 patients who underwent a post-operative polysomnogram, 18 patients had an AHI ≥5; 2 patients with syndromic diagnoses underwent PPF takedown. Ten patients underwent revisional VPD surgery. Patients with 22qDS (22q11.2 deletion syndrome) or non-cleft VPD had an increased risk of demonstrating significant residual hypernasality requiring revisional surgery.ConclusionsThis simple, reproducible PPF surgical technique yields reliably improved resonance in patients with syndromic and non-syndromic VPD. Patients with 22qDS and those with non-cleft VPD may have higher odds of demonstrating residual hypernasality and needing additional surgery. Although there is low risk of flap takedown for obstructive sleep apnea (OSA), long-term airway monitoring remains essential.