T & A in Patients with Cleft Palate and/or VPI
Background/Purpose: Performing tonsillectomy and adenoidectomy (T & A) in patients with cleft palate and/or velopharyngeal insufficiency (VPI) without a cleft has been addressed by several reports in the related scientific literature. However, the issue is still controverted. Adenoid tissue contributes to velopharyngeal closure during speech. In contrast, hypertrophied pharyngeal tonsils can hinder velum movements during speech causing or increasing VPI. When surgery for VPI is being performed, an enlarged adenoid pad can force the surgeon to set a pharyngeal flap or a sphincter pharyngoplasty lower than planned decreasing their effectiveness for restoring velopharyngeal closure. Thus, in selected cases, an adenoidectomy may be a prerequisite for successfully performing surgery for VPI. Another issue to be considered is when to perform adenoidectomy: in the same surgical stage of velopharyngeal surgery? A couple of months before? Several months before? Concerning hypertrophied tonsils in cases of VPI, besides the possible limitation of velar movements tonsils can create a high risk of obstruction when pharyngeal flap or sphincter pharyngoplastsy is performed. The purpose of this article is to address and discuss the questions: When T & A should be performed? How should it be performed? How long should velopharyngeal surgery be delayed after T & A? Methods/Description: The different roles of tonsils and adenoids in velopharyngeal closure will be demonstrated and discussed using diagrams, videonasopharyngoscopies, and videofluoroscopies. Statistics about how often T & A is indicated in preparation for velopharyngeal closure at the Ian Jackson Craniofacial Clinic of Beaumont Royal Oak Hospital in the last 5 years will be presented and discussed. The controverted indication of adenoidectomy in preparation for velopharyngeal surgery for correcting VPI will be discussed. The risk of obstruction by hypertrophied pharyngeal tonsils when velopharyngeal surgery is performed will be discussed. The possible difficulties of performing tonsillectomy and adenoidectomy after velopharyngeal surgery will be described and discussed. The important issue of timing of T & A in preparation for velopharyngeal surgery will be discussed, and histopathological findings at different times after adenoidectomy will be presented. The surgical techniques for performing T & A in patients with cleft palate and/or VPI without a cleft will be described and their advantages and disadvantages will be presented and discussed.