A.11. What is the relation of tonsillectomy and adenoidectomy to velopharyngeal incompetence and postoperative obstructive breathing episodes?
Answer:
There is often a considerable mass of tonsillar and adenoidal tissue at the age when orofacial cleft surgery is performed. In fact, adenotonsillar hypertrophy is the leading cause of obstructive sleep disordered breathing in young children and the leading indication for adenotonsillectomy. Children with cleft palate are already prone to development of obstructive sleep apnea due to a narrow airway. Furthermore, bulky tonsils can hinder retrodisplacement of the soft palate or block airflow by obstructing the cavum, which has already been reduced in volume by the retrodisplacement and presence of the flap after palate repair. In addition to the latent danger of infection, the flap used in pharyngoplasty creates an obstruction that seriously complicates plans for subsequent adenotonsillectomy. Therefore, it might be preferable to remove the tonsils and adenoids a few months before pharyngoplasty if indicated. Small studies have advocated for adenotonsillectomy and cleft palate repair in one surgical procedure, reporting lower obstructive respiratory events postoperatively without negative speech effects.
Parents might question the logic behind adenotonsillectomy if they received information that adenoid removal in the case of a cleft palate might create or aggravate velar insufficiency by removing the adenoid tissue's compensation for a short or poorly mobile palate. However, once velar inadequacy is confirmed, these precautions are no longer justified. In fact, tonsillar hypertrophy can impair velopharyngeal closure due to impingement of its upper pole between the palate and the posterior pharyngeal wall. Therefore, tonsillectomy can improve speech. During tonsillectomy, it is important to leave the tonsillar pillars intact because their muscle structure has a vital physiologic role.
References