A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence

Abstract

Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options. Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech. Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study. Results Among the patients (median [range] age 7 [4-48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique. Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.

Keywords: autologous; clinical decision-making; inadequate velopharyngeal closure; pharyngeal pedicled flap; predictive medicine; speech intelligibility; transplantation.

Fig. 1

Fibroscopic views. Upper left: view of a short palate at rest. Lower left: short and dysraphic palate during phonation. Upper right: normal palate at rest. Lower right: normal palate during phonation.

Fig. 2

Intraoperative image of fat graft: preparation of the infiltration site.

Fig. 3

Intraoperative image of fat graft: gentle infiltration.

Fig. 4

Frequency distribution of propensity scores between the two considered treatments. The overlap of the distributions of patient characteristics was verified for each score quintile.

Fig. 5

Perfect speech probability after surgery with marginal analysis. In this figure, we can appreciate the probability to achieve a perfect speech result after surgery on the basis of this variable: T) treatment: AFG in white and pharyngoplasty in black; G) genetics: genetic alteration or syndrome present in red, none in blue; B) BMpre: with a darker green tinge increasing depending on the preoperative VPI severity D) diagnosis: CLP in light orange, CP in orange, isolated IVP in dark orange. A) age: less than 7 years in pink, and more than 7 years in violet. As we can observe, on the left side of the figure we have the features associated with a high probability of better outcome, on the right side the feature with a less probability of postoperative perfect speech. For a probability of perfect speech of 94.5%, we need the following features: a patient with less than 7 years with a syndrome, a preoperative intermittent VPI, and a previous cleft lip and palate, operated with pharyngoplasty. For a probability of 27% we need a patient of more than 7 years, with a syndrome, a continuous nasal air leak without good intelligibility, a previous cleft palate, operated with a pharyngoplasty. We can observe a pattern distribution of variable along the probability trend: age less than 7 years, a previous diagnosis of cleft lip and palate, an intermittent VPI without syndrome seem to be correlated with a better outcome, despite the surgical technique chosen. Like in the Mastermind game, all features are to be considered simultaneously. It represents a prognostic tool of the personal profile of the patient to obtain a perfect speech result.