Surgical Management of Velopharyngeal Incompetence in Velocardiofacial Syndrome

2004 ◽  
Vol 41 (2) ◽  
pp. 124-135 ◽  
Author(s):  
Felicity V. Mehendale ◽  
Malcolm J. Birch ◽  
Louise Birkett ◽  
Debbie Sell ◽  
Brian C. Sommerlad
Keyword(s):  
Posterior Pharyngeal Wall ◽  
Velocardiofacial Syndrome ◽  
Prospective Data ◽  
Pharyngeal Wall ◽  
Velopharyngeal Incompetence ◽  
Staged Approach ◽  
Velopharyngeal Function ◽  
And Function ◽  
Nasal Emission ◽  
Results Of Surgery

Objective To analyze the results of surgery for velopharyngeal incompetence (VPI) in velocardiofacial syndrome. Design Prospective data collection, with randomized, blind assessment of speech and velopharyngeal function on lateral videofluoroscopy and nasendoscopy. Setting Two-site, tertiary referral cleft unit. Patients Forty-two consecutive patients with the 22q11 deletion underwent surgery for symptomatic VPI by a single surgeon. Interventions Intraoral examinations, lateral videofluoroscopy (± nasendoscopy) and intraoperative evaluation of the position of the velar muscles through the operating microscope. Based on these findings, either a radical dissection and retropositioning of the velar muscles (submucous cleft palate [SMCP repair]) or a Hynes pharyngoplasty (posterior pharyngeal wall augmentation pharyngoplasty) was performed. As anticipated, a proportion of patients undergoing SMCP repair subsequently required a Hynes. The aim of this staged approach was to maximize velar function, thereby enabling a less obstructive pharyngoplasty to be performed. Thus, there were three surgical groups for analysis: SMCP alone, Hynes alone, and SMCP+Hynes. Main Outcome Measures Blind perceptual rating of resonance and nasal airflow; blind assessment of velopharyngeal function on lateral videofluoroscopy and nasendoscopy; and identification of predictive factors. Results Significant improvement in hypernasality in all three groups. The SMCP+Hynes group also showed significant improvement in nasal emission. There were significant improvements in the extended and resting velar lengths following SMCP repair and a trend toward increased velocity of closure. Conclusions Depending on velopharyngeal anatomy and function, there is a role for SMCP repair, Hynes pharyngoplasty, and a staged combination of SMCP+Hynes, all of which are procedures with a low morbidity.

Treatment of Stress Velopharyngeal Incompetence With Injection of Hyaluronic Acid

2017 ◽  
Vol 55 (4) ◽  
pp. 615-618 ◽  
Author(s):  
Steven Koprowski ◽  
Michael J. VanLue ◽  
Michael E. McCormick
Keyword(s):  
Hyaluronic Acid ◽  
Posterior Pharyngeal Wall ◽  
Clinical Entity ◽  
Multidisciplinary Management ◽  
Pharyngeal Wall ◽  
Safety And Efficacy ◽  
Velopharyngeal Incompetence ◽  
Acid Compound

Stress velopharyngeal incompetence (VPI) is a challenging clinical entity that can be managed by a variety of surgical and nonsurgical approaches. We describe the case of a clarinetist who presented with nasal air escape while playing. She had successful improvement in her symptoms after targeted injection of a hyaluronic acid compound to her posterior pharyngeal wall. Our objective is to describe the safety and efficacy of this technique, to emphasize the multidisciplinary management of patients with stress VPI, and to review the importance of both nasopharyngoscopy and videofluoroscopy in their evaluation.

Augmentation of Oral Tissues in Rabbit Using Autogenous Fat

1995 ◽  
Vol 32 (1) ◽  
pp. 1-6 ◽  
Author(s):  
John W. Canady ◽  
Sue Ann Thompson ◽  
Jerald B. Moon ◽  
Richard L. Glowacki
Keyword(s):  
Oral Cavity ◽  
Speech Therapy ◽  
Donor Site ◽  
Posterior Pharyngeal Wall ◽  
Donor Site Morbidity ◽  
Speech Disorders ◽  
Pharyngeal Wall ◽  
Synthetic Materials ◽  
Velopharyngeal Incompetence ◽  
The Stability

Patients with mild velopharyngeal incompetence (VPI) may have speech disorders, which are not sufficiently severe to warrant extensive surgical intervention, yet may not be amenable to correction by speech therapy alone. Augmentation of the posterior pharyngeal wall to aid in closure of the velopharyngeal sphincter may be beneficial in establishing better speech patterns, especially when combined with speech therapy. A variety of materials and techniques have been used in the past for this purpose. In this setting, autogenous fat may be transplanted without the risks incurred by augmentation with synthetic materials and involves very little donor site morbidity. The literature is somewhat contradictory, however, regarding the stability of the augmentation achieved using autogenous fat and there are no histologic studies describing the fate of fat injected into tissues of the oral cavity. Prior to introduction of this technique into clinical practice, this study was designed to investigate the fate of autogenous fat injected submucosally in the oropharyngeal region. Autogenous fat was injected into the anterior soft palate using the rabbit as a model. Histologic and gross inspections were performed at 2 days, 1, 2, and 4 weeks after injections. At the end of 4 weeks, at least 50% of the injection sites had visible evidence of augmentation, and 90% had histologic evidence of submucosal fat. In some instances most of the fat was resorbed; however, there were no instances of clinical infection or necrosis of the injection site. We conclude that submucosal injection of autogenous fat is a feasible alternative to using synthetic or other biologic materials for augmentation in the oral cavity.

Nasalance Scores in Wearers of a Palatal Lift Prosthesis in Comparison with Normative Data for Japanese

2004 ◽  
Vol 41 (3) ◽  
pp. 315-319 ◽  
Author(s):  
Takashi Tachimura ◽  
Yasuko Kotani ◽  
Takeshi Wada
Keyword(s):  
Cleft Palate ◽  
Outcome Measures ◽  
Normative Data ◽  
Normal Limits ◽  
Velopharyngeal Incompetence ◽  
The Mean ◽  
Velopharyngeal Function ◽  
Normative Score ◽  
Nasal Emission ◽  
Normal Controls

Objective This study was designed to examine whether nasalance score is changed in association with placement of a palatal lift prosthesis (PLP) and whether normative data previously reported are applicable to evaluate the effect of a PLP on velopharyngeal function as it relates to nasality. Design Nasalance scores were obtained as subjects read the Kitsutsuki Passage three times with the PLP in place and then removed. Participants Forty-three children (mean age 9.0 years, SD = 3.6 years) with repaired cleft palate who were treated with a PLP were selected as subjects. Their speech was characterized by nasal emission of air, slight hypernasality without a PLP but within normal limits with a PLP in place, or both. Main Outcome Measures Comparisons were made between normative scores and the average mean nasalance score of subjects with and without the PLP. Results Average values of the mean nasalance score for subjects were 17.3% (SD 7.6%) with the PLP in place and 33.5% (SD 13.3%) without the PLP in place. These scores were greater than the mean score of 9.1% (SD 3.9%) obtained from normal controls previously reported. Conclusion A PLP can decrease nasalance scores for speakers with repaired cleft palate who exhibit velopharyngeal incompetence. It was suggested that the normative score obtained from normal adult speakers is not applicable to evaluate the effect of a PLP to improve velopharyngeal function for children wearing the PLP.

An Electromyographic Study of Velopharyngeal Function in Speech

1976 ◽  
Vol 19 (2) ◽  
pp. 225-240 ◽  
Author(s):  
Fredericka Bell-Berti
Keyword(s):  
Muscle Activity ◽  
American English ◽  
Posterior Pharyngeal Wall ◽  
Stop Consonants ◽  
Vowel Quality ◽  
Pharyngeal Wall ◽  
Constrictor Muscle ◽  
The Third ◽  
Velopharyngeal Closure ◽  
Velopharyngeal Function

Electromyographic (EMG) recordings were obtained from the levator palatini, superior pharyngeal constrictor, middle pharyngeal constrictor, palatoglossus, and palatopharyngeus muscles of three talkers of American English. Bipolar hooked-wire electrodes were used. Each subject read nonsense words composed of three vowels (/i, a, u/), six stop consonants (/p, b, t, d, k, g/), and two nasal consonants (/m, n/) to form various stop-nasal and nasal-stop contrasts. Multiple repetitions of each utterance type were recorded and subsequently processed by computer. The levator palatini was found to be the primary muscle of velopharyngeal closure for each of the subjects. The palatopharyngeus also showed consistent oralization activity for each of the subjects, although the activity of this muscle was strongly affected by vowel environment. Two subjects showed pharyngeal constrictor muscle activity related to oral articulation, but pharyngeal constrictor activity for the third subject was related to vowel quality. Nasal articulation was accomplished by suppression of oral articulation for each subject. Vowel quality affected the strength of EMG signals for lateral and posterior pharyngeal wall muscles. In those cases where activity was different for the three vowels, activity was greatest for /a/.

Velopharyngeal Morphology of Patients with Persistent Velopharyngeal Incompetence following Repushback Surgery for Cleft Palate

2003 ◽  
Vol 40 (6) ◽  
pp. 612-617 ◽  
Author(s):  
Norifumi Nakamura ◽  
Yuko Ogata ◽  
Kyoko Kunimitsu ◽  
Akira Suzuki ◽  
Masaaki Sasaguri ◽  
...  
Keyword(s):  
Cleft Palate ◽  
Cervical Vertebrae ◽  
Posterior Pharyngeal Wall ◽  
Cranial Base ◽  
Normal Children ◽  
Pharyngeal Wall ◽  
Velopharyngeal Incompetence ◽  
Posterior Maxilla ◽  
Dental Hospital ◽  
Pharyngeal Depth

Objective To characterize the velopharyngeal morphology of patients with persistent velopharyngeal incompetence (VPI) following repushback surgery for cleft palate. Participants Seven patients with moderate to severe VPI following repushback surgery for secondary correction of cleft palate, and 14 patients who had already obtained complete velopharyngeal closure function (VPF) were enrolled. Control data were obtained from the longitudinal files of 20 normal children in Kyushu University Dental Hospital. Main Outcome Measures Skeletal landmarks and measurements were derived from tracing of lateral roentgenographic cephalograms. The measurements included velar length, pharyngeal depth, and pharyngeal height and the ratio of velar length to pharyngeal depth. Additionally, the configuration of the upper pharynx (pharyngeal triangle) involving the cranial base, cervical vertebrae, and the posterior maxilla and also the position of posterior pharyngeal wall (PPW) in the pharyngeal triangle were analyzed. Results The VPI group had a significantly shorter velar length and greater pharyngeal depth, resulting in a smaller length/depth ratio than the controls. The points of PPW and cervical vertebrae of the VPI group were located more posteriorly and inferiorly than those in the group with complete VPF after the primary operation and the controls. The positions of cranial base and maxilla were not significantly different. Additionally, the position of PPW in the pharyngeal triangle was located significantly posteriorly and superiorly in the VPI group, compared with the controls. Conclusions The craniopharyngeal morphology of patients with persistent VPI was characterized by a short palate, wide-based and counterclockwise-rotated pharyngeal triangle, and posteriorly and superiorly positioned PPW. These might be contributory factors for the prediction of VPF before repushback surgery for cleft palate.

Structure of the Musculus Uvulae: Functional and Surgical Implications of an Anatomic Study

1997 ◽  
Vol 34 (6) ◽  
pp. 466-474 ◽  
Author(s):  
Martin H. S. Huang ◽  
S. T. Lee ◽  
K. Rajendran
Keyword(s):  
Cleft Palate ◽  
Posterior Pharyngeal Wall ◽  
Anatomic Study ◽  
Pharyngeal Wall ◽  
Cleft Palate Repair ◽  
Palate Repair ◽  
Velopharyngeal Function ◽  
Intravelar Veloplasty ◽  
Anatomic Information

Objective: The role of the musculus uvulae in velopharyngeal function, its morphologic status in cleft palate, and its fate in palatoplasty procedures are subjects of controversy. The aims of this investigation were to re-examine this velar muscle to clarify its anatomic characteristics, to analyze its role in speech physiology, and to study the surgical implications of this information for cleft palate repair. Methods: Its attachments, morphology, and relations were examined in 18 fresh human adult cadavers by detailed dissection under 3.2× magnification and light microscopy. Results: The musculus uvulae was observed to be a paired midline muscle extending between the tensor aponeurosis anteriorly and the base of the uvula posteriorly along the nasal aspect of the velum. It had no attachments to the hard palate. Conclusions: These findings suggest that its action is to increase midline bulk on the nasal aspect of the velum, thus contributing to the levator eminence. It may also have an extensor effect on the nasal aspect of the velum, displacing it toward the posterior pharyngeal wall. Both of these actions would serve to maximize midline velopharyngeal contact. One clinical application of this anatomic information is that the muscle should be preserved in the dissection performed during intravelar veloplasty. Furthermore, it should be recognized that the musculus uvulae is invariably divided and reoriented incorrectly in the Furlow double opposing Z-plasty.

Palate Re-Repair Revisited

2002 ◽  
Vol 39 (3) ◽  
pp. 295-307 ◽  
Author(s):  
Brian C. Sommerlad ◽  
Felicity V. Mehendale ◽  
Malcolm J. Birch ◽  
Debbie Sell ◽  
Caroline Hattee ◽  
...  
Keyword(s):  
Previous Attempt ◽  
Consecutive Series ◽  
Operating Microscope ◽  
Prospective Data ◽  
Velopharyngeal Incompetence ◽  
Cleft Palate Repair ◽  
Palate Repair ◽  
Pharyngeal Flap ◽  
Intravelar Veloplasty ◽  
Nasal Emission

Objective: To analyze the results of a consecutive series of palate re-repairs performed using the operating microscope and identify predictive factors for outcome. Design: Prospective data collection, with blind assessment of randomized recordings of speech and velar function on lateral videofluoroscopy and nasendoscopy. Patients: One hundred twenty-nine consecutive patients with previously repaired cleft palates and symptomatic velopharyngeal incompetence (VPI) and evidence of anterior insertion of the levator veli palatini underwent palate re-repairs by a single surgeon from 1992 to 1998. Syndromic patients, those who had significant additional surgical procedures at the time of re-repair (23 patients), and all patients with inadequate pre- or postoperative speech recordings were excluded, leaving a total of 85 patients in the study. Interventions: Palate re-repairs, with radical dissection and retropositioning of the velar muscles, were performed using the operating microscope with intraoperative grading of anatomical and surgical findings. Main Outcome Measures: Pre- and postoperative perceptual speech assessments using the Cleft Audit Protocol for Speech (CAPS) score, measurement of velar function on lateral videofluoroscopy, and assessment of nasendoscopy recordings. Results: There were significant improvements in hypernasality, nasal emission, and nasal turbulence and measures of velar function on lateral videofluoroscopy, with improvement in the closure ratio, velopharyngeal gap at closure, velar excursion, velar movement angle, and velar velocity. Conclusions: Palate re-repair has been shown to be effective in treating VPI following cleft palate repair, both in patients who have not had an intravelar veloplasty and those who have had a previous attempt at muscle dissection and retropositioning. Palate re-repair has a lower morbidity and is more physiological than a pharyngoplasty or pharyngeal flap.

Use of Preoperative Cervical Vascular Imaging in Patients With Velocardiofacial Syndrome and Velopharyngeal Dysfunction in the United Kingdom

2020 ◽  
Vol 57 (6) ◽  
pp. 694-699 ◽  
Author(s):  
Nefer Fallico ◽  
Norma Timoney ◽  
Duncan Atherton
Keyword(s):  
Retrospective Study ◽  
Posterior Pharyngeal Wall ◽  
Velocardiofacial Syndrome ◽  
Vascular Imaging ◽  
Preoperative Imaging ◽  
Pharyngeal Wall ◽  
The United Kingdom ◽  
The Uk ◽  
Internal Carotid Arteries

Objective: In patients with velocardiofacial syndrome (VCFS), medial displacement of the internal carotid arteries (ICAs) may increase the risk of vascular injury during the surgical correction of velopharyngeal dysfunction (VPD). Some surgeons advocate the use of vascular imaging studies prior to surgery. Nevertheless, the role of preoperative imaging is still controversial. This study aimed to review the current practice of the UK cleft units and also examine our own practice at the Evelina London Children’s Hospital in relation to children with VCFS undergoing speech surgery over the previous 7 years. Design: A questionnaire was sent to all UK cleft surgeons to enquire about the management and use of preoperative vascular imaging in patients with VPD and VCFS. A retrospective study was also conducted of the unit’s 7-year series of patients with VPD and VCFS. Results: Thirty-four completed questionnaires were returned (response rate 100%). Most UK surgeons (73.5%) do not regularly order preoperative vascular imaging for patients with VCFS although some reportedly would consider it if a posterior pharyngeal wall pulsation was visible. In our unit, between 2013 and 2019, a total of 40 patients affected by VCFS have been assessed for VPD. A magnetic resonance angiography (MRA) was performed for 23 patients. Medial deviation of the ICAs was identified in 7 (30%) patients. Conclusions: The results of the national survey showed no consensus on routine use of preoperative vascular imaging. Our retrospective study showed a 30% prevalence of medialized ICAs in our patient cohort. In these patients, the MRA findings influenced the choice of speech surgery.

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