Surgical Treatment of Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) is a condition where the soft palate and posterior oropharynx fail to close adequately, leading to complications such as abnormal speech, nasal regurgitation and nasal emission. Although there exist many approaches to treating VPI depending on the shape and severity of the insufficiency, this chapter describes the three most frequently used and well-researched techniques: the Furlow Palatoplasty (double-opposing Z-palatoplasty), the creation and placement of a pharyngeal flap, and a sphincter pharyngoplasty. This chapter contains an introduction to VPI causes and treatment, a description of patient assessment methods, step-by-step instructions for the different operative procedures, and the recovery process.

Characteristics and surgical outcomes of cleft palate in kabuki syndrome: a case series of 11 patients

Objective A significant number of patients with KS have cleft palate (CP) or submucous cleft palate (SMCP) and show delayed speech development. However, few reports have discussed the characteristics of CP in KS and the outcomes of postoperative speech development. The purpose of this study was to investigate the characteristics and surgical outcomes of CP in patients with KS, and to discuss the importance of the diagnosis of CP or SMCP. Methods We conducted a retrospective study on patients with clinically diagnosed KS who underwent palatoplasty. Clinical and surgical data were collected from patients’ medical records, and velopharyngeal function was evaluated using nasopharyngoscopy and speech analysis. Results In 11 cases, 5 patients had CP (45.5%) and 6 had SMCP (54.5%). Four patients who were genetically tested had a pathogenic variant of KMT2D. Seven of nine patients (77.8%) who underwent conventional palatoplasty showed velopharyngeal insufficiency and hypernasality. All patients who underwent pharyngeal flap surgery achieved velopharyngeal competency. Statistical analysis revealed a statistically significant difference in postoperative results between non-syndromic and KS patients. Conclusion Patients with SMCP may be more common than previously reported. The results showed that it is difficult to produce optimal results with conventional palatoplasty; therefore, pharyngeal flap surgery should be considered as a treatment to obtain favorable results. Pharyngeal flap surgery in patients with KS should be carefully designed based on speech evaluation and nasopharyngoscopic findings.

Speech Outcome and Self-Reported Communicative Ability in Young Adults Born With Unilateral Cleft Lip and Palate: Comparing Long-Term Results After 2 Different Surgical Methods for Palatal Repair

Objective: To compare speech outcome and self-reported speech and communicative ability (SOK) in young adults treated with one-stage (OS) or two-stage (TS) palatal repair. Furthermore, to compare with normative data on individuals without cleft lip and palate and to study the relationship between patients’ and experts’ judgments. Design: A cross-sectional group comparison study with long-term follow-up. Participants: Patients born with unilateral cleft lip and palate treated at 2 cleft centers; 17 with OS at 14 months and 25 with TS, soft palate repair at 7 months and hard palate repair at 6.2 years. Pharyngeal flap surgery was performed in 53% (OS) and 24% (TS) of patients. Main Outcome Measure(s): Speech characteristics were blindly assessed by speech and language pathologist from audio recordings, SOK at 19 years of age. Results: No group differences were found. Although the occurrence of nasality symptoms was low in both groups, only 60% (OS)/65% (TS) were assessed with competent velopharyngeal function (VPC). Articulation proficiency (percentage of consonants correct [PCC]) was 91%/97%, the /s/-sound specifically 87%/91%. Good intelligibility was found in 91%/87%. Patient opinion was in agreement with norms and significantly associated with intelligibility ( rs = 0.436, P < .01), PCC ( rs = −0.534, P < .01), and correct /s/ ( rs = −0.354, P < .05). Conclusions: No differences in speech outcome were related to operation method. The low prevalence of VPC was not clearly reflected in nasality symptoms. Patient opinion was related to articulation and intelligibility. A higher burden of care in terms of pharyngeal flap surgery was seen after the OS technique.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A “Good-Fast-Cheap” Technique for Any Etiology of Velopharyngeal Incompetence

Objective: To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication. Design: Retrospective review. Setting: Tertiary care center. Patients: Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded. Intervention: Modified pharyngeal flap with through-and-through dissection of the soft palate. Main Outcome Measure(s): Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale. Results: The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours. Conclusions: This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Impact of Surgery for Velopharyngeal Insufficiency on Eustachian Tube Function in Children: Pharyngeal Flap Versus Sphincter Pharyngoplasty

Objective: Velopharyngeal insufficiency (VPI) is a common speech disorder in patients with a history of cleft palate (CP) or 22q11.2 deletion syndrome. Pharyngeal flap (PF) and sphincter pharyngoplasty (SP) are 2 common surgeries to treat this disorder by decreasing unwanted nasal air emission and hypernasal resonance. Because Eustachian tube dysfunction (ETD) in patients with CP may be more frequent after surgery for VPI, we examined whether ETD was associated with either type of surgery. Design: Retrospective cohort study. Setting: Children’s hospital-based tertiary referral center. Patients: A total of 225 children with VPI who underwent primary PF (201) or SP (24) between 2006 and 2017. Outcome measures: We examined differences in risk of ETD according to both surgical groups and proxies for postoperative nasal obstruction. These proxies included postoperative resonance measures and development of obstructive sleep apnea (OSA). Results: Both surgical groups had similar preoperative measures, except the PF group had higher hypernasality by PSA. Postoperatively, the PF group demonstrated lower hypernasal resonance by nasometry and PSA. There were no differences between PF and SP groups with regard to ETD. Proxies for postoperative nasal obstruction also were not predictive of postoperative ETD. Degree of CP and younger age were found to be risk factors for ETD. Conclusion: There was no significant difference in the effects of PF and SP on ETD in this study. Neither lower hypernasality nor incidence of OSA had any impact on ETD. Degree of CP and younger age were the only significant risk factors for ETD that this study identified.

Successful Pharyngoplasty After Le Fort I Advancement In A Severely Neglected Cleft Lip And Palate Patient

Background: When indicated, velopharyngeal insufficiency (VPI) is treated with pharyngoplasty with consideration of patient’s age. Several studies have evaluated the relationship between age at surgery and speech outcome. The best results regarding reduction of open nasality were obtained when surgeries were performed around age of 5 to 6 years and operative complications were also less frequent in the younger age group than in older patients. Pre-operative assessment such as nasopharyngoscopy and/or videofluoroscopy gives surgeons a chance to estimate flap dimension to correct the defect causing the VPI. Moreover, velopharyngoplasty proceeded with speech therapy yields better recovery.Case History : A seriously neglected case of cleft lip and palate was reported. A 24 years old female underwent two palatorrhaphy at age 13 and 14 years old, which were far beyond the recommended age of 10 – 12 months. The resulting hypernasality was further worsened by absence of speech therapy which should have been followed from age 1 – 4 years old. On presentation, this patient requested to have immediate orthognatic surgery to repair his severe type 3 facial profile and malocclusion, a procedure which he underwent worsening the VPI. We decided to surgically correct the VPI. Nasoendoscopic assessment revealed he had an antero-posterior velopharyngeal closure problem which indicated a pharyngoplasty using a superiorlybased pharyngeal flap. Three months post-operatively his speech was re-evaluated by a speech therapist and nasoendoscopically. Despite imperfectness, significant improvement was achieved.Conclusion : Pharyngoplasty could still be reliable to a certain extent as a correction treatment of VPI in a seriously neglected case. A posterior pharyngeal flap helped this patient to recover significant speech capacity.