Lateral Pharyngeal Wall Movement Research Articles

Videofluoroscopy Versus Nasopharyngoscopy of Lateral Pharyngeal Wall Movement for Assessment of Velopharyngeal Insufficiency.

Competent speech requires closure of the velopharyngeal sphincter by dynamic apposition of the velum and posterior and lateral pharyngeal walls. An accurate estimation of lateral pharyngeal wall motion is an important determinant in the planning and the outcome of any operation to correct velopharyngeal insufficiency (VPI). The purpose was to compare the assessment of lateral pharyngeal wall movement by videofluoroscopy (VP) versus nasopharyngoscopy (NP). The authors retrospectively reviewed the charts of 269 consecutive patients in our cleft lip/palate clinic from 1982 to 2008 and culled those treated with a pharyngeal flap for VPI. The authors included patients who were evaluated preoperatively by both VP and NP, and had studies of suitable quality. Percentage of lateral pharyngeal wall motion was estimated with each technique and compared for each patient. The authors identified 25 patients who underwent both VP and NP at the same median age (4.7 years). The estimated percentage of lateral pharyngeal wall motion between the 2 techniques was significantly different ( P <0.001). Average lateral pharyngeal wall motion was estimated to be 59±25% (range: 5%-90%) by VP and only 40%±25% (range: 0%-95%) during NP. VP and NP are complementary, but assessment of lateral pharyngeal wall motion can vary between the 2 methods. The surgeon should be aware of the difference in estimated lateral pharyngeal wall movement when planning a procedure to correct VPI.

Pharyngoplasty versus buccinator myomucosal flap in the management of velopharyngeal-insufficiency coronal pattern of closure

Background Velopharyngeal insufficiency (VPI) is an anatomical or structural defect that hinders sufficient velopharyngeal closure, as visualized on nasoendoscopy. Aim The aim of this work was to compare the result of sphincter pharygoplasty versus buccinator myomucosal flap in management of VPI cases with coronal pattern of closure in order to select the proper operation for managing these cases. Patients and methods This study included 20 patients in our institute with residual VPI after primary repair of cleft palate with age range between 3 and 12 years. Randomly, patients with coronal pattern of closure were categorized into two groups: (A) 10 patients underwent sphincteroplasty and (B) 10 patients underwent buccinator myomucosal flap. Preoperatively and 2 months after operation, every patient was evaluated by auditory perceptual assessment, flexible nasopharyngoscopy, and nasometry. The results were documented, tabulated, and statistically analyzed. Results There were statistically significant improvements of auditory perceptual assessment in obligatory speech disorders and intelligibility of speech, nasometeric evaluation in oral and nasal sentences in both groups. Additionally, there were significant improvements of nasoendoscopic evaluations in the degree of velar movement, presence or absence and size of persistent gap in both groups, and in the degree of lateral pharyngeal wall movements in group A. Conclusion Sphincterpharyngoplasty or buccinator myomucosal flap have satisfactory results in treatment of VPI patients with coronal pattern of closure with no statistically significant difference between both groups.

Patterns of velopharyngeal closure during speech in individuals with normal habitual resonance: A nasoendoscopic analysis

ObjectiveVelopharyngeal valve closure is essential for adequate speech intelligibility as well as for other activities. The variations in the contribution of different components of the velopharyngeal port walls produce different closure patterns. The aim of this cross-sectional study is to identify the prevalence of the different velopharyngeal closure patterns in Arabic-speaking individuals with no perceived hypernasality or velopharyngeal dysfunction. MethodsAfter verification of selection criteria, 100 subjects with age range between 15 and 60 years underwent nasoendoscopic examination and both the extent of movement of the different velopharyngeal walls as well as closure pattern were observed. ResultsAlmost all participants had grade 4 (full range) velar mobility, most participants had grade 3 lateral pharyngeal wall movement, and none showed any observable posterior pharyngeal wall movement. Coronal closure pattern was the most frequent (75%) among participants followed by circular pattern (25%). There was no statistically significant difference between both genders in the extent of velar and lateral pharyngeal wall movements, yet the frequency of closure patterns differed statistically significantly between males and females. ConclusionCoronal pattern was the most prevalent type of velopharyngeal closure in subjects with normal habitual resonance, of both sexes, yet it occurred more frequently in males.

Pharyngeal wall and soft palate motion after two common speech surgeries

PurposeTo assess how pharyngeal wall and soft palate motion are affected after two common interventions for velopharyngeal insufficiency. Materials and methodsA retrospective observational study was performed. A database of patients who had undergone Furlow palatoplasty or pharyngeal flap surgery between 2011 and 2019 and had video-archived preoperative and postoperative nasopharyngoscopy recordings was created. Recordings were deidentified and randomized, with 5 randomly-selected videos duplicated to determine intra-rater reliability. The videos were scored by 3 experienced raters using a modified Golding-Kushner scale. Pre- and postoperative scores were compared using paired t-test. Inter- and intra-rater reliability were estimated using intra-class correlation (ICC). ResultsThere were 17 patients who met inclusion criteria. The mean age was 6.9 years (range 3–22 years, 59% male). In the Furlow palatoplasty group (n = 9), an increase in left soft palate motion was noted postoperatively (t(8) = 2.71, p = 0.02). In the pharyngeal flap group (n = 8), increases in lateral pharyngeal wall motion (left: t(7) = 3.58, p = 0.008, right: t(7) = 3.84, p = 0.006) and right soft palate motion (t(6) = 2.49, p = 0.04) were identified. Intra-rater reliability and inter-rater agreement were lower than prior studies utilizing the Golding Kushner scale. ConclusionsOur results provide objective evidence that Furlow palatoplasty and pharyngeal flap surgeries achieve velopharyngeal closure by increasing movement at different anatomical sites. Palatal and pharyngeal wall motion observed during preoperative nasopharyngoscopy may influence a surgeon's choice of intervention.

Assessment of pharyngeal motor function using a novel velopharyngeal squeeze maneuver and a novel endoscopic pharyngeal contraction grade scale in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

BackgroundTo investigate a novel velopharyngeal squeeze maneuver (VPSM) and novel endoscopic pharyngeal contraction grade (EPCG) scale for the evaluation of pharyngeal motor function.MethodsDuring endoscopic examination of 77 post‐irradiated nasopharyngeal carcinoma patients and control subjects, VPSM was rated and lateral pharyngeal wall movement graded with EPCG scale during swallowing. Pharyngeal constriction ratio (PCR) measured by videofluoroscopy was used for correlation.ResultsVPSM and EPCG scale showed almost perfect intra‐rater and inter‐rater reliability (Kappa: >0.90). VPSM was present in 61% of patients suggesting good pharyngeal motor function. VPSM was predictive of EPCG scale (Wald statistic = 29.99, p < 0.001). EPCG scale also correlated strongly with PCR (r: 0.812) and was predictive for aspiration (odds ratio: 22.14 [95% CI 5.01–97.89, p < 0.001]).ConclusionsVPSM and EPCG scale are two novel tools to assess pharyngeal motor function, and both correlate well with pharyngeal contractility and aspiration.

On the role of the frontal projection in videoradiography of velopharynx in decision-making for a velopharyngeal flap plasty in patients with cleft palate

Despite uneventful primary surgery, patients with cleft palate may experience velopharyngeal insufficiency (VPI) and hypernasal speech. Videoradiography of velopharynx is a commonly used method to visualize velopharyngeal function and a velopharyngeal flap is often used to counteract VPI. The aim of this study was to investigate whether the frontal projection on videoradiography plays a role in the decision-making about velopharyngeal flap surgery, or possibly the width and orientation of the flap. A secondary aim was to evaluate the effect of the flap in improving velopharyngeal function. Between 2007 and 2016, 75 patients had received a flap at our department. During the same period of time, 41 patients who had undergone videoradiography did not receive a flap. Medical records, particularly regarding speech assessments, videoradiography statements and operating records, were scrutinised to seek information about the factors leading up to the decision about whether or not to perform a flap. In only one instance, reduced lateral pharyngeal wall movement found on the frontal projection was clearly taken into account when deciding to refrain from performing a velopharyngeal flap. Only a slight agreement was found between pre-operative speech assessment and findings in videoradiography. Hypernasality was reduced by flap surgery in 97% of the patients. We conclude the frontal projection of the videoradiographic examination seems to have no crucial role in the decision-making on performing a velopharyngeal flap or not in patients with cleft palate. Even with reduced lateral pharyngeal wall movement, a velopharyngeal flap effectively reduces hypernasality and VPI.

Age and Preoperative Velar Closure Ratio Are Significantly Associated With Surgical Outcome of Furlow Double-Opposing Z-Plasty in Palatal Re-Repair

The patient selection criteria for Furlow double-opposing Z-plasty in palatal re-repair remain obscure. This study investigated whether patients' preoperative characteristics significantly affected the surgical outcome of Furlow double-opposing Z-plasty in palatal re-repair. We designed and implemented a case-control study nested in a cohort, which could be divided into 2 stages. In the first stage, a retrospective cohort study was performed to collect basic information and the preoperative status of the patients who would undergo Furlow double-opposing Z-plasty to correct velopharyngeal insufficiency after primary cleft palate repair. Eight predictor variables were included: age, gender, primary surgical technique, velopharyngeal closure pattern, velar movement, lateral pharyngeal wall movement, levator muscle orientation, and preoperative velar closure ratio. The outcome variable was postoperative velopharyngeal function described as velopharyngeal competence or velopharyngeal insufficiency. In the second stage, a case-control analysis was performed to explore the potential factors affecting the surgical outcome. Univariate and multivariate analyses were applied to examine the relationship between the predictor variables and surgical outcome. The sample was composed of 83 patients and resulted in 54 velopharyngeal competence outcomes and 29 velopharyngeal insufficiency outcomes after surgery. Two predictors showed statistical significance: age and preoperative velar closure ratio. The possibility of postoperative velopharyngeal insufficiency in patients older than 14.5years was 6 times higher than that in patients younger than 14.5years. The possibility of postoperative velopharyngeal insufficiency in patients with preoperative velar closure ratios of 0.9 or greater was one fifth that in patients with preoperative velar closure ratios between 0.8 and less than 0.9. The results of this study suggest that age and preoperative velar closure ratio are significantly associated with postoperative velopharyngeal insufficiency. Age was a risk factor in achieving good surgical outcomes, and the preoperative velar closure ratio remained a protective factor.

Multicenter Interrater Reliability in the Endoscopic Assessment of Velopharyngeal Function Using a Video Instruction Tool.

Assess interrater agreement of endoscopic assessment of velopharyngeal (VP) function before and after viewing the video instruction tool (VIT). We hypothesized improvement in interrater agreement using the Golding-Kushner scale (GKS) after viewing the VIT. Prospective study. Multi-institutional. Sixteen fellowship-trained pediatric otolaryngologists who treat velopharyngeal insufficiency (VPI) rated 50 video segments using the GKS before and after watching the VIT. Raters assessed gap size percentage and lateral pharyngeal wall (LPW), soft palate (SP), and posterior pharyngeal wall (PPW) movement. Intraclass correlation coefficient was estimated for these continuous measures. Raters also indicated the presence of a palatal notch, Passavant's ridge, and aberrant pulsations (categorical variables). Fleiss κ coefficient was used for categorical variables. Wilcoxon signed-rank test was performed on the difference between the pre/post individual video ratings. Reliability improved for all continuous variables after watching the instructional video. The improvement was significant for PPW (0.22-0.30, P < .001), SP (left: 0.63-0.68, P < .001 and right: 0.64-0.68, P = .001), and LPW (left: 0.49-0.54, P = .01 and right: 0.49-0.54, P = .09) but not significant for gap size (0.65-0.69, P = .36). Among categorical variables, agreement on Passavant's ridge significantly improved (0.30-0.36, P = .03). Exposure to a video instruction tool improves interrater agreement of endoscopic assessment of VP function. Significant improvement was observed in our primary end points, specifically posterior pharyngeal wall movement, soft palate movement, and lateral pharyngeal wall movement. There was less impact of the VIT on the interrater agreement of the categorical variables, palatal notch, Passavant's ridge, and aberrant pulsations.

What's New in Cleft Palate and Velopharyngeal Dysfunction Management?

After studying this article, the participant should be able to: 1. Have a clear understanding of the evolution of concepts of velopharyngeal dysfunction, especially as it relates to patients with a cleft palate. 2. Explain the subjective and objective evaluation of speech in children with velopharyngeal dysfunction. 3. On the basis of these diagnostic findings, be able to classify types of velopharyngeal dysfunction. 4. Develop a safe, evidence-based, patient-customized treatment plan for velopharyngeal dysfunction founded on objective considerations. Velopharyngeal dysfunction is improper function of the dynamic structures that work to control the velopharyngeal sphincter. Approximately 30 percent of patients having undergone cleft palate repair require secondary surgery for velopharyngeal dysfunction. A multidisciplinary team using multimodal instruments to evaluate velopharyngeal function and speech should manage these patients. Instruments may include perceptual speech analysis, video nasopharyngeal endoscopy, multiview speech videofluoroscopy, nasometry, pressure-flow, and magnetic resonance imaging. Velopharyngeal dysfunction may be amenable to surgical or nonsurgical treatment methods or a combination of each. Nonsurgical management may include speech therapy or prosthetic devices. Surgical interventions could include palatal re-repair with repositioning of levator veli palatini muscles, posterior pharyngeal flap, sphincter pharyngoplasty, or soft palate or posterior wall augmentation. Treatment interventions should be based on objective assessment and rating of the movement of lateral and posterior pharyngeal walls and the palate to optimize speech outcomes. Treatment should be tailored to specific anatomical and physiologic findings and the overall needs of the patient.

Abstract: Central Defect-Control Pharyngeal Flap Surgery Based on Nasoendoscopic Assessment and Speech Outcomes Following Surgery

INTRODUCTION: The main strategy behind Hogan’s lateral port control pharyngeal flap surgery is to change a single central incompetent sphincter to two competent lateral sphincters. The concept of tailoring pharyngeal flaps, introduced in 1972 by Scolnick and McCall, was an improvement on existing techniques in that they varied the type of flap according to the patients lateral pharyngeal wall motion. The purpose of this study was to describe a central defect-control pharyngeal flap, as we call it, with varying width determined by preoperative nasoendoscopic findings, and assess surgical outcomes by perceptual speech evaluation and nasometric analysis. MATERIALS AND METHODS: The authors reviewed medical records of all children who underwent a central defect-control pharyngeal flap performed by the senior author (Rong-Min Baek) from May 2008 to January 2014. 74 patients were included. Preoperative nasopharyngeal endoscopy had been performed to make a complete observation of sphincteric movement and central velopharyngeal port during speech. The unique cobblestone pattern on the posterior pharyngeal wall for each patient was used as landmarks to determine the width of flap. During surgery, watertight closure was performed at all sites to prevent scar contracture of raw surfaces. Preoperative and postoperative velopharyngeal function was assessed through perceptual speech evaluation and nasometric analysis. The correlation factors of long-term surgical outcome were analyzed. RESULTS: 96.3 % of the patients showed velopharyngeal competency after surgery. No obstructive sleep apnea was seen. Significant improvement was observed in perceptual speech evaluation and nasometric analysis at both short term (6 months) and long term(2 years) follow-up (p<0.001). The preoperative size of velopharyngeal gap, the closure pattern of velopharyngeal sphincter, symmetry of lateral pharyngeal wall, the degree of hypernasality, the degree of nasal emission, the age at surgery, and the etiology of VPI did not correlate to long-term postoperative velopharyngeal function. CONCLUSION: The central defect-control pharyngeal flap with emphasis on filling the central velopharyngeal port defect with inidividually-sized flaps, is highly successful in treating velopharyngeal insufficiency without major complications. Preoperative nasopharyngoscopy is a valuable tool in determining the size of flap. Individualized design of flap dimension, together with elimination of all raw surfaces during surgery, seems to produce adequate velopharyngeal closure that lasts over time, as demonstrated in the patients’ speech evaluation and nasometric analyses. DISCLOSURE/FINANCIAL SUPPORT:No funding was received for this study. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript

Predictors of Success in Furlow Palatoplasty for Submucous Clefts: An Experience with 91 Consecutive Patients.

The aim of this study was to evaluate, through multivariate ordinal logistic regression, variables contributing to good postoperative speech outcomes following Furlow palatoplasty. A series of 91 consecutive patients was evaluated. Variables analyzed included demographics; speech perceptual assessment; and measures on videonasopharyngoscopy and videofluoroscopy such as preoperative closure pattern, velopharyngeal gap, and lateral pharyngeal wall motion. Univariate and multivariate analysis of predictors of high scores of articulation, nasal resonance, and resolution of velopharyngeal insufficiency were performed using simple and multinomial logistic regression. A summative perceptual assessment score was generated and analyzed for correlation with postoperative speech outcomes. There were 39 patients (42.9 percent) with a good outcome as defined by adequate articulation and lack of velopharyngeal insufficiency with normal nasal resonance. There was improvement of articulation in 53 patients (58.2 percent), of nasal resonance in 75 patients (82.4 percent), and of velopharyngeal insufficiency in 80 patients (87.9 percent). Predictors of good postoperative speech outcomes (p < 0.05) were preoperative articulation, nasal resonance, and lateral pharyngeal wall movement greater than 37.5 percent on one side. Preoperative severity of velopharyngeal insufficiency, velopharyngeal gap, pattern of closure, age, and sex were not predictive of a good outcome. Logistic regression demonstrated that the preoperative perceptual assessment score was predictive of postoperative outcome, with a significant difference (p < 0.05) between mild and severe groups. A scoring system based on summated perceptual assessment parameters is predictive of good postoperative speech outcomes. Risk, III.

Clinical Application of Subjective Measurements for OSAS Assessment: Predictive Factors of Syndrome Severity

Purpose of the Study: To examine the clinical value of subjective evaluations of obstructive sleep apnea syndrome (OSAS) in correlation with syndrome severity as diagnosed with polysomnography. Procedures: 210 patients with mild to severe OSAS were assessed. Objective evaluation included polysomnography. Subjective assessment included full ENT examination, neck circumference (NC) plus body mass index measurements, Mueller maneuver and Epworth Symptom Scale (ESS). Results: The presence of lateral pharyngeal wall movement, abnormal ESS scoring and male gender can be considered independent risk factors for the prediction of moderate/severe OSAS (p < 0.05). Increased NC can also be considered a clinical risk factor related to male gender and lateral pharyngeal wall movement (p = 0.05). Conclusions: Subjective OSAS assessment, including evaluation of lateral pharyngeal wall movement, ESS scoring and NC measurement can safely predict, mainly in males, OSAS severity, as diagnosed with polysomnography. Message of the Paper: Subjective assessment from the ENT point of view should raise high suspicion towards the early diagnosis of moderate/severe OSAS.

Speech Outcomes following Pharyngeal Flap in Patients with Velocardiofacial Syndrome

Velocardiofacial syndrome is the most common defined disorder associated with palatal insufficiency. The authors' purpose is to evaluate one surgeon's experience with correction of velopharyngeal insufficiency in velocardiofacial syndrome using a tailored pharyngeal flap. The authors reviewed the records of all children with velocardiofacial syndrome and velopharyngeal insufficiency who were managed with a pharyngeal flap between 1983 and 2009. Data collected included age at operation, preoperative videofluoroscopic findings, speech outcomes, complications, and need for a secondary operation. The authors identified 33 patients with velocardiofacial syndrome and velopharyngeal insufficiency who had postoperative speech evaluations. Velopharyngeal insufficiency was diagnosed at a median age of 5 years. Palatal findings were: Veau type I (n = 4), overt submucous (n = 6), or occult submucous (n = 23). Median preoperative lateral pharyngeal wall movement was 22 percent (range, 0 to 90 percent). Successful correction of velopharyngeal insufficiency was achieved in 29 of 33 patients (88 percent). One patient had a medially displaced right internal carotid artery, and evidenced intraoperative bleeding and required a blood transfusion. One patient developed obstructive sleep apnea. A tailored pharyngeal flap is highly effective for correction of velopharyngeal insufficiency in velocardiofacial syndrome with few complications.

Through-and-Through Dissection of the Soft Palate for High Pharyngeal Flap Inset: A New Technique for the Treatment of Velopharyngeal Incompetence in Velocardiofacial Syndrome

Patients with velocardiofacial syndrome often present with refractory velopharyngeal incompetence. Whereas the high wide pharyngeal flap has been advocated for these patients, poor visualization makes high inset of the flap technically difficult. We present a consecutive series of patients with velocardiofacial syndrome and severe velopharyngeal incompetence treated with high inset pharyngeal flap achieved by through-and-through dissection of the soft palate. All patients with velocardiofacial syndrome in whom secondary surgical management was recommended for treatment of severe velopharyngeal incompetence over the last 7 years were treated with a high inset pharyngeal flap achieved by through-and-through dissection of the soft palate (to be described). All patients had nasendoscopy and videofluoroscopy preoperatively and underwent perceptual speech assessment preoperatively and at least 12 months postoperatively. Eight patients met the inclusion criteria with a mean age at presentation of 7 years, 3 months. No patient had a history of cleft palate. All patients had minimal lateral pharyngeal wall motion and a medium to large velopharyngeal gap (>6 mm). Velopharyngeal incompetence, as measured by perceptual speech score, improved from a mean of 10.3 (range, 9 to 12 on a maximum scale of 13) to a mean of 1.9 (range, 0 to 4), achieving velopharyngeal competence (p < 0.01) without nasal airway obstruction in any patient. The present report demonstrates restoration of velopharyngeal competence in a consecutive series of patients with velocardiofacial syndrome who presented with severe velopharyngeal incompetence. We attribute this outcome to the development of a reliable technique for high inset of the pharyngeal flap using through-and-through dissection of the soft palate, enabling direct visualization of flap placement.

Lateral Pharyngeal Wall and Velar Movement and Tailoring Velopharyngeal Surgery: Determinants of Velopharyngeal Incompetence Resolution in Patients with Cleft Palate

After primary palatoplasty, patients with cleft palate may still require secondary surgical procedures to correct residual velopharyngeal incompetence. This study evaluated speech outcomes of patients who underwent differential velopharyngeal surgery based on degree of lateral pharyngeal wall movement and velar movement. In this retrospective cohort study, 31 patients with cleft palate from 1992 to 2003 underwent tailor-made velopharyngeal surgery with complete preoperative and postoperative speech assessments. All patients were evaluated postoperatively for velopharyngeal incompetence resolution, persistent velopharyngeal incompetence, and hyponasality. Velopharyngeal incompetence was resolved in 90 percent of patients. Severe hyponasality occurred as a complication in 16 percent, requiring subsequent division of the pharyngeal flap. Patients with lateral pharyngeal wall movement greater than 25 percent had a significantly greater chance of incompetence resolution compared with those with lateral pharyngeal wall movement less than 25 percent (p < 0.001). Regarding combined lateral pharyngeal wall movement plus velar movement, all groups showed significantly lower velopharyngeal competence scores following surgery (p < 0.001). Patients with lateral pharyngeal wall movement less than 25 percent and velar movement greater than 50 percent had the least successful speech outcome. The data also showed that various types of surgical operations performed on patients with similar combined degrees of lateral pharyngeal wall movement and velar movement can result in equally successful speech outcomes. This finding indicated flexibility in following the treatment algorithm for tailoring velopharyngeal surgery. The degree of lateral pharyngeal wall movement and velar movement, rather than type of surgical procedure chosen, is a more important determinant of velopharyngeal incompetence resolution in patients with cleft palate.

Interrater and Intrarater Reliability in the Evaluation of Velopharyngeal Insufficiency Within a Single Institution

To explore the interrater and intrarater reliability in nasoendoscopic assessment of velopharyngeal (VP) function using the standardized reporting method described by Golding-Kushner within a single institution. Prospective blinded study. Academic, tertiary care, pediatric hospital. Six health care providers (2 pediatric otolaryngology faculty members, 2 pediatric otolaryngology fellows, and 2 speech pathologists) independently rated 50 videotaped nasoendoscopy segments twice. The segments on the videotape were obtained in a clinical setting. The Golding-Kushner rating system was used to rate VP function. Raters described VP closure quantitatively by rating palatal and lateral pharyngeal wall movement for each segment. They also qualitatively described characteristics of the VP gap, rated gap size as none, small, medium, or large, and estimated the percentage gap size relative to the resting position. Reliability coefficients were calculated for the data sets. Fairly good interrater and intrarater reliability was seen in the quantitative measures. Faculty otolaryngologists rated segments more similarly to each other than did pediatric otolaryngology fellows, but intrarater reliability was similar for both the experienced and less experienced otolaryngologists. Less consistency was seen in the ratings of the speech pathologists. Raters tended to rate with less consistency when describing qualitative characteristics of the VP gap than when making quantitative measurements. The Golding-Kushner scale is a reasonably reliable tool for reporting nasoendoscopic findings at our institution. However, these data also indicate that there exists room for improvement and that rater training may increase reliability.

Results with Furlow palatoplasty in management of velopharyngeal insufficiency.

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

Superiorly based flap pharyngoplasty: the degree of postoperative ‘tubing’ and its effect on speech

It is recognised that superiorly based pharyngeal flaps tend to contract resulting in narrowing and lowering of the flaps. If lateral pharyngeal-wall motion is unable to close against the "tubed" flap or if the flap migrates below the level of medial displacement of the lateral pharyngeal walls, velopharyngeal insufficiency will result. The extent of this phenomenon of flap contracture or shrinkage has not been previously quantified. A consecutive series of 120 superior flap pharyngoplasty operations were assessed critically and carefully. The mean width of the harvested flap measured 89% of the width of the pharyngeal posterior wall and shrank over 6 months to 45% of the lateral pharyngeal diameter. The relations between speech results, complication rate and remaining flap width are analysed. All flaps shrink but to a varying degree.

Evaluation of velopharyngeal insufficiency with magnetic resonance imaging and nasoendoscopy.

Several radiological methods have been utilized to assess velopharyngeal function. The more recent imaging technique, magnetic resonance imaging (MRI), which has a number of advantages over radiographic and computed tomographic imaging, has been used rarely for evaluating velopharyngeal insufficiency. In this study, 5 normal volunteers and 10 patients with surgically repaired cleft palate were examined with MRI using midsagittal, coronal, and axial images. Nasoendoscopy was also performed to complete and confirm the diagnoses. Complete and tight closure of the velopharynx and full backward and upward movement of the soft palate was observed in volunteers. In coronal images, medial movement of lateral pharyngeal walls could also be seen. Despite this, patients with surgically repaired cleft palate had some degree of motion of the soft palate, ranging from no movement to maximal movement. In most of the patients, short soft palates with restricted motion was seen. MRI visualizes the velopharyngeal sphincter in all planes and provides high-resolution images of the soft tissues. Objective measurements can be made as well. In this study, MRI and nasoendoscopy were used together in the diagnosis of velopharyngeal insufficiency and gave satisfactory results.

Velopharyngeal Motion after Sphincter Pharyngoplasty: A Videonasopharyngoscopic and Electromyographic Study

Sphincter pharyngoplasty is a surgical procedure for managing velopharyngeal insufficiency after palatal closure. This procedure is intended to create an active diaphragm for velopharyngeal closure. The purpose of this study was to evaluate velopharyngeal motion after sphincter pharyngoplasty, by using selective electromyography and simultaneous videonasopharyngoscopy. Twenty-five patients who were subjected to sphincter pharyngoplasty from 1985 to 1996 were reviewed. All conditions were evaluated by using electromyography with simultaneous videonasopharyngoscopy. The following velopharyngeal muscles were examined: superior constrictor pharyngeus, palatopharyngeus, and levator veli palatini. The palatopharyngeus was included in the superiorly based surgical flaps inserted at the posterior pharyngeal wall. Twentythree patients (92 percent) showed complete velopharyngeal closure. The two patients with residual velopharyngeal insufficiency showed a defect size of 20 and 25 percent. None of the patients showed electromyographic activity at the superiorly based flaps, indicating absence of activity of the palatopharyngeus muscles. However, all patients showed normal electromyographic activity at the superior constrictor pharyngeus and the levator veli palatini. Videonasopharyngoscopy demonstrated that lateral pharyngeal wall movements, which ranged from 25 to 40 percent, were related to strong electromyographic activity at the superior constrictor pharyngeus. It is concluded that the superiorly based pharyngeal flaps of the sphincter pharyngoplasty do not seem to create an active diaphragm for velopharyngeal closure. Moreover, the observed sphinctering seems to be passive, caused by the contraction of the superior constrictor pharyngeus. (Plast. Reconstr. Surg. 104: 905, 1999.)