Soft Palate Length Research Articles

Long-term Morphological Changes of the Velum and the Nasopharynx in Patients With Cleft Palate.

To investigate long-term morphological changes in the soft palate length and nasopharynx in patients with cleft palate. We hypothesized that there would be differences in the morphological development of the soft palate and nasopharynx between patients with and without cleft palate and that these developmental changes would negatively affect the soft palate length to pharyngeal depth ratio involved in velopharyngeal closure for patients with cleft palate. Retrospective, case-control study. Institutional practice. Ninety-two patients (Group F) with unilateral cleft lip, alveolus, and palate and 67 patients (Group CLA) with unilateral cleft lip and alveolus not requiring palatoplasty were included. The soft palate length, nasopharyngeal size, and soft palate length to pharyngeal depth ratio were measured via lateral cephalograms obtained at three different periods. Group F showed a shorter soft palate length and smaller nasopharyngeal size than Group CLA at all periods. Both these parameters increased with age, but the increase in amount was significantly less in Group F compared with that in Group CLA. The soft palate length to pharyngeal depth ratio in Group F decreased with age. In patients with cleft palate, the soft palate length to pharyngeal depth ratio, which is involved in velopharyngeal closure, can change with age. Less soft palate length growth and unfavorable relationship between the soft palate and nasopharynx may be masked in early childhood but can manifest later on with age.

Heritability Analysis in Twins Indicates a Genetic Basis for Velopharyngeal Morphology.

The velopharyngeal mechanism is comprised of several muscular components that act in a coordinated manner to control airflow through the nose and mouth. Proper velopharyngeal function is essential for normal speech, swallowing, and breathing. The genetic basis of normal-range velopharyngeal morphology is poorly understood. The purpose of this study was to estimate the heritability of velopharyngeal dimensions. We measured five velopharyngeal variables (velar length, velar thickness, effective velar length, levator muscle length and pharyngeal depth) from MRIs of 155 monozygotic and 208 dizygotic twin pairs and then calculated heritability for these traits using a structural equation modeling approach. The heritability estimates were statistically significant (95% confidence intervals excluded zero) and ranged from 0.19 to 0.46. There was also evidence of significant genetic correlations between pairs of traits, pointing to the influence of common genetic effects. These results indicate that genetic factors influence variation in clinically relevant velopharyngeal structures.

Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

To determine prognostic factors for postoperative velopharyngeal function following the primary cleft palate repair at the age of five and above.This study reviewed patients with cleft palate who had undergone Furlow palatoplasty at age 5 or older from 2009 to 2014. We obtained intraoperative measurements, including velar length, pharyngeal depth, cleft width, maxillary width, cleft palate index (cleft width/maxillary width) and palatopharyngeal ratio (velar length/pharyngeal depth), as well as speech evaluation results at least 1 year after surgery. Logistic regression and retrospective analyses were performed to determine factors associated with speech performance after the primary cleft palate repair.Among the six intraoperative measurements of velopharyngeal morphology, only pharyngeal depth was incorporated into the regression model, and was found to have an inverse association with postoperative velopharyngeal function, Exp (B) 0.883 (95% CI 0.798-0.976). Moreover, a pharyngeal depth greater than 16 mm was significantly associated with a higher risk of postoperative velopharyngeal insufficiency (P < 0.01).Pharyngeal depth is potentially a prognostic indicator for the primary management of cleft palate in older patients. Pharyngoplasty may need to be considered when the pharyngeal depth is large and the patient’s access to surgery is limited.

SYSTEMATIC REVIEW AND META-ANALYSIS OF THE PALATAL SURGERIES IN THE TREATMENT OF OBSTRUCTIVE SLEEP APNEA

Abstract Background The first description of a patient with obstructive sleep apnea was in ‘The Posthumous Papers of the Pickwick Club’ published by English writer Charles Dickens in 18361. The first introduction of the terms ‘sleep apnea syndrome’ and ‘obstructive sleep apnea syndrome’ was by Guilleminault et al in 1967. Subsequently, Guilleminault coined the term ‘upper airway resistance syndrome’ in 19932. Objectives This paper aims to examine published articles between January 2008 and January 2019 on the different palatal surgeries performed on OSA patients and the treatment outcomes, which in turn will be used to determine two things. The first being the effectiveness of various palatal surgical techniques in treating OSAS and the second (if applicable) the most effective of the palatal surgical techniques in treating OSAS. Patients and Methods The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA)5. The detailed steps of methods were described elsewhere as well as PRISMA checklist. The quality of relevant studies was assessed using NIH quality assessment tool for observational cohort and cross -sectional studies as well as NIH tool for quality assessment for case series studies. Results Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on AHI was the lateral pharyngoplasty followed by the Anterior Palatoplasty, with a significant mean reduction of [(SMD= -0.848, 95% CI (-1.209 – -0.487), p-value&amp;lt;0.001) and (SMD= -0.864, 95% CI (-1.234 – -0.494), p-value&amp;lt;0.001), respectively]. The technique responsible for the best improvement in ESS was the Relocation Pharyngoplasty, with a significant mean reduction of [SMD= -0.998, 95% CI (-1.253 – -0.743), p-value&amp;lt;0.001]. Minimal O2 saturation level improved most with the Expansion Sphincter Pharyngoplasty, with a significant mean reduction of [SMD= 1.011, 95% CI (0.581 – 1.440), p-value&amp;lt;0.001]. The surgical procedure that result in the best post-operative VAS was Z-Palatoplasty, with a significant mean reduction of [SMD= -1. 551, 95% CI (-2.049 – -1.052), p-value&amp;lt;0.001]. soft palate length change with a significant mean reduction of [SMD= -2.219, 95% CI (-2.730 – 1.708), p-value&amp;lt;0.001]. Finally, meta-analyses of relevant studies showed that expansion sphincter pharyngoplasty achieved the overall highest success rate [Event rate= 77%, 95% CI (65.4%– 85.5%), p-value&amp;lt;0.001] Conclusion The best procedure for treating OSA varies from patient to patient and there is no universal cure-all. Careful patient selection and pre-operative evaluation are mandatory.

A retrospective study of the influence of obesity on polysomnography and cephalometric parameters in males with obstructive sleep apnea

ABSTRACT Objective Evaluate the influence of obesity on the polysomnographic and cephalometric parameters in obstructive sleep apnea (OSA). Methods Fifty records of male patients with OSA, containing information on dental, medical, polysomnographic, and cephalometric exams were selected. The degree of obesity was based on Body Mass Index (BMI). Group I comprised normal or overweight individuals (BMI ≤ 29.9 kg/m2), whereas Group II consisted of obese individuals (BMI ≥ 29.9 kg/m2). Results BMI significantly correlated with apnea and hypopnea index (p < 0.0005), minimal oxyhemoglobin saturation (p < 0.0005), and two cephalometric variables (soft palate length, p = 0.01 and width, p = 0.01). Group II showed a significant correlation with the position of the hyoid bone (p = 0.02). Soft palate length and width significantly differed between groups (p = 0.014; 0.016). Conclusion Obese males present wider and longer soft palate dimensions, and patients with a greater BMI present a more inferiorly positioned hyoid bone.

Pharyngeal Airway and Craniocervical Angle among Different Skeletal Patterns.

The aim of the present study was to investigate the pharyngeal airway dimensions and their correlations among the craniocervical angle and skeletal patterns. Cephalometric radiographs were obtained from 300 patients (≥15 years of age), of whom 150 were male patients and 150 were female patients. The patients were divided into three groups according to their skeletal patterns. The following dimensions were measured: NP: nasopharyngeal airway; PS: shortest distance from the soft palate to the pharyngeal wall; MP: Me-Go line intersecting the pharyngeal airway; TS: shortest distance from posterior tongue to pharyngeal wall; LP: laryngopharyngeal airway; UE length: shortest distance from the uvula to the epiglottis; PW: width of soft palate; PL: length of soft palate; ANB angle; palatal angle; and craniocervical angle. Paired t-test, one-way analysis of variance (ANOVA), and Pearson correlation were applied for statistical analysis. The null hypothesis was that there were no differences among skeletal patterns in terms of pharyngeal airway dimensions. The C4C2-SN angle of the Class II pattern (108.1°) was significantly greater than that of the Class III pattern (104.4°). The Class II PL was significantly longer than the Class III PL in the all patients and female patients groups. The ANB angle exhibited moderate positive correlation with palatal angle (r: 0.462) and moderate negative correlation with TS (r: -0.400) and MP (r: -0.415) length. No significant differences were found in vertical hyoid lengths among all skeletal patterns. Class III (PS, TS, and MP) lengths were significantly greater than Class I and Class II in the all patients group. Regarding the LP length, no significant difference was found in the all patients group. Therefore, the null hypothesis was rejected. Class III had significantly greater pharyngeal airway dimensions (PS, TS, and MP) than Class I and Class II. In all skeletal patterns, NP length was moderately correlated with the palatal angle. The PS was weakly negatively correlated with the ANB and PL. The TS and MP were moderately negatively correlated with the ANB angle.

An Observational Study to Evaluate Association Between Velopharyngeal Anatomy and Speech Outcomes in Adult Patients With Severe Velopharyngeal Insufficiency.

By measuring velopharyngeal structure and evaluating speech intelligibility, to explore and observe the association between velopharyngeal anatomy and speech outcomes in these patients. Thirty-one adult patients with velopharyngeal insufficiency after the primary palatoplasty aged 18 to 35 years (mean 22.03 years) were enrolled as the study group. The patients had significant hypernasality and audible nasal emission. The degree of velopharyngeal closure assessed by electronic nasopharyngeal fiberoptic endoscopy was grade III. Cephalometric analysis was performed on lateral cephalograms to measure velopharyngeal structure, including hard palate length (ANS-PNS), velar length (PNS-U), pharyngeal depth (PNS-PPW), and oropharyngeal airway space (U-MPW). Their speech intelligibility was evaluated through the Mandarin Chinese speech intelligibility test, and each speech sample was examined by 2 speech and language pathologists. The results were assessed with the SPSS 23.0 software package, and regression analysis was used to examine the relationship between velopharyngeal structure and speech outcomes. A significant negative correlation was confirmed between speech intelligibility and pharyngeal depth. Pharyngeal depth also showed a linear relationship with speech intelligibility, and there was no significant correlation between speech intelligibility and other measures (hard palate length, velar length, oropharyngeal airway space). In the velopharyngeal anatomy, only pharyngeal depth was associated with speech intelligibility in adult patients with severe velopharyngeal insufficiency, this is consistent with our clinical observation. It suggests that appropriate reduction of pharyngeal depth during palatopharyngoplasty may have a good effect on the speech recovery in patients with cleft palate and patients with velopharyngeal insufficiency after palatorrhaphy.

Assessing the Prevalence of Velopharyngeal Dysfunction and Obstructive Sleep Apnea by Correlating Cone Beam Computed Tomography Parameters of Soft Palate with the Stop Bang Questionnaire

Introduction: The relationship between soft palate length and nasopharyngeal depth can be used to determine the velopharyngeal dysfunction and is called Need's ratio. Need's ratio should be in a range of 0.6–0.7 in normal subjects. Any increase greater than 80% demonstrated a risk for developing velopharyngeal dysfunction. Aim: To assess the prevalence risk rate of obstructive sleep apnea using snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck circumference, gender (STOP-BANG) questionnaire and to evaluate various parameters of the soft palate, pharyngeal depth, and determination of Need's ratio using CBCT. Materials and Method: In this prospective study, patients who reported for CBCT assessment in the age group ranging from 20 to 50 years were included. The sample size of the study was calculated to be 42. Furthermore, the patients were screened with the STOP- BANG questionnaire and shapes of the soft palate, velar length, width, and pharyngeal depth were obtained with the CBCT sections, and Need's ratio was calculated. Results: The collected data were analyzed with IBM. SPSS software 23.0. Based on the results of the STOP- BANG questionnaire, P value was found to be significant. Based on the CBCT parameters, the most common shape was the leaf-shaped soft palate. The velar length, width, and pharyngeal depth were found to be higher in males. Need's ratio was found to be increasing with an increase in age. A significant correlation of risk for OSA was established based on a comparison of questionnaire results with the results obtained from CBCT parameters with Need's ratio. Conclusion: CBCT is a static imaging technique, it can identify the anatomic risk factors for developing sleep apnea.

An Innovative Palatoplasty for Primary Cleft Palate Repair

Summary: Many surgical techniques have been developed to restore function in patients with cleft palate. Despite the development of many surgical techniques for primary cleft palate repair there is no standard procedure that ensures palatal function as that in normal children. Furlow’s and intravelar veloplasty are the most common methods for velar repair in patients with cleft palate; however, some limitations have been described by different authors. The objective of this study was to present an innovative method for primary cleft palate repair that addresses the shortcomings of conventional methods. Since 2017, 88 consecutive patients with nonsyndromic unilateral cleft palate have undergone primary anatomical repair of palatal deformity using this technique. This method combines nasal mucosa Z plasty and muscular overlapping with the use of one hemiuvula for uvular repair (unilateral uvuloplasty). The nasal mucosa Z plasty produces velar lengthening by transposition of nasal mucosa and myomucosal flaps. The unilateral uvuloplasty reduces anatomically the velopharyngeal gap and increases the velar length, thus reducing velopharyngeal distance. This innovative palatoplasty, achieves proper anatomical and functional reconstruction of the repaired palate. Only four patients (4.54%) developed mild or severe hypernasality and one patient (1.13%) had postoperative palatal fistula in this group of patients. This innovative technique results in low rates of nondesirable outcomes, improving limitations of conventional methods. Reduced oral mucosa incisions, limited velar muscle dissection, and preservation of the tensor veli palatini anatomy are some of the benefits of this technique.

A Preliminary Study of Anatomical Changes Following the Use of a Pedicled Buccal Fat Pad Flap During Primary Palatoplasty.

The purpose of this study was to examine the surgical impact of the pedicled buccal fat pad (BFP) flap on the levator veli palatini (LVP) muscle and surrounding velopharyngeal (VP) anatomy following primary palatoplasty using magnetic resonance imaging (MRI). Observational, prospective. MRI studies were completed at 3 different facilities. All participants with BFP flap were operated on by the same surgeon. Five pediatric participants with cleft palate with or without cleft lip (CP±L) who underwent primary palatoplasty with BFP flap placement. Comparison groups consisted of 10 participants: 5 with CP±L who did not receive the BFP flap and 5 healthy controls. All participants underwent nonsedated MRI 2 to 5 years postoperatively. Anatomical measures of the velopharynx and LVP among the 3 participant groups. Median values were significantly different among groups for velar length (P = .042), effective velar length (P = .048), effective VP ratio (P = .046), LVP length (P = .021), extravelar LVP length (P = .009), and LVP origin-origin distance (P = .030). Post hoc analysis revealed a statistically significant difference between the BFP and traditional repair groups for effective VP ratio (P = .040), extravelar LVP length (P = .033), and LVP length (P = .022). This study provides preliminary support that the BFP flap creates a longer velum, with increased distance between the posterior hard palate and the LVP, and a larger effective VP ratio compared to traditional surgical techniques. Future research is needed to determine whether this procedure provides a more favorable mechanism for VP closure.

An MRI Case Study: The Anatomic Cleft Restoration Concept Utilizing Buccal Flaps in a Primary Palatoplasty

Purpose: Primary palatoplasties using the Anatomic Cleft Restoration Philosophy uses the buccinator myomucosal flap (buccal flap) as the major tissue replacement flap to correct the tissue deficiency within the cleft palate malformation. The surgical approach aims to close the palate without tension, lengthen the palate, reconstruct the levator muscular sling, not inhibit craniofacial growth and achieve proper resonance for speech. The purpose of this study is to present preliminary data on velopharyngeal variables to demonstrate the muscle and tissue morphology in adults with cleft palate who have not received a secondary surgery for speech or orthognathic surgery. Methods: Magnetic resonance imaging was used to analyze velopharyngeal variables for 2 individuals with the buccal flap approach and 2 individuals who received a traditional cleft palate repair. Linear measurements were obtained and 2 velopharyngeal ratios were calculated. Results: All variables were compared to previously published normative data of velopharyngeal variables for individuals with non-cleft anatomy who are of the same race, sex, and of similar age. The individuals with the buccal flap approach presented with a similar velar length and levator length in comparison to individuals with non-cleft anatomy. The individuals with the buccal flap approach presented with a longer effective velar length and velar length in comparison to individuals with a traditional cleft palate repair. Visually, the individual with the buccal flap presents with a thicker tissue mass between the hard and soft palate junction. Conclusions: In this case study, individuals who received a primary palatoplasty with the buccal flap approach presented with a longer velum and effective velar length in comparison to individuals with a traditional cleft palate repair and those with non-cleft anatomy. This study highlights the utility of using magnetic resonance imaging to quantify the changes that occur to the velopharyngeal anatomy following the buccal flap surgical approach.

Obstructive Sleep Apnea

Aim: To evaluate diagnostic cephalometric parameters and their influence on skeletal and soft tissue components in obstructive sleep apnea (OSA). Materials and Methods: The study is a prospective case study of 40 diagnosed cases (as diagnosed by Type IV level study) of obstructive sleep apnea who were reported to the Department of Oral Medicine and Radiology with their age ranging from 28 to 75 years. Lateral cephalometric radiographs in upright and supine posture were taken, with teeth in centric relation, and the head aligned with Frankfort horizontal (FH) plane parallel to the floor. The focus-coronal plane distance was 5 feet, the film-coronal plane distance was 15 cm, and the magnification was 10%. Results: OSA patients experience an increase in values of sella nasion point A (SNA) and sella nasion point B (SNB) at the supine position with respect to the upright position and experience a decrease in values of nasion sella turcica odontoid process tangent (NSL-OPT) and nasion sella turcica- cervical vertebra tangent (NSL-CVT) at the supine position with respect to the upright position. The parameters of paramount importance in the pathogenesis of OSA are soft palate thickness, length, and tongue length. Conclusion: SNA, SNB and NSL-OPT, NSL-CVT are inversely related to each other and play a role in the consequence or pathogenesis of OSA. Tongue height is of the least significance in the pathogenesis of OSA. The cephalometric findings are of paramount importance to know the exact site of obstruction in the pathogenesis of OSA.

Cephalometric evaluation of soft palate changes after maxillary advancement in lip and palate cleft patients

Introduction: Changes in the soft palate and velopharyngeal function are among the most important concerns for maxillofacial surgeons in patients with midface deficiency, especially in those with cleft palate who needed maxillary advancement. In this study, we evaluated cephalometric changes in soft palate after maxillary advancement. Materials and Methods: This study included 16 cleft patients (7 females and 9 males), with a mean age of 22 ± 3.47. The maxillary advancement alone was done in 10 patients and bimaxillary osteotomy in the other six patients. Cephalometric characteristics were assessed before and 6 months after the surgery, and the results were analyzed using paired t-test or Wilcoxon test. Results: The results showed a 6% increase (P &lt; 0.05) for PNS-U (soft palate length) index. In addition, PTM-UPW (upper pharyngeal space) and U-MPW (middle pharyngeal space) increased by 5% (P &lt; 0.05) and 5% (P &lt; 0.08), respectively, after the surgery. V-LPW (lower pharyngeal space) also increased by 0.6% but was not statically significant. Conclusions: According to the results of this study, after surgical maxillary advancement, changes were observed in upper and middle pharyngeal spaces, soft palate length, and inclination, but lower pharyngeal space remained unchanged.

Cephalometric predictors of hypernasality and nasal air emission.

During times of increasingly recognized importance of interprofessional practices, professionals in Medicine, Dentistry, and Speech Pathology areas cooperate to optimize treatment of velopharyngeal dysfunction (VPD), after primary palatoplasty for correction of cleft palate. Objective Our study aims to compare velar length, velar thickness, and depth of the nasopharynx of patients with unilateral cleft lip and palate (UCLP) with the presence, or absence, of hypernasality and nasal air emission; and to verify if the depth:length ratio, between nasopharynx and velum, would be predictive of consistent hypernasality and nasal air emission (speech signs of VPD).Methodology Cephalometric radiographs and outcome of speech assessment were obtained from 429 individuals, between 6 and 9 years of age, with repaired unilateral cleft lip and palate. Velar length, velar thickness, depth of the nasopharynx, depth:length ratio, scores of hypernasality, and scores of nasal air emission were studied and compared; grouping the radiographs according to presence or absence of hypernasality and nasal air emission.Results For the group with speech signs of velopharyngeal dysfunction (those with consistent hypernasality and nasal air emission), the velums were shorter and thinner; the nasopharynx was deeper and the depth:length ratio was larger than the group without hypernasality and nasal air emission. Velar length was significantly shorter in individuals with consistent hypernasality and nasal air emission (p<0.001) and with history of palatal fistula (p=0.032). Depth of nasopharynx was significantly greater in individuals with consistent hypernasality and nasal air emission (p<0.001). Depthlength ratio was significantly larger in individuals with consistent hypernasality and nasal air emission (p<0.001). A depth:length ratio larger than 0.93 was always associated with speech signs of VPD.Conclusion Estimated with cephalometric radiographs, a depth:length ratio greater than 0.93, between the nasopharyngeal space and the velum, was 100% accurate in predicting hypernasality and nasal air emission after primary repair of unilateral cleft lip and palate.

Systematic Review and Meta-Analysis of the Palatal Surgeries in the Treatment of Obstructive Sleep Apnea

Background: This paper aims to examine published articles between January 2008 and January 2019 on the different palatal surgeries performed on OSA patients and the treatment outcomes, which in turn will be used to determine the effectiveness of various palatal surgical techniques in treating OSAS and the most effective of the palatal surgical techniques in treating OSAS. Patients and Methods: The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA). The quality of relevant studies was assessed using NIH quality assessment tool for observational cohort and cross-sectional studies as well as NIH tool for quality assessment for case series studies. Results: Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on AHI (Apnea/Hypopnea Index) was the lateral pharyngoplasty followed by the Anterior Palatoplasty, with a significant mean reduction of [(SMD = −0.848, 95% CI (−1.209 - −0.487), p-value < 0.001) and (SMD = −0.864, 95% CI (−1.234 - −0.494), p-value < 0.001), respectively]. The technique responsible for the best improvement in Epworth Sleepiness Score (ESS) was the Relocation Pharyngoplasty, with a significant mean reduction of [SMD = −0.998, 95% CI (−1.253 - −0.743), p-value < 0.001]. Minimal O2 saturation level improved most with the Expansion Sphincter Pharyngoplasty, with a significant mean reduction of [SMD = 1.011, 95% CI (0.581 - 1.440), p-value < 0.001]. The surgical procedure that results in the best post-operative Visual Analogue Scale (VAS) was Z-Palatoplasty, with a significant mean reduction of [SMD = −1.551, 95% CI (−2.049 - −1.052), p-value < 0.001]. Soft palate length changes with a significant mean reduction of [SMD = −2.219, 95% CI (−2.730 - −1.708), p-value < 0.001]. Finally, meta-analyses of relevant studies showed that expansion sphincter pharyngoplasty achieved the overall highest success rate [event rate = 77%, 95% CI (65.4% - 85.5%), p-value < 0.001]. Conclusion: The best procedure for treating OSA varies from patient to patient and there is no universal cure-all. Careful patient selection and pre-operative evaluation are mandatory.

Velopharyngeal Incompetence in Children With 22q11.2 Deletion Syndrome: Velar and Pharyngeal Dimensions.

The surgical management of velopharyngeal incompetence (VPI) in children with 22q11.2 deletion syndrome (22q11.2 DS) is challenging. There are numerous approaches and children often undergo more than one operation. Our aim was to develop a method using images from routine lateral videofluoroscopy to study the dimensions of the velopharynx in this cohort.We analyzed 22 pre-operative lateral videofluoroscopy recordings of children with 22q11.2 DS and VPI. Fourteen had a submucous cleft palate (SMCP) and 8 had no obvious palatal abnormality but who were subsequently labelled as having an occult submucous cleft palate (OSMCP). The control data were 10 historic records of children with cleft lip and an intact palate. The authors identified key points on radiographs of the velum at rest and when elevated to measure the total velar length, functional velar length and pharyngeal depth and compared them ratiometrically.The intra-observer reliability was > 0.9 whereas the inter-observer reliability was > 0.74. The velopharyngeal depth/total velar length was significantly greater in 22q11.2 DS than the control group P < 0.001. There was no difference between SMCP and OSMCP patients, P = 0.556. There was no difference in the functional velar length/total velar length between 22q11.2 DS and controls (P = 0.763).In this study, the authors demonstrate a reliable method to gain useful ratiometric measurements of the velopharynx. This may help with treatment planning. Children with 22q11.2 DS and VPI have a larger velopharyngeal depth/total velar length ratio that may explain some of the difficulty in management.

An Magnetic Resonance Imaging Case Study: The Anatomic Palate Restoration Concept Utilizing Buccal Flaps in a Primary Palatoplasty

BACKGROUND: Primary palatoplasties using the Anatomic Palate Restoration Concept use the buccinator myomucosal flap (buccal flap) to correct the tissue deficiency within the cleft palate malformation. Buccal flaps are used to replace the missing tensor veli palatini aponeurosis and mucus membrane. The surgical approach aims to close the palate without tension, lengthen the palate, reconstruct the levator muscular sling, not inhibit craniofacial growth and achieve proper oral-nasal resonance for speech.1,2 To the best of our knowledge, this is the first study to use magnetic resonance imaging (MRI) to demonstrate the changes that occur to the velopharyngeal anatomy following the surgical repair. The purpose of this study is to present preliminary data on velopharyngeal variables to demonstrate the muscle and tissue morphology in adults with cleft palate who have not received a secondary surgery for speech or orthognathic surgery. METHODS: MRI was used to analyze velopharyngeal variables for a single participant. The participant was a 19-year-old Caucasian male with a unilateral cleft lip and palate who received primary palatoplasty using the buccal flap approach. MRI data were viewed in Amira 6.5.0 Visualization Modeling software. Velopharyngeal measurements were obtained on the midsagittal image. RESULTS: All variables were compared to previously published normative data of velopharyngeal variables for individuals with noncleft anatomy who are of the same race, sex, and of similar age.3 Velar length and velar thickness were both greater in the individuals with the buccal flap repair, in comparison to the individuals with noncleft anatomy. Levator length and the distance from the PNS to PPW were both shorter in the individual with the buccal flap repair. Visually, the individual with the buccal flap presents with a thicker and longer velum. CONCLUSIONS: This study is the first to demonstrate the velopharyngeal muscle and tissue arrangement following primary palatoplasty using the buccal flap approach. The individual presents with a longer and thicker velum in comparison to age- and sex-matched individuals with noncleft anatomy. This study highlights the utility of using MRI to quantify the changes that occur to the velopharyngeal anatomy following the buccal flap surgical approach. Future studies should assess how these anatomical changes impact speech and compare data to Z-Plasty without the use of the buccal flap repair and to individuals with noncleft anatomy. Our research team is currently investigating this line of research and specifically seeking to improve our understanding of the functional impact of this surgical method on speech. REFERENCES: 1. Mann RJ, Fisher DM. Bilateral buccal flaps with double opposing Z-plasty for wider palatal clefts. Plast Reconstr Surg. 1997;100:1139–1143. 2. Mann RJ, Martin MD, Eichhorn MG, et al. The double-opposing Z-plasty plus or minus buccal flap approach for repair of cleft palate: a review of 505 consecutive cases. Plast Reconstr Surg. 2017;139:735e–744e. 3. Perry JL, Kollara L, Sutton BP, et al. Growth effects on velopharyngeal anatomy from childhood to adulthood. J Speech Lang Hear Res. 2019;62:682–692.

Effective Velopharyngeal Ratio: A More Clinically Relevant Measure of Velopharyngeal Function.

Purpose Velopharyngeal (VP) ratios are commonly used to study normal VP anatomy and normal VP function. An effective VP (EVP) ratio may be a more appropriate indicator of normal parameters for speech. The aims of this study are to examine if the VP ratio is preserved across the age span or if it varies with changes in the VP portal and to analyze if the EVP ratio is more stable across the age span. Method Magnetic resonance imaging was used to analyze VP variables of 270 participants. For statistical analysis, the participants were divided into the following groups based on age: infants, children, adolescents, and adults. Analyses of variance and a Games-Howell post hoc test were used to compare variables between groups. Results There was a statistically significant difference (p < .05) in all measurements between the age groups. Pairwise comparisons reported statistically significant adjacent group differences (p < .05) for velar length, VP ratio, effective velar length, adenoid depth, and pharyngeal depth. No statistically significant differences between adjacent age groups were reported for the EVP ratio. Conclusions Results from this study report the EVP ratio was not statistically significant between adjacent age groups, whereas the VP ratio was statistically significant between adjacent age groups. This study suggests that the EVP ratio is more correlated to VP function than the VP ratio and provides a more stable and consistent ratio of VP function across the age span.

Velar Closing Ratio As a Predictor for the Verlopharyngeal Function After Double Opposing Z-Plasty for Postpalatoplasty Velopharyngeal Insufficiency in Patients With Cleft Palate.

This study was designed to identify the potential predictors of postoperative velopharyngeal function after double opposing Z-plasty (DOZP) for the treatment of velopharyngeal insufficiency (VPI) in patients who had prior palatoplasty for cleft palate. This retrospective study reviewed the medical records of consecutive patients who received DOZP for VPI after receiving a prior palatoplasty treating cleft palate between 2004 and 2017. The speech outcome of patient was measured using the Pittsburgh Weighted Speech Scale (PWSS) at 6 months following surgery and determined the outcome suggests velopharyngeal competence (PWSS ≤2) or incompetence (PWSS >2). Stepwise logistic regression was used to identify the variables for the prediction of competent surgical outcome. The specific receiver operating characteristic curves with an area under the curve (AUC) was used to evaluate the predictor related to the surgical outcome as competence. The study included 93 patients. Age, relative velar length, velar lengthening, and closure pattern were not significantly associated with postoperative competence status of the patient. The only variable that predicted a successful surgical outcome was preoperative velar closing ratio. However, the accuracy of velar closing ratio in predicting a competent surgical outcome is only moderate (AUC = 70.37). The results of this study showed that preoperative velar closing ratio may predict, with moderate accuracy, a successful surgical outcome in patients with postpalatoplasty VPI who undergo DOZP. Therefore, in patients with a low preoperative velar closing ratio, some alternative surgical methods other than DOZP may be considered to avoid unsatisfactory surgical outcome.

Clinical value of upper airway MSCT measurement in adult male patients with moderate to severe OSA

Objective:To investigate the pathogenesis of OSA-related through 128-slice spiral CT measurements of adult male patients with moderate to severe OSA at different respiratory phases, and to optimize treatment options for patients with OSA. Method:128-slice spiral CT was used to scan the upper airway in 52 adult male patients with moderate to severe OSA and 20 normal controls under two different breathing states: calm breathing and Müller maneuver. The plane diameter and length of each area of the upper airway were measured. Area size, soft palate length, thickness, airway volume, airway length, total thickness of the pharyngeal wall, and calculate the compliance of the pharyngeal cavity, including the compliance of the pharyngeal wall, the compliance of the anterior and posterior pharyngeal wall, and the total pharyngeal compliance. Comparison of measurement results and correlation analysis with related parameters.Result: In the OSA group, the length and area of the smallest plane of each airway area（except the posterior epiglottic area） during calm breathing are greater than Müller's movement, and the difference was statistically significant（P<0.05）. The soft palate length and thickness of the OSA group during calm breathing were significantly larger than those of the normal group, and the difference was statistically significant（P<0.01）, In the OSA group, the total thickness of the soft palate region and the posterior lingual area of the pharyngeal wall in the Müller group was significantly greater than the calm breathing state, and the difference was statistically significant（P<0.01）. The volume of the nasopharynx, posterior epiglottic area and airway length in the OSA group during calm breathing were significantly larger than those in the normal group, and the difference was statistically significant（P<0.01）. The compliance of the pharyngeal cavity in the OSA group was greater than that in the normal group, and the difference was statistically significant（P<0.05）. In the OSA group, the volume of the posterior soft palate, posterior tongue, and total airway volume during Müller movement were significantly smaller than those of calm breathing, and the differences were statistically significant（P<0.01）. In the OSA group, the compliance of the pharyngeal wall in the posterior region of the soft palate was greater than the compliance of the anterior and posterior wall of the pharynx, while the compliance of the posterior region of the pharynx in the posterior region of the pharynx was greater than the compliance of the pharynx. There was a significant positive correlation between BMI and AHI in OSA patients（P<0.05）, which was statistically significant. Conclusion:Through MSCT measurement of the upper airways of adult male patients with moderate to severe OSA, the morphological structure and compliance of the upper airways can be observed intuitively, and the degree and location of upper airway stenosis can be accurately assessed, and the measurement indicators and related parameters can be combined. The correlation can optimize the clinical treatment options for adult male patients with OSA.