Surgery For Velopharyngeal Insufficiency Research Articles

Obstructive Sleep Apnea After Dynamic Sphincter Pharyngoplasty

In patients who require additional surgery for velopharyngeal insufficiency (VPI), a higher incidence of obstructive sleep apnea (OSA) may be incurred. Although this phenomenon has been demonstrated with the posterior pharyngeal flap, the effect of dynamic sphincter pharyngoplasty (DSP) on OSA is less clear. The purposes of this case series were to (1) determine the incidence of OSA after DSP, (2) assess the changes in polysomnography after DSP, and (3) identify risk factors for the development of OSA after DSP. Our global hypothesis is that OSA and VPI exist on a continuum and that speech outcomes should not be considered in isolation. For a 13-year period, 146 patients with idiopathic VPI, submucous cleft palate, cleft palate only, or cleft lip and palate underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy by a pediatric sleep medicine physician. The incidence of OSA preoperatively and postoperatively was compared using Fisher exact test. When available, preoperative and postoperative apnea-hypopnea indices (AHIs) were compared using the pairwise, 2-tailed, Student's t-test. Patient factors, such as obesity (body mass index ≥ 95th percentile), the presence of a craniofacial syndrome, surgical history, and a preexisting OSA diagnosis, were noted. A multiple logistic regression was performed to elucidate risk factors for the development of OSA. The average age at surgery was 9.2 years (range, 4-40 y), and the mean follow-up time was 4.5 years (range, 1 mo to 12 y). The incidence of OSA increased after DSP, from 2 to 33 patients (1.4%-22%, respectively; P = 0.05). In 23 patients (16%), both preoperative and postoperative AHIs were available. There was a significant increase in AHI after DSP, from 3.1 to 8.4 episodes per hour of sleep (P = 0.001). Previous tonsillectomy/adenoidectomy was predictive of OSA after DSP (relative risk = 2.4; P = 0.04). We report an increased incidence of OSA and higher-than-average AHIs postoperatively after DSP. Preoperative tonsillectomy/adenoidectomy predicted the development of OSA after DSP. A high index of suspicion for development of OSA must be maintained in patients who undergo secondary speech operations for VPI. Clinical screening for OSA should be used in this population, with a low threshold for polysomnographic evaluation. The surgeon must be wary that improvements in speech after DSP may change airway dynamics and increase the risk of OSA.

Recent Advances in Surgical Pharyngeal Modification Procedures for the Treatment of Velopharyngeal Insufficiency in Patients With Cleft Palate

Background To review recent advances in pharyngeal modification procedures for the treatment of velopharyngeal insufficiency (VPI) in patients with cleft palate after primary repair. In addition, we discuss some of the advantages and disadvantages of the various pharyngoplasty techniques, as well as their safety and efficacy. Methods A review of frequently used pharyngeal modification techniques in correction of VPI was performed, and their advantages and disadvantages are outlined. Several techniques in pharyngoplasty most recently described in the literature are compared and contrasted. Results The goal of surgical pharyngeal modification procedures is to correct the abnormal failure of velopharyngeal closure. Multiple techniques used in VPI surgery have proven to be effective. They have similar adverse effect profiles, but what distinguishes them is likely their effectiveness in cases of severe VPI. Conclusions Velopharyngeal insufficiency is a problematic issue both for the patient and the treating surgeon. The negative effect of VPI on patients' quality of life has long been known, and over the years numerous techniques have been described to correct or improve this problem. Pharyngoplasty and pharyngeal flap or combination procedures are most effective in cases of severe VPI.

Velopharyngeal Insufficiency Repair Outcomes in Patients with Velocardiofacial Syndrome

Objective: Analyze outcomes of operations for velopharyngeal insufficiency (VPI) in patients with velocardiofacial syndrome (VCFS). We hypothesize that patients with more severe phenotypic features of VCFS have greater VPI and are more likely to require revision VPI surgery. Method: Retrospective chart review. Demographic data, VCFS characteristics, anatomical variations, perceptual speech investigation, nasal endoscopy, acoustic nasometry, and operative intervention data were collected for each patient with VCFS and VPI at Vanderbilt University Medical Center. Sixteen patients with VCFS were reviewed. Results: Average age was 7.38 years, with 8 female patients. Surgery was necessary in 12 of 16 patients (75%). Eight patients (50%) underwent pharyngeal flap, 2 patients (12.5%) underwent Furlow palatoplasty, and 2 patients (12.5%) underwent sphincter pharyngoplasty. Six patients had heart anomalies (37.5%). Eight patients (50%) had hearing loss (average loss of 31 dB), and 3 patients had significant hypocalcemia (18.8%). Two patients had submucous clefts (12.5%), while 1 patient had cleft palate (6.3%). Two patients (12.5%) required revision operations. Both patients requiring revision had Tetralogy of Fallot, mild/moderate conductive hearing loss, and moderate to severe hypernasality preoperatively. Conclusion: VPI is common in VCFS, and most patients require surgical intervention. VCFS patients presenting with a more severe phenotype as exhibited by increasing severity of heart disease, hearing loss, and hypernasality are more likely to require revision surgery to correct VPI.

The occurrence of velopharyngeal insufficiency in Pierre Robin Sequence patients

ObjectiveChildren born with Pierre-Robin Sequence (PRS) have cleft palate, micrognathia, and macroglossia. After the repair of the cleft palate, velopharyngeal insufficiency (VPI) can occur in a subset of patients. We hypothesize that the need for the surgical correction of VPI in PRS children is no different than cleft palate only (CPO) patients. MethodsA retrospective study of 21 children with non-syndromic PRS who were matched to 42 non-syndromic, CPO controls for age and sex. We reviewed incidence of VPI, the need for secondary speech surgery, and speech outcomes post-operatively. ResultsSecondary surgery to correct VPI was necessary in 3 of 21 (14.29%) PRS patients (2 Pharyngeal Flaps, 1 Z-plasty), vs. 10 of 42 (23.81%) CPO (9 Pharyngeal Flaps, 1 Z-plasty) controls. Mean age for VPI surgery for PRS vs. controls: 5.33 vs. 6.41 years, respectively. For final speech outcomes, 73.68% of PRS vs. 71.88% of controls showed no evidence of hypernasality, 89.47% of PRS patients vs. 93.75% of controls showed no evidence of hyponasality, and 76.47% of PRS patients vs. 78.13% of controls had normal velopharyngeal competence (p>0.90 for all three measures). ConclusionOur findings suggest that children born with a Pierre-Robin Sequence do not have a higher rate of post-operative VPI after cleft palate repair and are no more likely to require additional surgical intervention.

Palatoplasty as the Technique of Choice for Prevention of Obstructive Sleep Apnea Secondary to Surgery for Velopharyngeal Insufficiency

The aim of this study is to compare patients treated with pharyngoplasty and those treated with palatoplasty for velopharyngeal insufficiency to establish what surgical procedure poses the highest risk for developing sleep apnea. The hypothesis tested in this study is that the incidence of obstructive sleep apnea syndrome associated with pharyngoplasty is greater than that associated with palatoplasty for velopharyngeal insufficiency. Twenty patients were taken from the Institution FISULAB. Observational cohort analytic study. An overnight polysomnographic study was used to determine the incidence and severity of obstructive sleep apnea syndrome. The incidence of obstructive sleep apnea syndrome following pharyngoplasty was shown to be significantly higher than after palatoplasty. The apnea-hypopnea index, also called the respiratory disturbance index, was 12.7 in the pharyngoplasty group and 1.35 in the palatoplasty group (p < .001). When obstructive sleep apnea syndrome was stratified into different levels of severity according to the values of respiratory disturbance index, there were noticeable differences between these two groups. In the palatoplasty group, one patient had mild obstructive sleep apnea syndrome. In the pharyngoplasty group, two patients had mild obstructive sleep apnea syndrome, one patient had moderate obstructive sleep apnea syndrome, and two patients had severe obstructive sleep apnea syndrome. When comparing the apnea-hypopnea index (i.e., respiratory disturbance index) of patients treated for velopharyngeal insufficiency with palatoplasty versus pharyngoplasty, we observed an important difference between the groups, with the highest indices in the pharyngoplasty group.

Cervical vascular and upper airway asymmetry in velo-cardio-facial syndrome: Correlation of nasopharyngoscopy with MRA

Purpose Velo-cardio-facial syndrome (VCFS), the most common genetic syndrome causing cleft palate, is associated with internal carotid and vertebral artery anomalies, as well as upper airway asymmetry. Medially displaced internal carotid arteries, often immediately submucosal, present a risk of vascular injury during pharyngeal flap surgery for velopharyngeal insufficiency (VPI). We evaluate the frequency and spectrum of cervical vascular anomalies in a large cohort of VCFS patients correlating MRA with nasopharyngolaryngoscopy in detecting at risk carotid arteries. Furthermore, we assess the relationship with respect to laterality between cervical vascular patterns and the asymmetric abnormalities of these subjects’ upper airways. Methods Cervical MRAs of 86 subjects with VCFS and 50 control subjects were independently reviewed by three neuroradiologists. The course of the internal carotid and vertebral arteries was identified within the pharyngeal soft tissues. Medial deviation, level of bifurcation, dominance, anomalous origin, and vessel tortuosity were recorded. Nasopharyngoscopy examinations were available for retrospective review in 43 patients and were assessed for palatal and posterior pharyngeal wall symmetry, true vocal cord motion and size, and for the presence or absence of carotid pulsations. The endoscopic findings were compared with MRA results. Results Of the 86 subjects, 80 (93%) had one or more vascular anomalies. 42 subjects (49%) were found to have medial deviation of at least one internal carotid artery. In 24 subjects (28%) the anomalous internal carotid artery was directly submucosal; four of these were bilateral (5% of the total sample, 17% of those with a submucosal internal carotid). Other carotid anomalies included low carotid bifurcation (44 subjects or 51%), anomalous origin of the right common carotid (32 cases, or 37%), and two cases of internal carotid agenesis/hypoplasia. Vertebral artery anomalies included vessel tortuosity (34 cases, or 40%), hypoplasia (10 cases, or 12%), looping (4 cases, or 5%), and one case of a double left vertebral artery. Though patients in our study showed an asymmetric distribution of vascular anomalies, no association was found between the laterality of palatal motion, pharyngeal fullness, or laryngeal movement and structure with ipsilateral vertebral or carotid artery anomalies. Of the 33 pulsatile carotid arteries visualized at nasopharyngoscopy, only nine were found to be submucosal on MRA. In contrast, 11 submucosal carotid arteries confirmed at MRA demonstrated no visible pulsations. Positive and negative predictive values of pulsative arteries seen endoscopically for MRA confirmation of a submucosal carotid course was 27% and 79% respectively. Conclusions Carotid and vertebral artery anomalies are common in VCFS including marked medial deviation of the internal carotid artery in close proximity to the donor site for pharyngeal flap surgery. Lack of correlation between laterality of vascular anomalies and upper airway structural asymmetry in VCFS does not support the hypothesis that palatal, pharyngeal, and laryngeal anomalies are due to secondary developmental sequences caused by in utero vascular insufficiency. The presence or absence of carotid pulsations seen by nasopharyngoscopy does not correlate with the carotid arterial depth identified on MRA. Furthermore, identification of the relative medial–lateral retropharyngeal position of a submucosal carotid affords the opportunity to modify the surgical approach. These findings further support the routine use of pre-operative neck MRA in VCFS patients in surgical planning.

Comparison of Pharyngeal Flap and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency-A Retrospective Study

Purpose: Velopharyngeal insufficiency (VPI) is incomplete closure of the velopharyngeal space causing hypernasal resonance during phonation. Both pharyngeal flap (PF) and sphincter pharyngoplasty (SP) had been used for the correction of VPI in the Craniofacial Center, Chang Gung Memorial Hospital. The purpose of this study is to compare the effectiveness and complication between the PF and SP. Material and Method: Eighty-seven patients underwent pharyngeal flap or sphincter pharyngoplasty for VPI between June of 1995 and August of 2001. Seventy-one patients of them who had complete preoperative and follow-up evaluations were included. The follow-up period ended at October of 2006. All operations were done by one surgeon. Standard speech evaluation was performed. Results: Overall speech outcome and success rate was 68%. No significant difference on the speech outcome was found between the PF group and SP groups (chi-square test, p=0.419). Overall nasal airway obstruction rate was 14%. However, a significant difference on airway obstruction was noted between the PF group and SP group (chi-square test, p=0.015). Lower incidence of airway obstruction occurred in PF group. A concomitant finding revealed that a better speech result was achieved in patients who received the VPI surgery at an age younger than 6 years. Conclusion: This study showed that, in the authors' center, the PF is a better choice than SP for the correction of VPI.

Incidence of Oronasal Fistulae and Velopharyngeal Insufficiency after Cleft Palate Repair: An Audit of 211 Children Born between 1990 and 2004

We present an audit of primary cleft palate surgery at our unit, including rates of oronasal fistula development, speech outcomes, and rates of velopharyngeal insufficiency requiring secondary surgery. A retrospective study of patients with all cleft palate types, born between January 1990 and December 2004, who underwent primary palatoplasty at Middlemore Hospital, Auckland, New Zealand. The study included 211 patients, collectively operated on by five different surgeons. The overall rate of true fistula development was 12.8% over a mean follow-up period of 4 years 10 months. The incidence of true fistulae that required surgical repair was 8.1%. Fistula rates were higher for more severe degrees of clefting but were not affected by gender or type of surgical repair. Overall, 31.8% of the study population had some degree of hypernasality following primary palatoplasty. Secondary surgery for velopharyngeal insufficiency was required in 13.3% of patients. Following surgical correction of velopharyngeal insufficiency, no patients were reported to have appreciable hypernasality and 21.7% were reported to have mild hypernasality, a result comparable to previously published audits. The requirement for secondary surgery was higher in patients with more severe clefts. Our results are comparable to other recent studies. We believe that highly coordinated cleft care helps ensure such outcomes. These data provide a benchmark against which we can measure future performance in our attempts to improve outcomes of cleft repair.

Early Long Term Speech Results on Two-Flap Palatoplasty

The Two-flap palatoplasty has been used in Chang Gung Craniofacial Center since 1988. The purpose of this study is to evaluate the early long-term surgical and speech result of this surgical technique. A retrospective review was performed on 140 complete cleft lip and palate patients who had their palate repaired around 1 year old and between Jan 1993 to Dec 1994. The incidence of secondary surgery for velopharyngeal insufficiency and their articulation were used for comparison. All of these patients were more than 7 years old at the time of evaluation. The incidence of oronasal fistula is quite low (4%). The Two-flap palatoplasty demonstrated fairly good results in the incidence for secondary surgery (12% of UCLP and 16% of BCLP) and articulation errors (35% of UCLP and 52% of BCLP). The Two-flap palatoplasty showed a fairly good early long-term result. However, it needs further observation for several years before we can make the final conclusion.

Does Velopharyngeal Closure Pattern Affect the Success of Pharyngeal Flap Pharyngoplasty?

Historically at The Hospital for Sick Children in Toronto, pharyngeal flap pharyngoplasty has been the treatment of choice for treatment of velopharyngeal insufficiency, regardless of velopharyngeal closure pattern. The authors hypothesize that pharyngeal flap pharyngoplasty is more effective in treating velopharyngeal insufficiency in patients with circular or sagittal velopharyngeal closure and less effective in treating the coronal closure pattern. Ninety-three patients who underwent superiorly based pharyngeal flap surgery for velopharyngeal insufficiency were evaluated in a retrospective chart review. Closure pattern was determined preoperatively by nasopharyngoscopy or multiview videofluoroscopy. Nasalance was assessed preoperatively and at 6 weeks and 1 year postoperatively. Nasalance during nonnasal speech was decreased on average, for all closure patterns, postoperatively. However, a significantly higher percentage of patients were corrected to normal nasalance scores in thenoncoronal group than in the coronal group (57 percent versus 35 percent, respectively) at 1 year postoperatively (p < 0.05). Surgical overcorrection, as determined by postoperative hyponasality, occurred at a rate of 13 percent in the coronal group versus 7 percent in the noncoronal group (not statistically significant). The results demonstrate that hypernasality in patients with a coronal velopharyngeal closure pattern can be improved by pharyngeal flap pharyngoplasty. This procedure, however, is more frequently effective in correcting noncoronal closure pattern velopharyngeal insufficiency than coronal pattern velopharyngeal insufficiency. The authors are now more selective in their approach to the management of velopharyngeal insufficiency and are more inclined to treat coronal pattern velopharyngeal insufficiency with sphincter pharyngoplasty.

Assessing the outcome of surgery to correct velopharyngeal insufficiency with the pediatric voice outcomes survey

To assess the functional outcome of surgery for velopharyngeal insufficiency (VPI) by administering the pediatric voice outcomes survey (PVOS) to the parents of the affected children. Prospective longitudinal study. Tertiary referral pediatric otolaryngology office. Twelve children who underwent surgery to correct VPI during the 12-month-period between 1 January 2002 and 31 December 2002. Parents of the 12 children were administered the PVOS prior to surgery and again 6 weeks post-operatively. The PVOS is a validated instrument designed to measure voice-related quality of life (V-RQOL). The score has been transformed to range from 0 (low V-RQOL) to 100 (high V-RQOL). The mean age of the children was 5 years (standard deviation [S.D.], 2.3 years). Seven children underwent sphincteroplasty and five had a superior based pharyngeal flap as a primary procedure. Three children required secondary procedures to correct their underlying VPI and one of those had a third procedure consisting of a posterior wall fat injection. The mean pre-operative PVOS score was 38.3 (S.D., 12) and the mean 6 weeks post-operative score was 72.3 (S.D., 22.7) (paired t-test; P < 0.001). The PVOS represents a valid clinical tool to measure the functional impact of surgery to correct pediatric velopharyngeal insufficiency.

From birth to maturity: a group of patients who have completed their protocol management. Part I. Unilateral cleft lip and palate.

The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Because of the large volume of data and potential differences in outcomes, the authors' intention is to present this as part I of a four-part series beginning with unilateral cleft lip and palate. The results of isolated cleft palate, isolated cleft lip, and bilateral cleft lip and palate will be presented as parts II, III, and IV, respectively. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples are provided.

Short-term and long-term results of speech improvement after surgery for velopharyngeal insufficiency with pharyngeal flaps in patients younger and older than 6 years old: 10-year experience.

Velopharyngeal insufficiency (VPI) is a well-known cause for hypernasality. To overcome this problem, the authors use a static surgical technique: a cranially or caudally based flap. In 93 patients, the results of this technique on speech (hypernasality, nasal air escape, articulation) and velopharyngeal function were evaluated over a period of at least 1 year. In 53 patients, pharyngoplasty flaps were based caudally. In 40 patients, pharyngoplasty flaps were based cranially. The patients were age 2.5 to 24.5 years, with a mean of 5.5 years (SD: 4 years and 2 months). Improvement was found in almost all patients. The patients who underwent surgery when they were younger than age 6 significantly improved better then the patients who were treated when they were older than age 6. There were no differences in outcome between cranially based and caudally based flaps. There were also no differences between patients with plain VPI and patients with VPI (e.g., Pierre Robin sequence and Shprintzen).

Perioperative complications of superior pharyngeal flap surgery in children.

A 7-year retrospective review of perioperative complications associated with surgical correction of velopharyngeal insufficiency was carried out. A total of 219 children who underwent surgery for velopharyngeal insufficiency between the years 1985 and 1992 were reviewed. Gender distribution was 58 percent male and 42 percent female. The mean age was 9.6 years, with a range of 4 to 22 years, at the time of surgery. Fourteen cases (6.4 percent) were considered a difficult intubation. There were 36 patients with early complications (16.4 percent incidence). Of these, 18 had postoperative bleeding and 20 developed airway obstruction. Most of these episodes occurred in the first 24 hours. Three patients required reintubation. Nine children developed sleep apnea after discharge. Four patients required take-down of the pharyngoplasty, while 7 others had revision of the flap. There was 1 death in the 219 patients. In summary, most complications following surgical correction of velopharyngeal insufficiency in our institution occur in the early postoperative period and are the result of bleeding and/or airway obstruction.

Obstructive Sleep Apnea Secondary to Surgery for Velopharyngeal Insufficiency

The files of 585 patients who had had pharyngeal flap surgery for the correction of velopharyngeal insufficiency were reviewed. Eighteen patients, ranging in age from 6 to 16 years, showed clinical symptoms of obstructive sleep apnea syndrome. All of these cases had a polysomnographic evaluation and videonasopharyngoscopy. Fifteen cases met the criteria for the diagnosis of obstructive sleep apnea syndrome and eventually underwent surgical treatment. A modified uvulopalatopharyngoplasty was done in 14 of the 15 cases. One patient had a prominent uvula flipping into the port of a Jackson's type pharyngoplasty, so a partial resection of the uvula was performed. Surgical treatment was successful in 14 of 15 cases, including the case with the partial uvular resection. In one case, severe sleep apnea persisted after surgery and a complete section of the flap was performed to correct the obstruction. Sizeable tonsils were found in 13 out of 15 cases, whereas flap width appeared unrelated to obstruction. Preoperative assessment of tonsillar tissue is of vital importance before pharyngeal flap surgery.

Obstructive sleep apnea secondary to surgery for velopharyngeal insufficiency.

The files of 585 patients who had had pharyngeal flap surgery for the correction of velopharyngeal insufficiency were reviewed. Eighteen patients, ranging in age from 6 to 16 years, showed clinical symptoms of obstructive sleep apnea syndrome. All of these cases had a polysomnographic evaluation and videonasopharyngoscopy. Fifteen cases met the criteria for the diagnosis of obstructive sleep apnea syndrome and eventually underwent surgical treatment. A modified uvulopalatopharyngoplasty was done in 14 of the 15 cases. One patient had a prominent uvula flipping into the port of a Jackson's type pharyngoplasty, so a partial resection of the uvula was performed. Surgical treatment was successful in 14 of 15 cases, including the case with the partial uvular resection. In one case, severe sleep apnea persisted after surgery and a complete section of the flap was performed to correct the obstruction. Sizeable tonsils were found in 13 out of 15 cases, whereas flap width appeared unrelated to obstruction. Preoperative assessment of tonsillar tissue is of vital importance before pharyngeal flap surgery.

Change in velopharyngeal valving after speech therapy in cleft palate patients. A videonasopharyngoscopic and multi-view videofluoroscopic study

Thirty-one cleft palate patients with velopharyngeal insufficiency and compensatory articulation in association with hypernasality after palate closure were studied. Videonasopharyngoscopy and multi-view videofluoroscopy were performed to all patients before and after speech therapy for correcting compensatory articulation. The ratios of movement of velopharyngeal structures were significantly increased after compensatory articulation had been corrected. Furthermore, the size of the gap at the velopharyngeal sphincter during closure was significantly reduced. The results in this study support the statement that articulation disorders in association with hypernasality in cleft palate patients should be corrected prior to the implementation of surgery for velopharyngeal insufficiency after palate closure.