Treatment Of Velopharyngeal Insufficiency Research Articles

Treatment of Velopharyngeal Insufficiency by Fat Injection

Free accessAbstractFirst published online August 2010Treatment of Velopharyngeal Insufficiency by Fat InjectionGiovanna Cantarella, MD, presenter, Lorenzo Pignataro, MD, […], Giovanna Baracca, MD, Mario Mantovani, MD, and Riccardo Mazzola, MD+2-2View all authors and affiliationsVolume 143, Issue 2_supplhttps://doi.org/10.1016/j.otohns.2010.06.410

Posterior Pharyngeal Augmentation in the Treatment of Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) remains a common problem in the care of patients with cleft palate and other related conditions. It may be successfully corrected with augmentation of the posterior pharynx. The purpose of this study was to review the experience and results of posterior pharyngeal augmentation over a 40-year period at one cleft center in the United States. All patients from 1968 to 2008 who underwent posterior pharyngeal augmentation for the treatment of VPI were reviewed retrospectively. Diagnosis, age at the time of operation, type of implant used, duration of follow-up, speech performance both pre- and postoperatively, and complications were analyzed. Speech performance preoperatively was assessed by video fluoroscopy and/or nasoendoscopy. Resonance was assessed by both the surgeon and speech pathologist using a 4 point grading scale. One hundred eleven patients underwent posterior pharyngeal augmentation. Thirteen patients required removal of the implant because of extrusion (n = 12) or postoperative sleep apnea (n = 1). Five patients with failed implants at the primary operation had successful replacement at a second operation, resulting in a retained implant success rate of 93%. Of the 103 patients who were successfully augmented, 15 were lost to follow-up, leaving 88 patients with full postoperative speech evaluations. Of the 88 patients evaluated, 64 exhibited normal or near normal speech (73%), 22 patients had mildly nasal speech (25%), and 2 patients (2%) were not improved. Highest extrusion rates were seen for smooth surface silicone and rolled gortex implants. Augmentation of the posterior pharyngeal wall is a safe and effective treatment for patients with VPI. Implants are well tolerated and speech is substantially improved.

Treatment of velopharyngeal insufficiency by autologous fat injection

Velopharyngeal insufficiency (VPI) is a structural or functional trouble, which causes hypernasal speech. Velopharyngeal flaps, speech therapy and augmentation pharyngoplasty, using different implants, have all been used to address this trouble. We hereby present our results following rhinopharyngeal autologous fat injection in 18 patients with mild velopharyngeal insufficiency (12 soft palate clefts, 4 functional VPI, 2 myopathy). 28 injections were carried out between 2004 and 2007. The degree of hypernasal speech was evaluated pre- and postoperatively by a speech therapist and an ENT specialist and quantified by an acoustic nasometry (Kay Elemetrics). All patients were exhaustively treated with preoperative speech therapy (average, 8 years). The mean value of the nasalance score was 37% preoperatively and 23% postoperatively (p = 0.015). The hypernasality was reduced postoperatively in all patients (1-3 degrees of the Borel-Maisonny score). There were no major complications, two minor complications (one hematoma, one cervical pain). The autologous fat injection is a simple, safe, minimally invasive procedure. It proves to be efficient in cases of mild velopharyngeal insufficiency or after a suboptimal velopharyngoplasty.

Surgical planning for restoring velopharyngeal function in velocardiofacial syndrome

Background Velocardiofacial syndrome (VCFS) is one of the most common multiple anomaly syndromes in humans. Around 70% of the cases show velopharyngeal insufficiency (VPI), as a consequence of cleft palate. VPI is much more frequent due to special abnormal conditions inherent to VCFS including: platybasia, hypotrophy of adenoid, enlarged tonsils, hypotonia and abnormal pharyngeal muscles. Objective To evaluate the surgical treatment of VPI in VCFS patients. Materials and methods In the Hospital Gea Gonzalez at Mexico City, all cases of VCFS from January 2000 to July December 2007 were studied. All patients subjected to velopharyngeal surgery for correcting VPI were selected. Twenty-nine patients underwent velopharyngeal surgery. All operations were planned according to findings of videonasopharyngoscopy (VNP) and multiview video fluoroscopy (MVF). Results Twenty patients underwent pharyngeal flap operations, and 9 patients were operated on with a sphincter pharyngoplasty. After a pharyngeal flap, 17 cases (85%) improved to normal nasal resonance or mild hypernasality. Three flaps showed moderate hypernasality postoperatively. From the 9 sphincter pharyngoplasties, 6 cases (66%) improved to moderate hypernasality. Four patients (33%) persisted with severe hypernasality postoperatively. There were no complications. Conclusions Tailor-made pharyngeal flaps seem to be the best option for restoring velopharyngeal function in cases of VPI in VCFS patients. The use of VNP and MVF is useful for planning the operations for VPI, and they are also useful for indicating the removal of tonsils in cases with high risk of obstruction. Moreover, VNP is also useful for preventing damage to the internal carotids which are usually displaced in VCFS patients.

Velopharyngeal insufficiency: diagnosis and management

Journal articles relevant to the diagnosis and treatment of velopharyngeal insufficiency were reviewed. All studies ascertained by PubMed search were included. Studies reported on the application of magnetic resonance scanning, reliability tests of the International Working Group diagnostic protocol, the use of nasometry, and techniques designed to assess the function of the velopharyngeal mechanism. Treatment studies focused on outcomes in small samples of cases and complication rates from pharyngeal flap. One study discussed ineffective speech therapy procedures. There were relatively few studies this past year. Those that were published were hindered by small and heterogeneous sample sizes and occasionally by inappropriate methods for assessing outcomes. None of the findings will have a major impact on the current state-of-the-art for diagnosis of velopharyngeal insufficiency. The speech therapy study has a very important message that should be taken to heart by all clinicians involved in the management of children with clefts and craniofacial disorders.

Velopharyngeal insufficiency: current concepts in diagnosis and management

To discuss principles of evaluation and treatment of children with velopharyngeal insufficiency, and to review recent reports of surgical outcomes. Velopharyngeal insufficiency significantly impacts both quality-of-life and speech intelligibility in children. Diagnosis is made through history and physical, perceptual speech assessment, and instrumental measures including nasendoscopy and radiographic multiplanar videofluoroscopy. Treatment options for velopharyngeal insufficiency consist of prosthetic management or surgery, supplemented with speech therapy when appropriate. Surgical interventions are palatal, palatopharyngeal or pharyngeal in nature. Despite some controversy, most recent reports identify no significant difference in outcomes following pharyngeal flap or sphincter pharyngoplasty. Complications of surgical therapy relate to postoperative obstructive breathing or persistent velopharyngeal insufficiency. Although there is no universally accepted measure to assess velopharyngeal insufficiency severity, nasendoscopy and multiplanar videofluoroscopy are most commonly used for clinical diagnosis. A speech pathologist is an integral member of the velopharyngeal insufficiency team, and momentum toward a standardized reporting system of perceptual speech measurements is increasing. Treatment of velopharyngeal insufficiency should be tailored to the specific needs of the child and family. Surgical therapy may improve velopharyngeal function but may negatively impact upper airway patency and respiration during sleep. The otolaryngologist should be familiar with strengths and limitations of different surgical options for velopharyngeal insufficiency.

The management of velopharyngeal insufficiency with Furlow double-opposing Z-plasty procedure

The aim of the study was an evaluation of Furlow’s method in correction of velopharyngeal insufficiency. A prospective study was conducted by a speech pathologist and a plastic surgeon. Rating of hypernasality and speech intelligibility were completed prior to and after surgical intervention. Nasometric measurements were also performed before and after surgical intervention. From May 2003 through September 2006, the first author performed 44 Furlow surgeries for the treatment of velopharyngeal insufficiency in patients with cleft palate. Patients with short, repaired cleft palates but with preserved normal function of pharyngeal sphincter qualified for the operation. The surgery was performed using double-opposing Z-plasty. The method was used in 24 males and 20 females aged from 6 to 25 years (mean age, 12 years). One patient (2%) developed wound dehiscence, and two further patients (4.5%) developed maceration of the wound margins, which delayed the healing process by only several days. Very good, good, or moderate results were obtained in 41 patients (91%). Poor outcome of treatment—excessive hypernasality or poor speech quality after the operation—was still present in four patients (9%). In our opinion, Furlow’s method is a very useful treatment method in patients with velopharyngeal insufficiency especially with sagittal orientation of levator veli palatini muscles.

Evaluation of Dynamic Magnetic Resonance Imaging in Assessing Velopharyngeal Insufficiency During Phonation

Velopharyngeal insufficiency (VPI) expresses the structural and neuromuscular disorder of soft palate and pharyngeal walls inhibiting the normal functions of velopharyngeal (VP) sphincter mechanism. In this study, efficacy of dynamic magnetic resonance imaging in the diagnosis of VPI is investigated. A total of 32 cases, 16 controls and 16 cleft palates, were included in this study. T1 fast spin echo-weighted imaging during rest, dynamic investigations with True-fast imaging with steady-state precession sequence during /sss/ and /mmm/ phonations were performed. During /sss/ phonation, complete closure was observed in the control group, whereas mean VP opening was 4.11 cm2 preoperatively and 0.21 cm2 postoperatively in the cleft palate group. In the postoperative period, only 3 patients did not have complete closure. In the second operations, performed 6 months later, only muscle repair was done. All 3 had complete closure. In cleft palate cases with delayed diagnosis, appropriate application of muscle repair will be sufficient for anatomic repair of VPI without any extra procedures. In addition, dynamic magnetic resonance imaging is an objective, noninvasive, reliable, and effective modality that may be used in the diagnosis and treatment of VPI without any extra investigations.

Palatopharyngeal sling: A new technique in treatment of velopharyngeal insufficiency

(a) Pharyngeal flap and sphincter pharyngoplasty are the procedures most frequently chosen by craniofacial surgeons for surgical management of velopharyngeal insufficiency. Both operations may be complicated by obstructive breathing and even sleep apnea. (b) The purpose of this study is to evaluate the efficacy of a palatopharyngeal sling in the treatment of velopharyngeal insufficiency in cases with weak palatal mobility and its effect on breathing. Seventeen cases of post-palatoplasty velopharyngeal insufficiency were subjected to treatment by palatopharyngeal sling. This sling, created by elevation of bilateral myomucosal flaps formed of palatopharyngeus and superior constrictor muscles, passed through palatal split, sutured together and to a raw area on the oral surface of the soft palate. Pre- and post-operative evaluation was carried out by perceptual speech analysis and flexible nasopharyngoscopy. Polysomnography was used to assess the effect of the operation on breathing. Complete closure was achieved in 13 cases (76.5%) while 4 cases showed incomplete closure (2 of them showed improvement when compared with the pre-operative video). The overall improvement of speech and velopharyngeal closure was 88.2%. Polysomnography showed no obstructive breathing. Palatopharyngeal sling is a useful technique for correction of velopharyngeal insufficiency in cases with little palatal motion and it carries no risk of obstructive sleep apnea.

Diagnosis and Treatment of Velopharyngeal Insufficiency

The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure. A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure. All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04). Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.

Outcomes for Children with Submucous Cleft Palate and Velopharyngeal Insufficiency

To review the outcomes of children with submucous cleft palate who also have velopharyngeal insufficiency (VPI). A retrospective chart review was carried out at a tertiary care academic centre of all patients who had VPI with a submucous cleft palate. The University of Iowa Cleft Palate registry parameters encompassing nasality (hyper- and hyponasality) were compared pre- and postoperatively. Preliminary results demonstrate a significant, stable improvement in children who underwent palatal surgery for VPI. Positive outcomes in the treatment of VPI in the submucous cleft palate population were demonstrated with a combined approach of speech therapy and palatal surgery.

Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience.

This retrospective study spans the years 1988 to 2000 and looks specifically at the treatment procedures and outcomes for the correction of velopharyngeal insufficiency (VPI). Ninety-eight patients underwent preoperative assessment by speech pathologists that included perceptual speech evaluation, videofluoroscopy, and, for some, nasendoscopy. Based on this evaluation protocol, a specific surgical procedure was chosen to serve the patients' needs. The four procedures of choice were the palatal pushback with a pharyngeal flap lining, sphincter pharyngoplasty, a superiorly based obturating pharyngeal flap, and Furlow palatoplasty. The criteria for selecting these procedures are reviewed. The results revealed VPI resolution and the establishment of normal nonnasal speech in more than 95% of the 75 patients for whom outcomes were determined. This study reiterates the importance of thorough preoperative evaluation and the individualization of the secondary corrective procedure.

Current techniques for treatment of velopharyngeal insufficiency

Velopharyngeal insufficiency (VPI) is most commonly seen as a result of cleft palate. Even when appropriately repaired in a timely fashion, there are still a small number of children who continue to have the speech sequela of an inappropriately functioning velopharynx. Noncleft children may also suffer from VPI. Although sometimes these children have the VPI as one of the manifestations of a syndrome such as velocardiofacial syndrome, there are others who have isolated velopharyngeal dysfunction. Occasionally, velopharyngeal dysfunction is also exasperated by adenoidectomy. The following pages will attempt to look at the techniques that are used for treatment of VPI in a treatment paradigm, which is based on the initial assessment of the problem.

A New Operation for Velopharyngeal Insufficiency

Myomucosal flaps employing the palatoglossi were used to correct posttonsillectomy velopharyngeal insufficiency because the palatopharyngeus were resected with the posterior tonsillar pillar. This new sphincter pharyngoplasty may have a role as a secondary option for treatment of velopharyngeal insufficiency. It should be remembered that this operation has only been performed in a single patient without cleft palate, and, therefore, its application in the cleft population and its potential complication rate are unknown.

咽頭弁形成術と鼻腔抵抗

Pharyngeal flap operations are commonly performed in the treatment of velopharyngeal insufficiency in patients with cleft palate or congenital velopharyngeal insufficiency (CVPI). It has been reported that nasal obstruction following this procedure usually disappears in 4 to 6 months.As previously reported, the difference between nasal resistance determined by the activeposterior method (Pp) and that determined by the active-anterior method (Pa) is thought to reflect the resistance of the nasopharynx or the pharyngeal flap.In the present study, we measured nasal airway resistance by both the active-posterior and the active-anterior methods before and after surgery periodically in 13 patients with cleft palate or CVPI, aged 5 to 24 years. The control group consisted of 57 patients with cleft palate without pharyngeal flap surgery, aged 4 to 36 years.The normal range of (Pp-Pa) was determined to be +0.2Pa/cm3/sec to -0.2Pa/cm3/sec because the value of (Pp-Pa) fell into this range in 55 out of 57 control subjects. The value of (Pp-Pa) returned to the normal range 6-7 months after flap surgery in 11 patients. However, it still remained abnormal 9 months following the procedure in 2 patients with stenosis of the lateral porus. Thus, if the flap operation is performed correctly, breathing through the nose is thought to normalize 6'-7 months after the pharyngeal flap operation.

Speech-Language Pathologists' Opinions on the Management of Velopharyngeal Insufficiency

A 16-item questionnaire designed to survey opinions on the management of velopharyngeal insufficiency (VPI) was distributed to all members (N = 296) of the American Cleft Palate Association who were speech-language pathologists. Questionnaires were completed by 173 respondents (58.4 percent). There were differences of opinion among speech-language pathologists on various management issues related to VPI, including the value of instrumental assessment of VPI, the importance of oral examination of velopharyngeal function, and the effectiveness of speech therapy in the treatment of VPI. The implications of these findings for clinical training in VPI are discussed.

Evaluating Velopharyngeal Incompetence

Numerous procedures and techniques for the treatment of velopharyngeal insufficiency (VPI) have been suggested over the past century, and the development of new procedures continues unabated. The emphasis on the success or failure in treatment has been the relative merits of each of these procedures, whether they be surgical, prosthetic, or therapeutic. It is more appropriate to place the emphasis on the indications for those procedures so that success or failure is dependent upon adequate diagnosis. The purpose of this article is to discuss what constitutes state-of-the-art in the diagnosis of VPI and how the results of this diagnosis affects treatment planning.

The design of prostheses used in the treatment of velopharyngeal insufficiency.

The design of prostheses used in the treatment of velopharyngeal insufficiency.

Lateral Defects in Velopharyngeal Insufficiency

A variety of surgical techniques is available for the closure of substantial velopharyngeal defects. While the use of the centrally based pharyngeal flap remains the cornerstone of surgical treatment, there are patients who have poor lateral pharyngeal wall (LPW) mobility. After surgery that uses a centrally based flap, the speech result in such patients is less than optimal, since the poorly mobile LPW does not approximate to the central flap, thus creating a lateral defect. We have added the Towne view to our protocol for cine-speech studies to study better the lateral defects. This view is perpendicular to the velopharyngeal spincter and shows the true-purse-string nature of it. The incidence of such defects in our last 40 consecutive patients is reviewed. Based on the existence of a lateral defect, recommendations are made for a system of operations in the treatment of velopharyngeal insufficiency.

The treatment of velopharyngeal insufficiency after palatal repair

The treatment of velopharyngeal insufficiency after palatal repair