Treatment Of Velopharyngeal Dysfunction Research Articles

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees-Part 1: Anatomy and Physiology.

The velopharyngeal (VP) port separates the nasopharynx from the oropharynx and is bordered by the velum, lateral pharyngeal walls, and posterior pharyngeal wall. Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the VP port, affecting speech and swallowing. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 1, the authors focus on the anatomy and physiology of the velopharyngeal port, the anatomy of cleft palate, and the causes of VPD. There are 3 types of VPD: velopharyngeal insufficiency, involving structural deficits; velopharyngeal incompetence, resulting from neuromuscular issues; and velopharyngeal mislearning, due to maladaptive speech habits. VPD is commonly associated with cleft palate due to anatomic disruptions that impair velopharyngeal function. However, there are numerous causes of noncleft VPD, including congenital or acquired structural defects, neuromuscular conditions, and developmental/behavioral factors. Diagnosis and management of VPD require a multidisciplinary approach involving, at a minimum, surgeons and speech-language pathologists. Plastic surgery trainees often receive education on the surgical treatment of VPD, but without a foundational knowledge of the disease spectrum and speech pathology, the complex terminology can impede a thorough understanding of its diagnosis and management. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.

"Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction."

Velopharyngeal dysfunction is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of velopharyngeal dysfunction (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of velopharyngeal dysfunction. Here, we investigate the effectiveness of buccal myomucosal flaps in the treatment of velopharyngeal dysfunction. A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016-2021. Pre- and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which velar closing ratio was obtained. A total of 25 patients underwent buccal myomucosal flap procedures for velopharyngeal dysfunction at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% vs 50%, p<0.001) and improved speech scores (p<0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea. :' Treatment of velopharyngeal dysfunction with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been utilized for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomic velar muscle correction for patients with a larger preoperative velopharyngeal gap.

Treatment of velopharyngeal dysfunction: A clinical report

Current tumor therapies can impair velopharyngeal function and lead to the development of hypernasality and nasal regurgitation. This article describes a prosthetic restoration of velopharyngeal dysfunction with a multidisciplinary approach including a speech pathologist and videofluoroscopic and nasal endoscopic procedures.

Diagnosis and treatment of velopharyngeal dysfunction: effectiveness of speech aid prosthesis for treatment of velopharyngeal dysfunction

Diagnosis and treatment of velopharyngeal dysfunction: effectiveness of speech aid prosthesis for treatment of velopharyngeal dysfunction

Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns.

To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD). A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice. We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD. A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038). Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.

Intensive Care Unit Monitoring After Pharyngeal Flap Surgery: Is It Necessary?

To assess the incidence of perioperative complications and the utility of intensive care monitoring in patients undergoing posterior pharyngeal flap surgery for velopharyngeal dysfunction (VPD). This study was a retrospective evaluation of patients who underwent posterior pharyngeal flap surgery for treatment of VPD and an assessment of the incidence of perioperative complications. Descriptive statistics were computed. Over an 18-year period, 145 patients underwent pharyngeal flap surgery for VPD; 133 (91.7%) had complete data and were included as subjects. Mean patient age was 9.4 ± 7.4years; 50.4% were female. One hundred twenty-six patients (94.7%) had a history of cleft palate. Thirty-four patients (25.5%) had asthma or obstructive sleep apnea. Eighty-three patients (62.4%) were admitted to the intensive care unit (ICU) for postoperative monitoring. The average length of hospital stay was 1.9 ± 0.9days (range, 1 to 5days). There were no incidents of serious postoperative complications, including death, bleeding, flap dehiscence or loss, or airway compromise requiring reintubation. Two patients (1.5%) had perioperative complications related to respiratory issues, one of whom required readmission to the ICU (0.8%). There were no differences in complications between those who were routinely admitted to the ICU and those who went directly to the floor (P= 1.00). There was no association between respiratory comorbidities and complications (P= .06). The perioperative complication rate for posterior pharyngeal flap surgery is low (<2%). Routine ICU admission for monitoring is not necessary.

Robotic Approaches to Palatoplasty and the Treatment of Velopharyngeal Dysfunction

The operative techniques used to address palatoplasty and velopharyngeal dysfunction rely on traditional methods of surgical exposure and tissue handling. As the role of robotic surgical systems has expanded, emphasis has shifted from extirpative to reconstructive applications. We discuss the possible role of surgical telemanipulation systems in the treatment of these diagnoses. Furthermore, we present a feasibility study that addresses a commonly performed treatment of velopharyngeal dysfunction-posterior pharyngeal flap (PPF). In brief, PPFs were successfully performed on a small series of cadaveric human specimens. The technical aspects of the procedure, including telemanipulator set-up, positioning, surgical instrumentation, and timing are described in detail. All cadavers underwent successful performance of PPFs. Operative times were within an acceptable range and use of the robotic system demonstrated a steep learning curve. Many of the potential advantages and costs associated with robotic surgical systems are discussed.

Velopharyngeal Insufficiency and Cleft

Management of orofacial clefts requires a comprehensive approach to address the multifaceted aspects of possible aesthetic and functional deficits. Many children with cleft palate with or without cleft lip continue to have speech abnormalities that can affect socialization, education, and childhood development. An interdisciplinary cleft team ideally manages most orofacial clefts and can include members from the fields of facial plastic surgery, otolaryngology, speech and language pathology, pediatrics, nursing, audiology, genetics, oral surgery, orthodontics, dentistry, and social work. These teams follow a relatively established timeline and algorithm for each of the discrete steps of orofacial cleft treatment. Cleft lip repair is often performed after 3–5 months of age. Palatoplasty is delayed after 8–14 months of age. Speech and language pathology assessment and therapy are targeted as the vocabulary develops (2–5 years old). This special issue deals with the cleft surgeon and speech therapists role in treatment of velopharyngeal dysfunction (VPD), which is often related to velopharyngeal insufficiency (VPI). This lack of coordinated closure of the soft palate to the posterior pharyngeal wall is often a sequela of cleft palate, even after primary repair. One paper from this issue titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” reports on cephalometric differences between the skull base and velopharyngeal anatomy in patients with unilateral cleft lip and palate compared to normal controls. These data contribute to the existing literature of abnormal skull base anatomy and inclination in children with velocardiofacial syndrome, which often associated with VPD. The next paper titled “Noncleft velopharyngeal insufficiency: etiology and need for surgical treatment” analyzes those children with VPD without obvious orofacial clefting, and assesses the etiologies and potential treatment options. This allows for comparison to the traditional orofacial cleft-related VPD management. The velopharyngeal workup is often a coordinated assessment by the cleft surgeon and speech pathologists. It can include subjective assessment, which is the subject of the next two papers. First, the next paper titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” assesses the relationship between two speech assessment tools, Lyapunov exponents, and Nasalance scores in the presence of hypernasal speech. Furthermore, an additional paper titled “Assessment of single-word production for children under three years of age: comparison of children with and without cleft plate” presents a case-control testing of a single word assessment tool in children less than 3 years of age with cleft palate, which indentified speech differences in error patterns, consonants, articulation, and accuracy between children with and with clefts. Objective assessment of VPD also can include either fluoroscopic speech examination or nasopharyngoscopy to characterize the pattern of VPD and target a surgical goal. The next paper titled “Objective assessment of hypernasality in patients with cleft lip and palate with the nasalView system: a clinical validation study” assesses the validity and reliability of a new tool for hypernasality testing called NasalView. Speech and language therapy is instituted to address typical compensatory speech patterns seen in children with cleft palate (e.g., glottal stops). If hypernasal speech is not responsive to speech and language therapy, secondary speech surgery is warranted to address hypernasality in this time period. Surgical options may include a superiorly based pharyngeal flap, dynamic sphincter pharyngoplasty, or posterior pharyngeal wall augmentation. Occasionally, a palate-lengthening procedure (Furlow double-opposing Z-plasty) is performed. These procedures can limit nasal air emissions, but potential obstructive sleep apnea from excessive nasal obstruction is a risk. The risk of sleep apnea after surgically treating the velopharynx may be decreased if the tonsils and adenoids are addressed preemptively. Before pharyngeal flap surgery, some surgeons perform tonsillectomy to limit the potential variability of speech and airway changes that comes with fluctuating tonsillar hypertrophy, tonsillitis, or upper respiratory infections. The use of tonsillectomy in the face of VPI in children with cleft palate is somewhat controversial and is the topic of the last paper “Speech outcomes after tonsillectomy in patients with known velopharyngeal insufficiency”. The guest editors are pleased to present a collection of papers dealing with management of the speech-related difficulties in children with orofacial clefts. In this era of the expanding role of evidenced-based medicine, the effectiveness of treatments can only be monitored and improved by assessment with valid and consistent outcome measures, which are reviewed in this issue. Travis T. Tollefson David White James Brookes Steven Goudy

The role of cephalometry in assessing velopharyngeal dysfunction in velocardiofacial syndrome

To report our experience with cephalometry in evaluating velopharyngeal dysfunction (VPD) in velocardiofacial syndrome (VCFS) and its utility in assessing the role of cervical spine abnormalities in VPD, prior to surgical correction of VPD. Clinical charts and cephalometric radiographs done prior to surgery for VPD were retrospectively analyzed to ascertain velopharyngeal measurements and cervical spine abnormalities. Twenty-six patients (age: 6-23 years) with molecularly confirmed VCFS. Wake Forest University Health Sciences (1997-2005). Cranial base angle, nasopharyngeal depth, velum length, and Need ratio at rest, velar dimple location, and velopharyngeal length during phonation; information on presence/absence of submucous cleft palate and cervical spine abnormalities were also obtained. The relationship between C1 anterior arch abnormalities and Need ratio was examined. Seventy-three percent of the VCFS patients had excessive nasopharyngeal depth, 80% had an abnormal Need ratio, 50% had a short velum, 81% had a submucous or occult submucous cleft palate, 90.5% had a cervical spine abnormality (C1 anterior arch abnormalities in 38%) and 11.5% had platybasia. There was a significant difference in the Need ratio between patients with and without C1 anterior arch abnormalities. Cephalometry can be used to delineate factors such as C1 vertebral abnormalities, excessive pharyngeal depth, and short velum that contribute to VPD in VCFS. This would help otolaryngologists better understand the anatomy prior to surgical treatment of VPD. This is the first study to highlight the frequent occurrence of C1 anterior arch abnormalities in VCFS.

Navigation of the nose with flexible fiberoptic endoscopy.

The introduction of flexible fiberoptics into medicine revolutionized the evaluation and treatment of velopharyngeal dysfunction. In this paper, rigid endoscopy and flexible fiberoptic scopes are discussed, including their respective advantages and disadvantages. Anesthetic and anatomic considerations relative to the endoscopic procedure are presented. Transnasal endoscopy permits documentation of static and dynamic anatomy, information that may be fundamental for the understanding and treatment of patients with velopharyngeal dysfunction.