Symptoms Of Velopharyngeal Insufficiency Research Articles

Use and Abuse of Electrocautery in Adenoidectomy Hemostasis.

Background and objectives: Bipolar electrocautery is commonly used to control bleeding after cold-instrument pediatric adenoidectomy, but the surgeon should be aware of the possible side effects. OBJECTIVE: The aim of our study is to investigate the effects of bipolar electrocautery when used for bleeding control at the end of an adenoidectomy procedure. Materials and Methods: We evaluated the effect of electrocautery on postoperative pain, velopharyngeal insufficiency symptoms, postoperative nasal obstruction, and rhinorrhea in a group of 90 children undergoing adenoidectomy in our ENT department over a period of 3 months. Results: After statistically analyzing the data, we found that the duration of postoperative pain, the duration of rhinorrhea and nasal obstruction, and the duration of painkiller administration, as well as the velopharyngeal insufficiency symptoms, were significantly longer in patients in whom electrocautery was used for hemostasis. A significantly higher incidence of posterior neck pain and halitosis (oral malodor) was noted in the patients in whom electrocautery was used for adenoidectomy hemostasis. Conclusions: Bipolar electrocautery use should be limited during pediatric adenoidectomy hemostasis because of the possible side effects: longer postoperative pain, prolonged nasal obstruction, rhinorrhea and velopharyngeal insufficiency, and halitosis. We noted some side effects that were specific to electrocautery use during adenoidectomy: posterior neck pain and oral malodor. Acknowledging the risk for these symptoms can help to alleviate the anxiety of both the parents and the patients regarding the expected postoperative outcomes.

A retrospective analysis of speech and hearing in patients receiving surgery for submucous cleft palate

Submucous cleft palate (SMCP) is an uncommon subtype of cleft palate that is associated with symptoms of velopharyngeal insufficiency (VPI), the most common being hypernasal speech. A high proportion of patients also suffer from conductive hearing loss, which is thought to be due to eustachian tube dysfunction. A number of surgical techniques have been proposed to correct the anatomical defect that is responsible for VPI. This exploratory study aims to describe surgical techniques and clinical outcomes in a series of patients who underwent surgical repair of SMCP at a single regional specialist cleft centre between 1999 and 2018. Through a retrospective case note review, records of 57 patients who underwent SMCP repair between the ages of 6 months and 16 years were examined. Patients underwent one of the three surgical techniques: Intravelar Veloplasty, Furlow or a novel technique we have termed as "Hemi-Furlow". Hypernasality, measured on the Great Ormond Street Speech Assessment, showed evidence of improvement post-operatively in all three surgical groups (P<0.005), with no evidence to favour any specific approach. Post-operative complications, including wound dehiscence and fistulae, occurred in nine patients (15.8%). Nine patients (15.8%) required revisional surgery, either due to post-operative complications or persistent speech problems. Otological disease was present in 54.4% of patients, comprising conductive hearing loss due to otitis media with effusion (52.6%) and sensorineural hearing loss (1.8%). There is now a need for large, multi-centre studies with robust outcomes measures to further examine relationships between surgical techniques and clinical outcomes in people born with SMCP.

The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis.

Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572). Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Soft palate reconstruction after radionecrosis: Combined anterolateral thigh adipofascial and nasoseptal flaps

Although radiation-based treatment for nasopharyngeal cancer may achieve excellent long term oncologic results, late effects of therapy may lead to soft tissue radionecrosis and velopharyngeal insufficiency (VPI). Repair of these oro- and nasopharyngeal defects presents a complex reconstructive challenge. We present a case of a long-term survivor treated with chemoradiotherapy for nasopharyngeal cancer who developed progressive dysphagia, velopharyngeal insufficiency, and radionecrosis of the nasopharynx and soft palate, leading to tracheostomy and gastrostomy tube dependence. A staged reconstruction was performed, initially with a tubed nasoseptal flap for a creation of a mucosal-lined nasopharyngeal port. An adipofascial anterolateral thigh free flap was subsequently performed for soft palate reconstruction. Within 2 months, the oropharyngeal reconstruction had remucosalized and she was decannulated, taking an oral diet. Her speech was intelligible and she had good nasal breathing without symptoms of velopharyngeal insufficiency.

Speech outcomes at 5 and 10 years of age after one-stage palatal repair with muscle reconstruction in children born with isolated cleft palate

Background: The aim of this study was to investigate speech outcomes in children with clefts in the hard and/or soft palate only (CPH/CPS), in order to determine the prevalence of cleft speech characteristics, the change between 5 and 10 years of age, and the difference in occurrence between CPH and CPS.Methods: A consecutive series of 88 children born with CPH or CPS were included in a retrospective cohort. All participants were treated with one-stage palatal repair using a minimal incision technique with muscle reconstruction (mean age 13 months). Twelve children (14%) received a velopharyngeal flap. Cleft speech variables were rated at 5 and 10 years of age independently by three experienced external speech-language pathologists. Inter- and intra-rater agreements were determined, and the prevalence of cleft speech characteristics was calculated.Results: Moderate-to-severe hypernasality and weak pressure consonants were present in 5%–10% of the children at 5 years, with marginal but statistically significant improvement at 10 years of age. Frequently or always occurring audible nasal air leakage was detected in 20% of children at age 5, and increased to ∼35% of the children at 10 years. Ten per cent had compensatory articulation at age 5, and 25% demonstrated s-distortions, whereas few had these problems at age 10.Conclusions: The results demonstrate low occurrence of compensatory articulation problems in this cohort, even by 5 years of age. The high presence of symptoms of velopharyngeal insufficiency at 10 years of age suggests a need for additional secondary velopharyngeal surgery.

Transillumination of the Occult Submucous Cleft Palate- Shining Light on a Diagnostic Technique

PURPOSE: Submucous cleft palate is a congenital deformity characterized by deficient union of the muscles that normally cross the velum and aid in elevation of the soft palate. Unlike overt submucous cleft palate, occult submucous cleft palate lacks clear external anatomic landmarks while still exhibiting insufficient median muscle interdigitation and abnormal function (Figure 1).Figure 1: Musculature of the normal velum and the occult submucous cleft palate.This absence of anatomic markers makes the diagnosis of occult submucous cleft less obvious, more dependent on ancillary tests, and potentially missed entirely. Current diagnostic methodologies are limited and often are unrevealing, however a missed diagnosis of occult submucous cleft palate can result in velopharyngeal insufficiency (VPI) and major functional impairment in patients following surgery on the oropharynx. By accurately and easily identifying occult submucous cleft palate, it is possible to defer or modify pharyngeal surgical intervention that may further impair velopharyngeal function in susceptible patients. METHODS AND MATERIALS: In this report, we introduce transillumination of the soft palate as a simple technique for submucous cleft palate identification, illustrate its use in the pre-operative patient work-up in comparison to other diagnostic methods, and describe its utility in a patient case. As part of assessing patients undergoing oropharyngeal surgery, a flexible fiberoptic nasopharyngoscope is routinely used to examine the velum, oropharynx and hypopharynx. We propose that the same scope be used to improve diagnosis of occult submucous cleft palate through transillumination. Following introduction of the scope through the nose or mouth, the lighted distal end of the scope should be directed anteriorly as to provide a backlight for the soft palate (Figure 2).Figure 2: Transillumination of a patient with submucous cleft palate. Note the central translucency and incongruity of velopharyngeal musculature.CONCLUSIONS: Occult submucous cleft palate is a frequently missed diagnosis that is often not recognized until a patient develops symptoms of VPI. As illustrated in our patient, the appearance of VPI symptoms following routine surgery can be debilitating for the patient and defeating for the surgeon in cases of missed occult submucous cleft. In patients undergoing oropharyngeal surgery, transillumination of the palate is an inexpensive, quick, and easily incorporated technique that can screen for undiagnosed occult submucous cleft palate and decrease the incidence of iatrogenic VPI post-operatively.

Posterior Pharyngeal Wall Augmentation with Acellular Dermis Implant for Velopharyngeal Insufficiency

Objectives: Review outcomes for children with velopharyngeal insufficiency (VPI) after posterior pharyngeal wall augmentation with an acellular dermis implant. Methods: Retrospective case series of children with VPI who underwent augmentation pharyngoplasty from 2002-2011 at a tertiary care children’s hospital. The posterior pharyngeal wall was augmented with rolled acellular dermis inserted in the subfascial plane. Pre- and postoperative nasometry, speech nasal endoscopy, and caretaker and clinician perceptual evaluation were reviewed. Results: Twenty-four children with VPI (average age 8.8 ± 4.0 yrs) who underwent augmentation pharyngoplasty were identified. The majority of these children had a small gap noticed on speech nasal endoscopy. Of the 24 children, 5 were lost to follow-up and were not assessed in the postoperative period. Average follow-up for the remaining 19 patients was 17.6±20.9 months. Fifteen of the 19 patients (79%) had some improvement in VPI symptoms as determined by clinical perceptual evaluation, but only 8 children (42%) demonstrated complete resolution after the operation. One implant extruded. No major complications related to the surgical procedure were identified. Conclusions: We present a novel technique to treat VPI using an acellular dermis implant to augment the pharyngeal wall. Although this approach does not successfully treat all children with VPI, no major complications were seen in this series. Vital tissue that may be used for future speech surgery is preserved if this treatment option fails.

Age of diagnosis and evaluation of consequences of submucous cleft palate

ObjectivesTo evaluate the frequency of submucous cleft palate (SMCP) in a group of children with clefts. The reason for suspecting submucous cleft, age of diagnosis, effect of age on speech development, problems in speech, hearing and swallowing were compared with previous literature. MethodsRetrospective chart review: Out of 33 patients with SMCP, registered by the Groninger cleft team over approximately 20 years (1990 until July 2012), 28 non-syndromic patients with a proven diagnosis of SMCP were included: 17 males and 11 females. Speech and hearing were examined and the number of patients with SMCP and age at time of diagnosis were evaluated. The percentages of problems in resonance, articulation and hearing, present at time of diagnosis, were compared with the percentages of problems found after surgery. ResultsOut of 800 patients with clefts, 28 patients (3,5%) were diagnosed with SMCP at a mean age of 3;9 years. All patients presented one or more symptomatic complaints at time of diagnosis: hypernasality (65%), problems in articulation (46%), conductive hearing loss (39%) and/or swallowing problems (32%). A bifid uvula was found in 92%. Following surgery, hypernasal speech and swallowing problems were no longer observed. The articulation problems remained after surgery. Age of diagnosis seems no predictor of articulation problems. An improvement in hearing was observed but normal hearing was not achieved. Pharyngoplasty appeared to be a successful and save treatment of hypernasality. ConclusionsSMCP is a rare cleft palate which is, despite the presence of a bifid uvula and symptoms of velopharyngeal insufficiency, often diagnosed late. In children with a bifid uvula and mild problems in speech, hearing and swallowing, it is important to be alert to SMCP because SMCP may account for these persistent mild complaints. Therefore, early detecting of SMCP can yield profits.

Results and complications of 1104 surgeries for velopharyngeal insufficiency.

Velopharyngeal insufficiency (VPI) means that the velopharyngeal closure is inadequate or disturbed. VPI may be organic or functional, congenital or acquired and is caused by structural alterations or paresis. The symptoms are primarily to be found in speech (hypernasality), more rarely in swallowing and hearing. The management types are as follows: speech therapy, surgery, speech bulb, and others. Surgery is indicated if the symptoms of VPI cannot be improved by speech therapy. Among the operative methods, velopharyngoplasty constitutes the basis of the surgery. The pharyngeal flap was incorporated and survived in 98.1% of the cases, hyperrhinophony disappeared or became minimal in 90% after surgery in our material (1104 cases). The speech results seemed to be the same with superiorly or inferiorly based pharyngeal flap. The Furlow technique, push-back procedure, the sphincteroplasty, and the augmentation were indicated by us if the VP gap was less than 7 mm; these methods may also be used as secondary operation. We observed among 1104 various surgeries severe hemorrhage in 5 cases, aspiration in 2 cases, significant nasal obstruction in 68 patients, OSAS in 5 cases; tracheotomy was necessary in 2 cases. Although the complication rate is rare, it must always be considered that this is not a life-saving but a speech-correcting operation. A tailor-made superiorly based pharyngeal flap is suggested today, possibly in the age of 5 years.

The submucous cleft palate: Diagnosis and therapy

Objectives To investigate age of diagnosis, typical symptoms, finding of the palate, therapy options and accompanying diseases. Methods A retrospective analysis of 439 patients with symptomatic submucous cleft palate (SMCP), who received a veloplasty operation (butterfly suture technique developed by Haase) was made. Results SMCP was initially diagnosed at the mean age of 4.9 years. Main symptoms were hyper nasal speech (51%) and conductive hearing loss (45%), which resolved after veloplasty (often in combination with adenotomy and insertion of ventilation tubes). Typical findings of the palate were a lack of posterior nasal spine (68%) and bifid uvula (59%). Following surgery 17.1% required speech therapy and 5.5% needed velopharyngoplasty due to continuing hyper nasal speech. Conclusion SMCP is often diagnosed very late, though symptoms of velopharyngeal insufficiency (hyper nasal speech, Eustachian tube dysfunction) and bifid uvula are present. We therefore recommend that all patients with such findings are examined by an appropriate specialist such as Phoniatrics, Otolaryngologist and Oral-Maxillofacial-Surgeon so that early diagnosis and palatoplasty can be performed. The veloplasty operation (butterfly suture technique) can be recommended as a safe therapy for velopharyngeal insufficiency for patients with symptomatic SMCP.

The Effect of Cleft Palate Repair on Contractile Properties of Single Permeabilized Muscle Fibers From Congenitally Cleft Goat Palates

Inherent differences in the levator veli palatini (LVP) muscle of cleft palates before palatoplasty may play a role in persistent postrepair velopharyngeal insufficiency (VPI). Contractile properties of LVP muscle fibers were analyzed from young (2-month) normal (YNP), young congenitally cleft (YCP) and again on the same YCP subjects 6 months after palatoplasty, mature repaired palate (MRP). The cross-sectional area and rate of force development (ktr) were measured. Specific force (sF(0)) and normalized power (nP(max)) were calculated. Using k(tr) to determine fiber type composition, YNP was 44% type 1 and 56% type 2, while YCP was 100% type 2. Two MRP subjects shifted to 100% type 1; 1 demonstrated increased resistance to fatigue. No differences in sF(0) were observed. nP(max) increased with presence of type 2 fibers. The persistent state of type 2 fibers following palatoplasty leads to increased fatigue in the LVP of MRP subjects and may cause VPI symptoms.

Z-Palatoplasty

Z-Palatoplasty

Velopharyngeal Insufficiency in Woodwind and Brass Players

Velopharyngeal insufficiency (VPI) has received little attention in the medical literature. The aim of the present study was to determine the extent to which VPI constitutes a problem for woodwind and brass musicians. A total of 148 musicians (professionals from a symphony orchestra and students, the latter mainly from a national youth orchestra) were asked if they were aware of the phenomenon of VPI and whether they experienced it. Intraoral pressure measurements were performed to determine pressure peaks, mean pressure, and maximum attainable pressures. Of the 148 musicians, 81 were aware of the VPI disorder, and 24 of them showed symptoms of it themselves. Six of the affected musicians reported that VPI occurred in association with colds or stress or the playing of extremely high notes. One musician noted that it occurred only on return from vacation leave. Of the symptom-free musicians, 15% reported that they noticed symptoms of VPI during their musical training but that these gradually dissipated of their own accord. VPI in woodwind and brass instrumentalists is obviously more common than previously recognized. Despite reports in the medical literature that predominantly young musicians are affected, in our study only 47% of the individuals with symptoms were school pupils or music students (who overall constituted 41% of the study subjects). Oboists and clarinettists were the most frequently affected, perhaps because they develop relatively high mean pressures. Although VPI frequently occurs when woodwind and brass musicians are undergoing training and then regresses, it may persist, particularly in instrumentalists in whom high mean pressures form. To prevent persistent VPI, it seems advisable for music teachers to perform pressure measurements during instructional periods.

Uvulopalatopharyngoplasty, maxillomandibular advancement, and the velopharynx.

To evaluate the presence of velopharyngeal insufficiency (VPI) symptoms and the associated changes of the velopharyngeal anatomy in patients who underwent maxillomandibular advancement (MMA) for persistent obstructive sleep apnea (OSA) after uvulopalatopharyngoplasty (UPPP). Preoperative and postoperative cephalometric radiographs were analyzed to assess the anatomic changes of the velopharynx. In addition, a questionnaire survey was sent to the patients between 6 to 12 months after MMA. The questionnaires evaluated the presence and extent of VPI symptoms, including nasal regurgitation while eating or drinking as well as hypernasal speech. A 10-cm visual analog scale (VAS 0-10) was included to assess the impact of VPI symptoms on the patient's quality of life. In the patients who reported VPI symptoms, telephone interviews were conducted 1 year after the survey to evaluate the changes in VPI symptoms over time. Fifty-two of the 65 questionnaires were returned. Five patients (9.6%) reported nasal regurgitation of liquids when drinking hastily, with 2 patients reporting the occurrences as occasional and 3 patients reporting as rare. The impact of these symptoms on the patient's quality of life was minimal (VAS 0.6 +/- 0.4). Regurgitation of food or hypernasal speech was not reported. The telephone interviews 1 year later revealed that the symptoms have completely resolved in all 5 patients. Comparison of the preoperative and postoperative cephalometric radiographs demonstrated the pharyngeal depth increase was 48% of the amount of maxillary advancement and the functional pharyngeal length increased 53% of the maxillary advancement. The functional depth of the pharynx after MMA was significantly greater in the patients with VPI symptoms (P=.01). The results of this study suggest that patients who undergo MMA for persistent OSA after UPPP have a low risk of developing VPI. If symptoms occur postoperatively, they are mild and have minimal effect on the patient's quality of life; moreover, the symptoms usually resolve over time.

Myotonic Dystrophy Revealed at Videoradiography of Deglutition and Speech in Adult Patients with Velopharyngeal Insufficiency: Presentation of Four Cases

Patients with velopharyngeal insufficiency (VPI) without cleft palate, who appear for the first time in adulthood for treatment, will probably reveal a high percentage of undiagnosed myotonic dystrophy (MD). Videoradiography of deglutition and speech reveals the diagnosis. Eleven adult noncleft palate patients with VPI were studied with videoradiography of the pharynx and esophagus. Three exhibited functional radiographic manifestations of MD during deglutition and speech. The diagnosis confirmed by neurologic examination was not known or suspected prior to videoradiography. An additional patient with VPI and suspected MD displayed the same constellation of radiographic findings. Follow-up examinations confirmed the diagnosis of MD. Three of the four patients had had symptoms of VPI since childhood, but none had complaints of deglutition problems except for accidental nasal regurgitations.

Velopharyngeal Insufficiency And Secondary Palatal Management: A New Look at An Old Problem

The main objective of primary palatoplasty is to achieve adequate velopharyngeal (VP) function and normal oral-nasal resonance. Many children, however, who undergo cleft palate repair fail to develop normal VP function. Symptoms of velopharyngeal insufficiency (VPI), such as hypernasality and audible nasal air emission, may have a variety of causes, which underscores the need for comprehensive evaluation. This article focuses on the problem of VPI and emphasizes the need for differential diagnosis at the most critical step in management planning. The challenge of the future is to implement the team approach, integrating the expertise of speech scientists and plastic surgeons, so that differential diagnosis can and will lead to differential management.