Management of soft palate agenesis in Nager syndrome with an elongated, superiorly based pharyngeal flap

Nager syndrome, or preaxial acrofacial dysostosis, is associated with aberrant development of the first and second branchial arch structures, as well as abnormal development of the limb buds. It is a rare disorder, and its clinical manifestations have not been completely defined. Absence of the soft palate has been reported in patients with Nager syndrome. In this report we describe the use of an elongated, superiorly based pharyngeal flap for the treatment of severe velopharyngeal insufficiency in a patient with Nager syndrome and absence of the soft palate. We also describe the dysmorphisms associated with Nager syndrome and present a differential diagnosis for the condition.

Effect of maxillary osteotomy on speech in cleft lip and palate: perceptual outcomes of velopharyngeal function

BACKGROUND

Abnormal facial growth is a well-known sequelae of cleft lip and palate (CLP) resulting in maxillary retrusion and a class III malocclusion. In 10-50% of cases, surgical correction involving advancement of the maxilla typically by osteotomy methods is required and normally undertaken in adolescence when facial growth is complete. Current evidence for the impact of the surgery on velopharyngeal function is weak and mixed.

AIMS

The first objective of the study was to investigate the nature of the effect of maxillary osteotomy on the perceptual outcomes of velopharyngeal function in CLP. The second objective was to establish if speech changes seen early at 3 months post-operation persisted for a year after/following surgery', when it is considered that the maxilla is relatively stable.

METHODS & PROCEDURES

Twenty consecutive patients with CLP undergoing maxillary osteotomy by a single surgeon were seen pre-operatively (T1), 3 months (T2) and 12 months (T3) post-operation. A non-cleft control group (NonCLP) undergoing surgery was also recruited. Speech data were collected using the Cleft Audit Protocol for Speech-Augmented (CAPS-A). A velopharyngeal composite score-summary (VPC-SUM) was derived from specific CAPS-A-rated parameters. An external CAPS-A-trained therapist, blinded to the study, rated the randomized samples and inter-rater reliability was established.

OUTCOMES & RESULTS

For the CLP group, hypernasality and nasal turbulence increased significantly post-operation. Planned comparisons were significant for T1-T2 only with a medium effect size. For hypernasality, the CLP group differed statistically from the NonCLP group at T2 and T3. For nasal turbulence, the CLP group differed statistically from the NonCLP group at T2. For VPC-SUM, there were statistically significant changes post-operatively between T1-T2 and T1-T3 only with medium effect sizes for the CLP group only.

CONCLUSIONS & IMPLICATIONS

This study provides evidence that maxillary osteotomy affects patients with and without CLP differently. In patients with CLP, surgery may impact negatively on velopharyngeal function for speech and changes seen early on at 3 months post-operatively appear to persist at 12 months postoperatively. The findings in this study have implications for the speech care pathway of patients with CLP undergoing maxillary osteotomy in terms of assessment, review and management.

An innovative technique to restore velopharyngeal incompetency for a patient with cleft lip and palate

Treatment of cleft lip and palate patients often demand well-coordinated work of medical and dental specialists. In spite of surgical and orthodontic therapy, prosthetic rehabilitation is always necessary because of partial anadontia, maxillary hypoplasia and velopharyngeal dysfuction. The aim of the prosthetic treatment is to improve aesthetics, function and speech of the patients; however, factors like underdeveloped and collapsed maxillary arch, retrognathic maxilla and reduced alveolar ridge height make the treatment challenging. This clinical report describes an interdisciplinary approach for the management of cleft lip and palate patient associated with mutilated dentition. The prosthetic phase began along with orthodontic treatment to achieve sufficient space distribution, which was restored with fixed dental prosthesis to stabilise the achieved status of occlusion. Palatal lift prosthesis was fabricated to restore the velopharyngeal incompetency with an innovative technique using 'standard orthodontic expansion screw' to eliminate hypernasality, decrease intelligibility of speech and to aid in deglutition.

Parental perceptions of posterior pharyngeal wall augmentation using autologous fat for treating velopharyngeal dysfunction

Posterior pharyngeal wall augmentation using autologous fat to treat velopharyngeal dysfunction (VPD) is an alternative surgical procedure to more commonly used invasive procedures such as the pharyngeal flap. However, limited research exists on this technique. The aim of this study was to qualitatively investigate parental perceptions of posterior pharyngeal wall augmentation using autologous fat when treating velopharyngeal dysfunction. Furthermore, this research aimed to examine parent's perspectives of their child's speech and quality-of-life following this procedure. A qualitative collective case study methodology was used in the form of semi-structured interviews with seven participants. These were then analysed using constant comparative analysis. Four distinct themes emerged: post-surgical outcomes; speech-language pathology, not just medicine; factors for successful post-operative speech and resonance; and long-term sustainability and worthiness of the procedure. Six out of seven participants expressed positive post-operative speech and resonance results. Five further expressed long-term satisfaction up to 6 years post-operatively. Overall the majority of participants were satisfied that this procedure provided their child with long-term successful speech outcomes. The participants also discussed the importance of receiving speech-language pathology services alongside surgery and the positive impact of the procedure on their child's quality-of-life including social interactions, confidence, friendships, as well as eating and drinking.

Autologous fat transplantation to the velopharynx for treating persistent velopharyngeal insufficiency of mild degree secondary to overt or submucous cleft palate

BACKGROUND

Autologous fat transplantation to the velopharynx has been described in a few smaller studies including heterogeneous groups of patients for the treatment of velopharyngeal insufficiency (VPI). The aim of this study was to evaluate speech and to measure velopharyngeal closure with magnetic resonance imaging (MRI) in patients who underwent autologous fat transplantation for the treatment of persistent VPI of mild degree secondary to overt or submucous cleft palate.

METHODS

A prospective study of 16 patients with persistent VPI of mild degree secondary to overt or submucous cleft palate who underwent autologous fat transplantation to the velopharynx. The patients were injected with a median of 5.6 (3.8-7.6) ml autologous fat to the velopharynx. Pre- and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. Hypernasality, hyponasality, nasal turbulence and audible nasal emission were scored on a five-point scale. Pre- and 1-year postoperative MRIs were obtained during vocal rest and during phonation in 12 patients. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane.

RESULTS

Hypernasality improved significantly (p=0.030), but not audible nasal emission (p=0.072) or nasal turbulence (p=0.12). The velopharyngeal distance during phonation decreased significantly (p=0.013), but not the velopharyngeal gap area (p=0.16). There was no significant correlation between speech and MRI results.

CONCLUSION

Autologous fat transplantation to the velopharynx improved hypernasality significantly, but not audible nasal emission or nasal turbulence in patients with persistent VPI of mild degree secondary to overt or submucous cleft palate. Given the low number of patients and the lack of a control group, the value of fat transplantation for the treatment of mild VPI is not proven for sure.

Analysis of the correlative factors for velopharyngeal closure of patients with cleft palate after primary repair

OBJECTIVE

The objective of this study was to analyze the correlative factors for velopharyngeal closure of patients with cleft palate after primary repair.

STUDY DESIGN

Ninety-five nonsyndromic patients with cleft palate were enrolled. Two surgical techniques were applied in the patients: simple palatoplasty and combined palatoplasty with pharyngoplasty. All patients were assessed 6 months after the operation. The postoperative velopharyngeal closure (VPC) rate was compared by χ(2) test and the correlative factors were analyzed with logistic regression model.

RESULTS

The postoperative VPC rate of young patients was higher than that of old patients, the group with incomplete cleft palate was higher than the group with complete cleft palate, and combined palatoplasty with pharyngoplasty was higher than simple palatoplasty. Operative age, cleft type, and surgical technique were the contributing factors for postoperative VPC rate.

CONCLUSIONS

Operative age, cleft type, and surgical technique were significant factors influencing postoperative VPC rate of patients with cleft palate.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.

An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure

The aim of this study was to compare velopharyngeal closure between patients who underwent Furlow palatoplasty and two-flap palatoplasty. A retrospective review of 88 patients with incomplete palate cleft was performed. 48 patients (17 males; 31 females) aged 2-28 years received Furlow palatoplasty. 40 patients (17 males; 23 females) aged 2-21 years received two-flap palatoplasty. Velopharyngeal function was categorized as adequate, marginal or inadequate. Complications associated with the operation were documented. Statistically significant differences were not found amongst sex distribution, age at operation, follow-up time, and preoperative speech intelligibility. After primary repairs using Furlow and two-flap palatoplasty, the surgeon's incidence of postoperative palatal fistula was 0%. The complications were not significantly different between the two groups. The authors achieved the lowest reported incidence of postoperative palatal fistulas in primary Furlow palatoplasty. The outcomes of the velopharyngeal closure were better in patients who received Furlow palatoplasty (P<0.05). Furlow palatoplasty was more effective than two-flap palatoplasty in obtaining perfect velopharyngeal closure. A probable explanation may be that Furlow palatoplasty can reposition and overlap the divergent palatal muscle and lengthen the soft palate.

The occurrence of velopharyngeal insufficiency in Pierre Robin Sequence patients

OBJECTIVE

Children 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.

METHODS

A 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.

RESULTS

Secondary 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).

CONCLUSION

Our 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.

Acellular dermal matrix in palatoplasty

The primary goal of palatoplasty is to allow normal speech through the correction of velopharyngeal incompetence. Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to postoperative fistula formation. Fistulas may in turn contribute to velopharyngeal incompetence. Reported fistula rates vary widely, ranging from 0% to greater than 70%; recurrence rates after attempted repair approach 65% in some series. These lesions therefore represent a significant clinical burden. Acellular dermal matrix materials have been introduced into various phases of palatoplasty as a strategy to augment repairs and minimize postoperative fistula formation, as well as repair fistulas when they do occur. In this article, the authors review the existing literature regarding acellular dermal matrix in palatoplasty and describe their own algorithm and results for primary and secondary palatoplasty in which acellular dermal matrix plays a central role.

Maxillary, mandibular, and chin advancement: treatment planning based on airway anatomy in obstructive sleep apnea

Surgical correction of obstructive sleep apnea (OSA) syndrome involves understanding a number of parameters, of which the 3-dimensional airway anatomy is important. Visualization of the upper airway based on cone beam computed tomography scans and automated computer analysis is an aid in understanding normal and abnormal airway conditions and their response to surgery. The goal of surgical treatment of OSA syndrome is to enlarge the velo-oropharyngeal airway by anterior/lateral displacement of the soft tissues and musculature by maxillary, mandibular, and possibly, genioglossus advancement. Knowledge of the specific airway obstruction and characteristics based on 3-dimensional studies permits a directed surgical treatment plan that can successfully address the area or areas of airway obstruction. The end occlusal result can be improved when orthodontic treatment is combined with the surgical plan. The individual with OSA, though, is more complicated than the usual orthognathic patient, and both the medical condition and treatment length need to be judiciously managed when OSA and associated conditions are present. The perioperative management of the patient with OSA is more complex and the margin for error is reduced, and this needs to be taken into consideration and the care altered as indicated.

Superiorly based pharyngeal flap for velopharyngeal insufficiency: intermediate and longer-term perceptual speech and nasometric outcomes

OBJECTIVE

To evaluate the intermediate and longer-term perceptual and objective speech outcomes in velopharyngeal insufficiency (VPI) patients treated with a superiorly based pharyngeal flap.

DESIGN

Retrospective review.

SETTING

Tertiary care centre, London, Ontario.

METHODS

Forty consecutive VPI patients (mean age 14.5 years) from 2004 to 2008 who had a first time superiorly based pharyngeal flap were included. The modified Hogan flap and lateral port control technique was used with a 70° endoscope to provide intraoperative coaxial and magnified lateral port visualization.

MAIN OUTCOME MEASURES

The American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment and nasalance measured via nasometry using the MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R). A comparison of mean outcomes from the pretreatment versus an intermediate (ACPA 4.3 months; SNAP-R 4.0 months) and longer-term (ACPA 19.5 months) posttreatment time point was performed, and the distribution of successful outcomes was assessed.

RESULTS

Mean perceptual scores improved significantly early after surgery (p < .0001; n  =  33) and in the longer term (p < .01; n  =  21), with high success rates for hypernasality (87.9% and 80.9%; p < .0001), audible nasal emission (90.9% and 90.5%; p < .0001), overall intelligibility (75.7% and 81.0%; p < .01), and compensatory articulation (81.8% and 85.7%; p < .01). Likewise, significant improvements were observed in posttreatment nasal (n  =  38; p < .01) and mean oral SNAP-R scores (n  =  39; p < .001), which demonstrated success rates of 100% (p < .0001) and 73% (p < .0001), respectively. Overcorrection was not observed in perceptual and nasometric testing.

CONCLUSION

The modified Hogan flap and lateral port control technique with the use of a 70° endoscope is highly successful in treating VPI. These results indicate that speech outcome improvement occurs early after surgery and is maintained over time.

Autologous fat injection to face and neck: from soft tissue augmentation to regenerative medicine

Minimally-invasive autologous fat injection of the head and neck region can be considered a valid alternative to major invasive surgical procedures both for aesthetic and functional purposes. The favourable outcomes of autologous fat injection in otolaryngological practice are due to the filling of soft tissue and, mainly, to the potential regenerative effect of adipose-derived mesenchymal stem cells. Herewith, some important biological preliminary remarks are described underlying the potential of autologous fat injection in regenerative medicine, and personal experience in using it for both consolidated clinical applications, such as fat grafting to the face and vocal fold augmentation in the treatment of glottic incompetence, and more recent applications including the treatment of post-parotidectomy Frey syndrome and velopharyngeal insufficiency.

[Relationship between the oral language development and restoration of velopharyngeal closure function in Chinese toddlers with repaired cleft palate]

OBJECTIVE

To evaluate how the oral language development enhances articulators to function well in cleft palate movement and velopharyngeal closure in the young Chinese children with repaired cleft palate.

METHODS

The recordings of 78 cases of Chinese toddlers with repaired cleft palate were reviewed. This group of children aged from 27 months to 33 months (average: 30 months). Transcription using Pinyin system was made. Mean utterance count (MUC) and mean special consonant correct count (MSCC) were calculated. Correlation between MUC and MSCC was statistically analyzed.

RESULTS

The correlation coefficient of MUC and MSCC is 0.360 (P < 0.01).

CONCLUSIONS

There is positive correlation between the oral language development and restoration of velopharyngeal closure function. Children with repaired cleft palate should be encouraged to start oral language as early as possible and as much as possible in order to get the restoration of velopharyngeal closure function.

Intravelar veloplasty reinforced with palatopharyngeal muscle: A review of a 10-year consecutive series

We describe a technique by which the intravelar veloplasty was reinforced by including the superior part of posterior pillars and their palatopharyngeal muscle sheet in patients with cleft lip and palate. Our aim was to increase the functional length and strength of the velum and to reduce nasal emission and the need for pharyngeal flaps. Since 1990 more than 200 patients have been operated on in this way at Uppsala University Hospital. This is a retrospective follow-up of 162 consecutive patients operated on by two senior surgeons between 1990 and 2000. We describe the technique, timing, and operative observations as well as the outcome and the need for revision of the palatoplasty in some cases because of complications. To facilitate speech, 21 patients born between 1990 and 1997 (16%) were provided with a pharyngeal flap.

Management of velopharyngeal insufficiency in the presence of enlarged tonsils: comparing a one-stage versus two-stage treatment result

Alterations in velopharyngeal function after removal of enlarged tonsils were noted. However, the changes varied from previous reports. The purposes of this study were to examine the effect of tonsillectomy on velopharyngeal function and to look for proper management of velopharyngeal insufficiency in the presence of enlarged tonsils. Thirty patients who received tonsillectomy at one craniofacial centre were reviewed. The influence of tonsillectomy on velopharyngeal function was examined and correlations to nasopharyngoscopic or videofluoroscopic findings were made. The outcomes between simultaneous and staged tonsillectomy and velopharyngeal surgery were compared. Tonsillectomy was found to either improve or impair velopharyngeal function in a small proportion of patients; however, it did not alter the surgical management of velopharyngeal insufficiency. Nasopharyngoscopic or videofluoroscopic findings did not predict the influence of tonsillectomy on velopharyngeal function. Finally, simultaneous tonsillectomy and velopharyngeal surgery had an efficacy and complication rate comparable to that of the staged approach.

Interventions for the management of submucous cleft palate

BACKGROUND

Submucous cleft palate (SMCP) is a common congenital malformation of the soft palate which may present as velopharyngeal insufficiency (VPI), which can affect the quality and intelligibility of speech. Surgical techniques, which can be used to reconstruct these structural or anatomical defects and to correct velopharyngeal insufficiency, include palatal repair and procedures that rearrange the muscle attachments of the soft palate.

OBJECTIVES

To provide reliable evidence regarding the effectiveness of surgical interventions to treat velopharyngeal insufficiency and improve speech in patients with submucous cleft palate.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register (to 21st December 2006); Cochrane Developmental, Psychosocial and Learning Problems Group Trials Register (on 12th March 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (from 1966 to 21st December 2006); EMBASE (from 1980 to 21st December 2006); and CINAHL, ERIC, PsycINFO (on 7th March 2007).

SELECTION CRITERIA

Randomised controlled trials comparing surgical interventions to correct velopharyngeal insufficiency in submucous cleft palate.

DATA COLLECTION AND ANALYSIS

Limited data from one included trial precluded pooling of data, and only a descriptive summary is presented.

MAIN RESULTS

This review included one trial, involving 72 participants aged 4 to 7 years with submucous cleft palate associated velopharyngeal insufficiency, which compared minimal incision palatopharyngoplasty (MIPP) to MIPP with additional velopharyngeal surgery, either pharyngeal flap (32) or sphincter pharyngoplasty (3). The trial provided no information about post-operative speech assessment, very limited data on any instrumental assessments and there were no reports of obstructive sleep apnoea or other adverse effects after the interventions. Complete closure occurred in 32 (86%) of the participants in the MIPP group and in 31 (89%) in the additional treatment group, P > 0.05. After eliminating the nine patients with residual velopharyngeal insufficiency, the post-operative gap size during closure was 7.4 +/-3.2% in the MIPP group and 8 +/-4.1% in the additional intervention group (P > 0.5).

AUTHORS' CONCLUSIONS

The trial provided some weak and unreliable evidence that there was no significant difference in the effectiveness of minimal incision palatopharyngoplasty versus the same procedure performed simultaneously with an individually tailored pharyngeal flap or sphincter pharyngoplasty for correcting velopharyngeal insufficiency associated with submucous cleft palate.

Snoring in cleft patients with velopharyngoplasty

Some patients with cleft lip/palate or isolated cleft palate seem to develop snoring as one possible symptom of an obstructive sleep apnoea syndrome after velopharyngoplasty (VPP). The aim of this paper was to determine whether there was a difference in the posterior airway space (PAS) between patients with a VPP who snored and those who did not. Four standard parameters were measured in lateral cephalograms of 20 patients with cleft lip/palate and isolated cleft palate, without diagnosis of further syndromes (e.g. Pierre Robin sequence), having undergone VPP, to examine the dimensions of the PAS. Data were set in correlation to the symptom of snoring, and compared with those of 40 patients without cleft undergoing orthodontic treatment and with 20 patients with cleft lip/palate or isolated cleft palate but not VPP. Metric parameters were significantly different after VPP in patients with clefting and snoring compared to the group of cleft patients without snoring. All patients with clefts exhibited at least in one dimension a constriction when compared to patients without clefting. In conclusion, cleft lip/palate and isolated cleft palate patients tend to have constrictions of the PAS. VPP may induce snoring and further narrowing. Recall and analysis for obstructive sleep apnoea syndrome should be mandatory.

Submucosal injection of micronized acellular dermal matrix: analysis of biocompatibility and durability

BACKGROUND

Posterior pharyngeal augmentation is a recognized treatment for velopharyngeal insufficiency in selected candidates. To date, however, the procedure has failed to gain widespread acceptance because of the absence of an implant material with sufficient safety, durability, and biocompatibility. In this study, the use of micronized acellular dermal matrix injection for augmentation of the posterior pharynx was investigated. Using a porcine animal model, the safety and durability of posterior pharyngeal augmentation by micronized decellularized dermis was evaluated.

METHODS

Twelve Yorkshire piglets were used in this study. Under general anesthesia, porcine-derived micronized acellular dermal matrix was injected into the submucosa of the right side of the pharynx. At 30 days, the animals were euthanized, and the implants and surrounding tissues were assessed grossly for degree of augmentation and histologically to determine the extent of host cell infiltration, vascularization, and matrix deposition and remodeling.

RESULTS

No animal perioperative or postoperative morbidity resulted from the operations. When the animals were euthanized and the tissue was harvested at 30 days, there existed no evidence of gross augmentation on the experimental side of the pharynx in any of the specimens. Histologic analysis demonstrated trace amounts of residual implant, with extensive host lymphocytic infiltration of the material.

CONCLUSIONS

Although micronized acellular dermal matrix is a safe material when injected into the pharyngeal wall, this study demonstrated that it is not a durable implant at this site. The authors do not recommend its use for long-term soft-tissue augmentation of the posterior pharyngeal wall in patients with velopharyngeal insufficiency.

Les séquelles vélopharyngées des fentes labioalvéolopalatovélaires. Les pharyngoplasties dynamiques types orticochea

Sphincter pharyngoplasty is one of the treatments for velopharyngeal insufficiency, in cleft palate patients. After Hynes, Orticochea described a procedure which became the reference. After studying 2 series of patients treated by two different surgical procedures, it appeared that the speech improvement was nearly the same. Improvement of the results was obtained when the surgical procedure took into account the physiopathology of the velopharyngeal insufficiency. When the velar mobility was weak or absent, but with an effective mobility of lateral pharyngeal walls, a pharyngoplasty with a pharyngeal flap and a superior pedicle was chosen. On the opposite, with an effective velar mobility, sphincter pharyngoplasty was chosen. When both were poor (velar and lateral pharyngeal walls), it seems that using a pharyngeal flap with a velum pushback gave the best result. If hypernasality persisted after pharyngoplasty, a second procedure had to be performed.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Pharyngoplastie par Lipostructure® du pharynx

Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Véloplasties et pharyngoplasties par lambeau pharyngé à pédicule supérieur ou inférieur

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.