Posterior pharyngeal flap for velopharyngeal insufficiency patients: A New Technique for Flap Inset

Correlation of the Chinese velopharyngeal insufficiency-related quality of life instrument and speech in subjects with cleft palate

OBJECTIVE

Assessment of the hypothesized correlation between the Chinese Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) instrument and measured speech parameters.

METHODS

A cross-sectional study was conducted in the Oral Clefts Center of West China Hospital of Stomatology between January 2019 and December 2019. Speech parameters including speech intelligibility deficit, VPI severity, VP gap, and need for speech therapy were evaluated by speech-language pathologists. All patients and their parents completed the VELO instrument. The correlation between aforementioned speech parameters and VELO scores was examined utilizing Spearman correlation coefficients. The reliability of VELO test-retest and parent proxy assessment was estimated utilizing intraclass correlation coefficients (ICC). A receiver operating characteristic curve was used to calculate the cutoff VELO score.

RESULTS

One hundred and forty patients with their parents were enrolled. The mean age was 12.58 ± 3.72 years. Both parent and youth VELO total and domain scores recorded moderate to strong correlations with all speech parameters (r > -.40, P ˂ .001) except the swallowing domain. Most VELO domain items have shown significant correlations with at least one speech parameter. Moreover, the scales of all speech parameters showed different VELO scores (P ˂ .001). The ICC reported test-retest correlation >.73 in all domains, and parent proxy correlation >.63 in most domains except the emotional and perception domains. The cutoff VELO score was 79.04 in parent version and 85.77 in youth version.

CONCLUSIONS

The correlations between VELO scores and measured speech parameters have provided evidence for test-retest and parent proxy reliability and criterion and construct validity of the Chinese version of the VELO instrument. A VELO score ≥79.04 (in parent version) or ≥85.77 (in youth version) mostly reflects proper speech-related quality of life. Hence, this instrument could serve as a simple tool to help clinicians understand the social, emotional, and physical influences of VPI.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence

OBJECTIVE

To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication.

DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded.

INTERVENTION

Modified pharyngeal flap with through-and-through dissection of the soft palate.

MAIN OUTCOME MEASURE(S)

Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale.

RESULTS

The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours.

CONCLUSIONS

This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Outcomes in Velopharyngeal Dysfunction Treatment: Comparing Two Approaches for Pharyngeal Flaps

BACKGROUND

The most common surgical intervention to treat velopharyngeal dysfunction in the US is the posterior pharyngeal flap (PPF). In this retrospective study, the authors compare surgical and speech outcomes across 2 PPF surgical approaches: the palatal split (PS) and fish mouth (FM) techniques.

METHODS

An Institutional Review Board approved retrospective chart review was performed for PPF cases performed by a single surgeon between 2008 and 2016. Overall, 40 patients received the PS technique and 47 received the FM technique. Age at surgery, operative length, length of stay (LOS), revisional surgery, and pain medication administration were measured. Speech outcomes were measured based on the Universal Parameters for Reporting Speech Outcomes and included Speech Language Pathologist ratings of hypo- and hypernasality, speech acceptability, and audible nasal emission. Two sample t-tests and multivariable-mixed effects logistic regression were used to analyze the data.

RESULTS

Comparing the 2 groups (PS versus FM), there were statistically significant differences among the operative approaches across multiple measures: LOS (32.86 hours versus 26.20 hours, P = 0.01), acetaminophen use (1523.54 mg versus 805.74 mg, P = 0.01), revisional surgery rate (17.5% versus 2.10%, P = 0.02), and degree of postoperative hypernasality (0.61 versus 0.29, P = 0.03). Syndromic patients were more likely to receive the FM technique (PS: 15% versus FM: 29.8%; P = 0.05). The odds ratio for revision surgery with the FM technique was -2.32 (CI: -4.32 to -0.35, P = .04).

CONCLUSIONS

In this study, the FM technique offered a shorter LOS, lower revision rate, less acetaminophen administration, and more favorable speech outcomes when compared to the PS technique.

Assessment of the New L Pharyngeal Flap for Velopharyngeal Insufficiency

OBJECTIVE

To assess the results of the new L pharyngeal flap for treatment of velopharyngeal insufficiency (VPI).

METHODS

This study included 60 patients who were diagnosed as persistent VPI (for > 1 year without response to speech therapy for 6 months at least). L-shaped superiorly based pharyngeal flap was tailored from oropharynx and inserted into the soft palate through a transverse full-thickness palatal incision 1 cm from the hard palate, then the distal horizontal part of the flap was spread 1 cm anteroposterior direction and 1 cm horizontally into the soft palate. Prior to and after surgery, patients were assessed by oral examination, video nasoendoscopy, and speech evaluation.

RESULTS

Postoperative speech assessment showed significant improvement in nasoendoscopic closure, speech assessment, and nasometric assessments. Grade 4 velopharyngeal valve closure (complete closure) could be achieved in 59 (98.3%) patients at 6 months postoperatively. No patients showed dehiscence (partial or total) of the flap and no obstructive sleep apnea was reported.

CONCLUSION

The newly designed L pharyngeal flap was proved to be highly effective, reliable, and safe in treating patients with persistent VPI with easy applicability and without significant complication.

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity

Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.

De-mucosalized pharyngeal flap: a modified technique for selected cases of velopharyngeal insufficiency

BACKGROUND AND PURPOSE

Superiorly based posterior pharyngeal flap is performed via rotation of tissues of the posterior pharyngeal wall anteriorly and anchoring it to the soft palate. Unfortunately, bad healing of the donor site defect might be a considerable cause of morbidity of the surgery. With some modifications of flap elevation we could achieve better surgical outcomes. The aim of this study was to present the new modification of the conventional maneuver and its surgical/functional outcomes.

SUBJECTS AND METHODS

The study design is a case series. 17 patients underwent the de-mucosalized superiorly based pharyngeal flap for the treatment of velopharyngeal insufficiency. A wide laterally based (mucosa-only) flap was elevated off the submucosa of the posterior pharyngeal wall and then a superiorly based posterior pharyngeal flap (bared of its covering mucosa) was elevated and sutured to the palate. The mucosal flap was draped over the bed and sutured.

RESULTS

No significant complications as airway problems, infection and bleeding were reported. Also, the postoperative pain was tolerable and there were no reports of neck rigidity with early ambulation; VAS showed significant improvement. No patients showed flap dehiscence or palatal fistula. Speech assessment showed improvement.

CONCLUSION

The modified de-mucosalized, superiorly based pharyngeal flap technique ensured self-mucosal draping of the bed, thus it would enhance primary healing and decrease postoperative pain with the resultant early ambulation. We believe that the new modified technique could correct VPI, in addition to the improvement of patients' comfort and decrease the morbidity of the procedure.

A novel technique for superior-based pharyngeal flaps: 10-year results with formal speech outcomes assessment

PURPOSE

Describe a novel technique for superior-based pharyngeal flaps allowing restoration of bulk to the soft palate and intraoperative fine-tuning of lateral port size, while avoiding midline palate-splitting. Validated speech assessment tools are employed for quantitative analysis.

METHODS

Retrospective review of all patients who underwent superior-based pharyngeal flap in a 10-year period by a single surgeon. Pittsburgh Weighted Values for Speech Symptoms Associated with VPI and the Goldman-Fristoe Test of Articulation were used for formal speech assessment.

RESULTS

78 patients met inclusion criteria with clinical data up to 10years postoperatively. 31 patients had congenital velopharyngeal insufficiency (VPI), and the remainder acquired VPI after cleft palate repair or adenoidectomy. 37 patients had a recognized syndrome. All patients noted subjective improvement in nasality, and evaluation with the validated speech assessment tools demonstrated statistically significant improvement in speech. Only one flap takedown was required in a patient with severe midface hypoplasia who developed sleep apnea several years postoperatively.

CONCLUSIONS

This technique is successful in congenital and acquired VPI, and in patients with complex craniofacial syndromes. Customization of lateral ports based on preoperative nasopharyngoscopy, and avoidance of a midline palate splitting incision, make this an attractive option for superior-based flap surgery.

Nasalance Changes Following Various Endonasal Surgeries

Introduction There is change in nasalance post endonasal surgery which is not permanent.

Objectives The objective of this study is to evaluate the long-term nasalance changes following different types of endonasal surgeries.

Methods We included in this study patients who underwent sinonasal surgery at the Otorhinolaryngology Department in Zagazig University Hospitals from February 2015 until March 2016. We divided the patients into two groups according to the surgeries they underwent: Group (A) was the FESS group and group (B), the septoturbinoplasty group. We checked nasalance using a nasometer before and after the sinonasal surgery.

Results Nasalance increased at one month after the operation in both groups. However, it returned to nearly original levels within three months postoperatively.

Conclusion FESS, septoplasty, and turbinate surgery may lead to hypernasal speech. This hypernasal speech can be a result of change in the shape and diameter of the resonating vocal tract. Hypernasal speech in these circumstances may be a temporary finding that can decrease with time. Surgeons should inform their patients about the possibility of hypernasality after such types of surgery, especially if they are professional voice users.

Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function.

METHODS

This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation.

RESULTS

All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001).

CONCLUSION

ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.

The effect of sound intensity on velopharyngeal function in normal individuals

OBJECTIVE

Velopharyngeal closure is an important physiological process contributing to the normal function of speech and swallowing. The aim of this study was to analyze the influence of sound intensity on velopharyngeal function in normal individuals.

MATERIALS AND METHODS

Lateral cephalograms of 38 volunteers obtained at rest and during phonation of vowel /i:/ at both high and low sound intensity were carefully analyzed. The digital sound level meter was used to evaluate and record the sound intensity of the phonation process. The angular and linear parameters on the lateral cephalograms were then measured to reveal the correlation between sound intensity and velopharyngeal closure.

RESULTS

All the angular parameter values measured in the study were significantly greater in high sound intensity condition. As for linear parameters, all values were found to be significantly larger at high sound intensity, except for the effective velopharyngeal length and the vertical velopharyngeal length. A multiple linear regression model was set up to describe the correlation between the sound intensity, the effective velopharyngeal length, and velopharyngeal closure. With the increase of sound intensity and the decrease of the effective velopharyngeal length, the width of velopharyngeal closure is enlarged.

CONCLUSIONS

As one of the characteristic features of sound wave, the sound intensity was found to affect the objectively measured parameters of velopharyngeal closure on lateral cephalograms.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children

OBJECTIVE

To describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children.

METHODS

Prospective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5-12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate.

RESULTS

All 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively.

CONCLUSIONS

Our modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.