Evaluation of the levator veli palatini muscle thickness in patients with velocardiofacial syndrome using magnetic resonance imaging

Growth and Symmetry of the Levator Veli Palatini Muscle Within the First Two Years of Life

OBJECTIVE

To quantify differences in levator veli palatini (LVP) muscle dimensions based on age, sex, and race and determine the typical range of asymmetry between the left and right sides of the LVP under age 2.

DESIGN

Retrospective cohort study.

SETTING

Children's tertiary care hospital.

PARTICIPANTS

A retrospective chart review of non-cleft patients under 2 who received a volumetric FLAIR MRI sequence within the past 18 months identified 216 patient scans. Exclusion criteria left 200 scans for analysis. Measurements of the LVP were obtained consistent with previous literature.

INTERVENTIONS

Corrected age, sex, and race.

MAIN OUTCOME MEASURE(S)

LVP muscle dimensions.

RESULTS

A significant (P < .0001) difference between corrected age groups based on the overall combination of LVP variables after controlling for sex and race. Significant age differences included average extravelar length (P < .0001), average intravelar length (P < .0001), midline thickness (P < .0001), and average (P < .0001) and difference (P = .0413) in insertion thickness. Significant sex differences included average intravelar length (P = .0412) and average insertion thickness (P = .0281). Significant race differences included average insertion thickness (P = .0334) and difference in intravelar length (P = .0473). Differences between left and right total length (P = .0491) and angle of origin (P < .0001) were significant.

CONCLUSIONS

Differences in LVP morphology were observed in individuals under 2 years or age related to age, sex, and race. While asymmetry was significant in some dimensions, it varied by age range.

Establishing a Clinical Protocol for Velopharyngeal MRI and Interpreting Imaging Findings

Traditional imaging modalities used to assess velopharyngeal insufficiency (VPI) do not allow for direct visualization of underlying velopharyngeal (VP) structures and musculature which could impact surgical planning. This limitation can be overcome via structural magnetic resonance imaging (MRI), the only current imaging tool that provides direct visualization of salient VP structures. MRI has been used extensively in research; however, it has had limited clinical use. Factors that restrict clinical use of VP MRI include limited access to optimized VP MRI protocols and uncertainty regarding how to interpret VP MRI findings. The purpose of this paper is to outline a framework for establishing a novel VP MRI scan protocol and to detail the process of interpreting scans of the velopharynx at rest and during speech tasks. Additionally, this paper includes common scan parameters needed to allow for visualization of velopharynx and techniques for the elicitation of speech during scans.

Three-dimensional finite element analysis on stress distribution after different palatoplasty and levator veli palatini muscle reconstruction

OBJECTIVES

To establish a three-dimensional finite element model of the upper palate, pharyngeal cavity, and levator veli palatini muscle in patients with unilateral complete cleft palate, simulate two surgical procedures that the two-flap method and Furlow reverse double Z method, observe the stress distribution of the upper palate soft tissue and changes in pharyngeal cavity area after different surgical methods, and verify the accuracy of the model by reconstructing and measuring the levator veli palatini muscle.

MATERIALS AND METHODS

Mimics, Geomagic, Ansys, and Hypermesh were applied to establish three-dimensional finite element models of the pharyngeal cavity, upper palate, and levator veli palatini muscle in patients with unilateral complete cleft palate. The parameters including length, angle, and cross-sectional area of the levator veli palatini muscle etc. were measured in Mimics, and two surgical procedures that two-flap method and Furlow reverse double Z method were simulated in Ansys, and the area of pharyngeal cavity was measured by hypermesh.

RESULTS

A three-dimensional finite element model of the upper palate, pharyngeal cavity, and bilateral levator veli palatini muscle was established in patients with unilateral complete cleft palate ; The concept of horizontal projection characteristics of the palatal dome was applied to the finite element simulation of cleft palate surgery, vividly simulating the displacement and elastic stretching of the two flap method and Furlow reverse double Z method during the surgical process; The areas with the highest stress in the two-flap method and Furlow reverse double Z method both occur in the hard soft palate junction area; In resting state, as measured, the two flap method can narrow the pharyngeal cavity area by 50.9%, while the Furlow reverse double Z method can narrow the pharyngeal cavity area by 65.4%; The measurement results of the levator veli palatini muscle showed no significant difference compared to previous studies, confirming the accuracy of the model.

CONCLUSIONS

The finite element method was used to establish a model to simulate the surgical procedure, which is effective and reliable. The area with the highest postoperative stress for both methods is the hard soft palate junction area, and the stress of the Furlow reverse double Z method is lower than that of the two-flap method. The anatomical conditions of pharyngeal cavity of Furlow reverse double Z method are better than that of two-flap method in the resting state.

CLINICAL RELEVANCE

This article uses three-dimensional finite element method to simulate the commonly used two-flap method and Furlow reverse double Z method in clinical cleft palate surgery, and analyzes the stress distribution characteristics and changes in pharyngeal cavity area of the two surgical methods, in order to provide a theoretical basis for the surgeon to choose the surgical method and reduce the occurrence of complications.

Simulation of Velopharyngeal Biomechanics Identifies Differences in Sphincter Pharyngoplasty Outcomes: A Matched Case-Control Study

The purpose of this study was to develop a framework for 3D subject-specific computational models capable of simulating velopharyngeal biomechanics for anatomic changes that occur following pharyngoplasty and to gain insight into biomechanical factors that may lead to different speech/surgical outcomes. Patient-specific models for two, matched participants with differing speech/surgical outcomes were developed: one with a successful pharyngoplasty outcome and one with a failed pharyngoplasty outcome. Surgical scenarios were simulated to model pharyngoplasty location, identify LVP muscle biomechanics, and identify an optimal pharyngoplasty location for each participant. These simulations illustrate the potential for optimizing pharyngoplasties based on patient-specific geometry.

Speech Telepractice and Treatment Intensity in a Cantonese-Speaking Case with 22q11.2 Deletion Syndrome Following Late Diagnosis and Management of Velopharyngeal Dysfunction

This case report explores clinical treatment efficacy in a Cantonese-speaking child with 22q11.2 Deletion Syndrome where diagnosis and management of velopharyngeal dysfunction can be considered late. All treatment sessions were undertaken via telepractice during the peak of the COVID-19 pandemic in Hong Kong. A hybrid of specialized cleft palate speech treatment techniques and traditional treatment approaches in Speech Sound Disorders were utilized. Treatment intensity components including dose, dose form, session duration, and total intervention duration were documented.

Assessment of the Velopharyngeal Mechanism at Rest and During Speech in Children With 22q11.2DS: A Cross-Sectional Study

OBJECTIVE

Velopharyngeal dysfunction (VPD) associated with 22q11.2 deletion syndrome (22q11.2DS) has a complex etiology. This study had 3 aims: (1) assess differences in velopharyngeal and levator muscle configuration during rest versus sustained speech production (2) compare differences in velopharyngeal changes between children with and without 22q11.2DS (3) examine the relationship between adenoid thickness, pharyngeal depth, and velopharyngeal changes.

DESIGN

Cross-sectional.

METHODS

A total of 22 participants, 11 with 22q11.2DS and 11 controls with normal speech and velopharyngeal anatomy (ages 4-12 years), underwent nonsedated MRI at rest and during sustained /i/. Differences in velar and levator muscle contraction across the 2 different conditions were analyzed, using matched paired t-tests. Mean differences across participant groups were examined. Correlation analyses were also conducted.

RESULTS

When comparing differences between rest and sustained phoneme production (aim 1), significant (P < .05) differences were noted for all velar and levator muscle variables. For differences in velopharyngeal changes between children with and without 22q11.2DS (aim 2), VP ratio and effective VP ratio were noted to be significantly different. Pharyngeal depth and adenoid thickness were correlated with velar and levator muscle change measures and ratios (aim 3).

CONCLUSION

Results from this study provide quantitative in vivo measurements of the contracted levator muscle and velum in young children with 22q11.2DS. Results demonstrated that VP ratio and EVP ratio are significantly different between children with and without 22q11.2DS and that pharyngeal depth is a strong clinical determinant of VPD in children with 22q11.2DS.

Precision Pharyngeal Flap: An Individualized, Patient-Specific Surgery for the Treatment of Velopharyngeal Insufficiency

BACKGROUND

The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author.

MATERIALS AND METHODS

Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined.

RESULTS

Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P < 0.01). Postoperative nasalance scores revealed sufficient postoperative resonance rating in 96% of patients. No patients experienced postoperative complications (bleeding, airway obstruction, and surgical wound dehiscence).

CONCLUSIONS

Individually configured pharyngeal flaps designed based on preoperative nasopharyngoscopic examination coupled with precise surgical techniques led to the high surgery success rate for VPI treatment.

Characteristics and surgical outcomes of cleft palate in kabuki syndrome: a case series of 11 patients

OBJECTIVE

A significant number of patients with KS have cleft palate (CP) or submucous cleft palate (SMCP) and show delayed speech development. However, few reports have discussed the characteristics of CP in KS and the outcomes of postoperative speech development. The purpose of this study was to investigate the characteristics and surgical outcomes of CP in patients with KS, and to discuss the importance of the diagnosis of CP or SMCP.

METHODS

We conducted a retrospective study on patients with clinically diagnosed KS who underwent palatoplasty. Clinical and surgical data were collected from patients' medical records, and velopharyngeal function was evaluated using nasopharyngoscopy and speech analysis.

RESULTS

In 11 cases, 5 patients had CP (45.5%) and 6 had SMCP (54.5%). Four patients who were genetically tested had a pathogenic variant of KMT2D. Seven of nine patients (77.8%) who underwent conventional palatoplasty showed velopharyngeal insufficiency and hypernasality. All patients who underwent pharyngeal flap surgery achieved velopharyngeal competency. Statistical analysis revealed a statistically significant difference in postoperative results between non-syndromic and KS patients.

CONCLUSION

Patients with SMCP may be more common than previously reported. The results showed that it is difficult to produce optimal results with conventional palatoplasty; therefore, pharyngeal flap surgery should be considered as a treatment to obtain favorable results. Pharyngeal flap surgery in patients with KS should be carefully designed based on speech evaluation and nasopharyngoscopic findings.

Velopharyngeal Incompetence in Children With 22q11.2 Deletion Syndrome: Velar and Pharyngeal Dimensions

ABSTRACT

The surgical management of velopharyngeal incompetence (VPI) in children with 22q11.2 deletion syndrome (22q11.2 DS) is challenging. There are numerous approaches and children often undergo more than one operation. Our aim was to develop a method using images from routine lateral videofluoroscopy to study the dimensions of the velopharynx in this cohort.We analyzed 22 pre-operative lateral videofluoroscopy recordings of children with 22q11.2 DS and VPI. Fourteen had a submucous cleft palate (SMCP) and 8 had no obvious palatal abnormality but who were subsequently labelled as having an occult submucous cleft palate (OSMCP). The control data were 10 historic records of children with cleft lip and an intact palate. The authors identified key points on radiographs of the velum at rest and when elevated to measure the total velar length, functional velar length and pharyngeal depth and compared them ratiometrically.The intra-observer reliability was > 0.9 whereas the inter-observer reliability was > 0.74. The velopharyngeal depth/total velar length was significantly greater in 22q11.2 DS than the control group P < 0.001. There was no difference between SMCP and OSMCP patients, P = 0.556. There was no difference in the functional velar length/total velar length between 22q11.2 DS and controls (P = 0.763).In this study, the authors demonstrate a reliable method to gain useful ratiometric measurements of the velopharynx. This may help with treatment planning. Children with 22q11.2 DS and VPI have a larger velopharyngeal depth/total velar length ratio that may explain some of the difficulty in management.

Speech Outcomes Following Orticochea Pharyngoplasty in Patients With History of Cleft Palate and Noncleft Velopharyngeal Dysfunction

OBJECTIVE

To report speech outcomes following Orticochea pharyngoplasty in 43 patients with cleft palate and noncleft velopharyngeal dysfunction.

DESIGN

A retrospective surgical audit of patients undergoing Orticochea pharyngoplasty between 2004 and 2012, with speech as a primary outcome measure.

SETTING

Patients known to a regional UK cleft center.

METHODS

Forty-three patients underwent Orticochea pharyngoplasty by a single surgeon in a UK regional cleft center. Twenty-one patients had undergone a prior procedure for velopharyngeal dysfunction. Pre- and postoperative speech samples were assessed blindly using the Cleft Audit Protocol for Speech-Augmented by a specialist cleft speech and language therapist, external to the team. Speech samples were rated on the following parameters: hypernasality, hyponasality, audible nasal emission, nasal, turbulence, and passive cleft speech characteristics. Statistical differences in pre- and postoperative speech scores were tested using the Wilcoxon matched-pairs signed-ranks test. Inter- and intrareliability scores were calculated using weighted Cohen κ.

RESULTS

Whole group: A statistically significant difference in pre- and postoperative scores for hypernasality (P < .001), hyponasality (P < .05), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported. Patients with cleft diagnoses: A statistically significant difference in scores for hypernasality (P < .001), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported for this group of patients. Patients with noncleft diagnoses: The only parameter to demonstrate a statistically significant difference was hypernasality (P < .01) in this group.

CONCLUSIONS

Orticochea pharyngoplasty is a successful surgical procedure in treating velopharyngeal dysfunction in both the cleft and noncleft populations.

Deep-learning-based segmentation of the vocal tract and articulators in real-time magnetic resonance images of speech

BACKGROUND AND OBJECTIVE

Magnetic resonance (MR) imaging is increasingly used in studies of speech as it enables non-invasive visualisation of the vocal tract and articulators, thus providing information about their shape, size, motion and position. Extraction of this information for quantitative analysis is achieved using segmentation. Methods have been developed to segment the vocal tract, however, none of these also fully segment any articulators. The objective of this work was to develop a method to fully segment multiple groups of articulators as well as the vocal tract in two-dimensional MR images of speech, thus overcoming the limitations of existing methods.

METHODS

Five speech MR image sets (392 MR images in total), each of a different healthy adult volunteer, were used in this work. A fully convolutional network with an architecture similar to the original U-Net was developed to segment the following six regions in the image sets: the head, soft palate, jaw, tongue, vocal tract and tooth space. A five-fold cross-validation was performed to investigate the segmentation accuracy and generalisability of the network. The segmentation accuracy was assessed using standard overlap-based metrics (Dice coefficient and general Hausdorff distance) and a novel clinically relevant metric based on velopharyngeal closure.

RESULTS

The segmentations created by the method had a median Dice coefficient of 0.92 and a median general Hausdorff distance of 5mm. The method segmented the head most accurately (median Dice coefficient of 0.99), and the soft palate and tooth space least accurately (median Dice coefficients of 0.92 and 0.93 respectively). The segmentations created by the method correctly showed 90% (27 out of 30) of the velopharyngeal closures in the MR image sets.

CONCLUSIONS

An automatic method to fully segment multiple groups of articulators as well as the vocal tract in two-dimensional MR images of speech was successfully developed. The method is intended for use in clinical and non-clinical speech studies which involve quantitative analysis of the shape, size, motion and position of the vocal tract and articulators. In addition, a novel clinically relevant metric for assessing the accuracy of vocal tract and articulator segmentation methods was developed.

Evaluation of the Symmetry of the Levator Veli Palatini Muscle and Velopharyngeal Closure Among a Noncleft Adult Population

PURPOSE

The goal of this study is to determine the typical range of asymmetry between the length and thickness of the levator veli palatini muscle and to explore the impact of the observed asymmetry on velopharyngeal closure. A second objective is to report normative length and thickness of the levator veli palatini muscle among adults with typical velopharyngeal anatomy.

METHOD

Magnetic resonance imaging (MRI) data and Amira 5.5 Visualization software were used to evaluate the levator veli palatini muscle among 89 participants with typical velopharyngeal anatomy. Flexible nasopharyngoscopy was used to determine the function of velopharyngeal closure among 39 of the 89 participants with typical velopharyngeal anatomy to examine the functional impact of observed asymmetry.

RESULTS

Matched paired t tests demonstrated a nonsignificant difference between the length and thickness of the right and left levator muscle. The mean difference between the right and left length of the levator muscle was 2.28 mm but ranged from 0.09 mm to 10.37 mm. In all cases where individuals displayed asymmetry in the levator muscle through MRI, there was no observed impact on the symmetry of velopharyngeal closure.

DISCUSSION

This study suggest that differences in the right and left levator veli palatini muscle are not significant among individuals without cleft palate. However, among individual cases where asymmetry was sizeable, there was no direct impact on the closure pattern. This may suggest there are multiple factors that contribute to asymmetrical velopharyngeal closure that are beyond the level of the levator veli palatini muscle.

Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study

OBJECTIVE

To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech.

METHODS

Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech.

RESULTS

Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls.

CONCLUSIONS

The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

Contracted Extravelar Segments of the Levator Veli Palatini Muscle: A Magnetic Resonance Imaging Morphometric Study

OBJECTIVES

To provide detailed descriptions of contraction-induced morphometric changes in the extravelar segments of the levator veli palatini (LVP) muscle using 3-dimensional (3-D) magnetic resonance imaging (MRI).

DESIGN

Three-dimensional MRI data were acquired at rest and during "silent /i/" from 4 singers. During silent /i/, participants voluntarily sustained velar elevation while breathing orally for the entire scan time. Focusing on the extravelar segments, LVP length, angle of the muscle origin, and cross-sectional area (CSA), measurements were obtained and compared between tasks.

RESULTS

Three of the 4 participants exhibited the expected patterns of change following concentric contraction of the LVP muscle. Consistent changes from the resting to the contracted state included reductions in LVP length by 13.5% and angle of the muscle origin by 9.8%, as well as increases in CSAs by 22.1%, on average.

CONCLUSIONS

This study presented high-resolution data of the LVP muscle behavior with the first in vivo 3-D measurements of the contracted LVP muscle, which can be useful for the validation of computational models that aim at describing biomechanical properties of the LVP muscle in future research. The active behavior of the extravelar LVP muscle also provides some insight on optimal LVP muscle geometry to consider during cleft palate repair.

Asymmetry and Positioning of the Levator Veli Palatini Muscle in Children With Repaired Cleft Palate

Purpose The purpose of this study is to examine the differences in velopharyngeal dimensions as well as levator veli palatini (levator) muscle morphology, positioning, and symmetry of children with repaired cleft palate with velopharyngeal insufficiency (VPI), children with repaired cleft palate with complete velopharyngeal closure, and children with noncleft anatomy. Method Fifteen children ranging in age from 4 to 8 years were recruited for this study. Ten of the participants had a history of repaired cleft palate, half with documented VPI and the other half with velopharyngeal closure. Five participants with noncleft anatomy were matched for age from a normative database. The magnetic resonance imaging protocol, processing methods, and analysis are consistent with that used in previous literature. Results Regarding velopharyngeal dimensions, median values were statistically significantly different between groups for sagittal angle (p = .031) and effective velopharyngeal ratio (p = .013). With respect to the levator muscle, median values were statistically significant for average extravelar length (p = .018), thickness at midline (p = .021), and thickness between the left and right muscle bundles at the point of insertion into the velum (p = .037). Remaining measures were not statistically significant. Conclusions The levator muscle is significantly different among these three groups with respect to thickness at midline, extravelar length, and symmetry at the point of insertion into the velum. Sagittal angle and effective velopharyngeal ratio are also significantly different. Participants with repaired cleft palate and VPI displayed the greatest degree of asymmetry. Future research should control for surgical procedure type to determine the impact of surgery on the levator muscle and surrounding velopharyngeal anatomy.

Speech-Language Disorders in 22q11.2 Deletion Syndrome: Best Practices for Diagnosis and Management

Purpose Speech and language disorders are hallmark features of 22q11.2 deletion syndrome (22qDS). Learning disabilities, cognitive deficits, palate abnormalities, velopharyngeal dysfunction, behavioral differences, and various medical and psychiatric conditions are also major features of this syndrome. The goal of this document is to summarize the state of the art of current clinical and scientific knowledge regarding 22qDS for speech-language pathologists (SLPs) and provide recommendations for clinical management. Method Best practices for management of individuals with 22qDS were developed by consensus of an expert international group of SLPs and researchers with expertise in 22qDS. These care recommendations are based on the authors' research, clinical experience, and literature review. Results This document describes the features of 22qDS as well as evaluation procedures, treatment protocols, and associated management recommendations for SLPs for the often complex communication disorders present in this population. Conclusion Early diagnosis and appropriate management of speech-language disorders in 22qDS is essential to optimize outcomes and to minimize the long-term effects of communication impairments. Knowledge of this diagnosis also allows anticipatory care and guidance regarding associated features for families, health care, and educational professionals.

Velopharyngeal Structural and Muscle Variations in Children With 22q11.2 Deletion Syndrome: An Unsedated MRI Study

Objective:

The 22q11.2 deletion syndrome (22q11.2DS) is the most common genetic cause of velopharyngeal dysfunction; however, limited information exists regarding variations in velopharyngeal anatomy in this clinically challenging population. The purpose of this study was to examine velopharyngeal characteristics among young children with 22q11.2DS in comparison to a normative cohort using an innovative, nonsedated magnetic resonance imaging (MRI) scanning protocol.

Methods:

Fifteen children with 22q11.2DS and 15 age- and gender-matched controls with normal velopharyngeal anatomy (ages 4-12) successfully completed the MRI protocol. Eighteen velopharyngeal and 2 related craniofacial measures were examined. Analysis of covariance was used to compare differences between the experimental and the control groups.

Results:

The 22q11.2DS group demonstrated a significantly thinner velum ( P < .0005) and a larger pharyngeal depth ( P = .007) compared to the matched control group. Findings in the current study also demonstrated that the levator veli palatini muscle is significantly shorter ( P = .037) and thinner ( P = .025) in the 22q11.2DS cohort, with a significantly shorter origin-to-origin distance ( P < .0005) and a greater angle of origin ( P = .001) compared to healthy peers.

Conclusion:

Children with 22q11.2DS demonstrated multiple variations that may contribute to velopharyngeal dysfunction by altering the anatomic characteristics of the velopharyngeal port, the levator muscle, and associated structures. This investigation represents the first and largest attempt to characterize velopharyngeal anatomy in children with 22q11.2DS using a nonsedated MRI protocol.

22q11.2 Deletion: Surgical and Speech Outcomes of Patients With Velopharyngeal Insufficiency Treated With a Superiorly Based Pharyngeal Flap as the Primary Surgery

The most frequent palate diagnoses in patients with chromosome 22q11.2 deletion syndrome are a classic submucous cleft, occult, and velopharyngeal insufficiency without cleft, which generates alterations in speech that require surgery. Surgical protocols are controversial owing to syndrome characteristics that make their handling more complex. Pharyngeal flap pharyngoplasty is effective for this type of patient. The objective of this study is to examine the surgical management of velopharyngeal insufficiency in patients with chromosome 22 deletion, using a pharyngeal flap as the primary surgery. The clinical records of patients with chromosome 22 deletion and velopharyngeal insufficiency between 2015 and 2017 were analyzed retrospectively. Eight patients underwent pharyngeal flap pharyngoplasty as a primary surgery, including 1 with velopharyngeal insufficiency without a cleft, 1 with a classic submucous cleft, and 6 with occult submucous cleft. The pre- and postoperative protocol performed by speech therapists and surgeons included clinical evaluation of the oral cavity; perceptual, video recording, and nasometry speech evaluation; and videonasopharyngoscopy. All perceptual parameters and nasometry results significantly changed. Of the cases, 88% achieved a flap with the expected width and height and complete closure of the velopharyngeal sphincter. One patient required flap revision. Four of the 8 patients achieved normal resonance, and 2 of 8 showed mild hypernasality. Using the pharyngeal flap pharyngoplasty as a primary technique to correct velopharyngeal insufficiency in patients with chromosome 22 deletion provides satisfactory outcomes and decreases the number of surgeries. Preoperative planning must be conducted carefully and needs to be individualized to be successful.

Effects of Surgical Intervention and Continuous Positive Airway Pressure Therapy on Velopharyngeal Structure and Function: A Case Report

Changes to the velum and velopharyngeal muscles following Furlow double-opposing Z-plasty in a 7-year-old female with submucous cleft palate and velopharyngeal dysfunction (VPD) were evaluated. Perceptual, instrumental (ie, nasometry and aerodynamic pressure flow), and research magnetic resonance imaging analyses were used during pre- and postsurgical time points at a university research clinic. Continuous positive airway pressure (CPAP) therapy was trialed following a failed surgery for residual VPD in the patient. Increases in velar length and thickness and decreases in levator veli palatini muscle angle of origin and contraction were observed following the Furlow double-opposing Z-plasty surgery. Variable improvements in residual hypernasality following the home-based CPAP therapy protocol were observed.

Clinical Significance of the Levator Veli Palatini Muscle in Velocardiofacial Syndrome Patients

Background:

Anatomical variation and deficits of velocardiofacial syndrome patients are related to unsatisfactory treatment results in surgical correction of speech abnormalities. The main purpose of the article is to investigate the clinical significance of thinned levator veli palatini muscle in VCFS patients.

Methods:

The authors reviewed medical records of all children with velocardiofacial syndrome who received pharyngeal flap surgery between March 2007 and September 2015. Data including thickness of levator veli palatini in magnetic resonance examination; preoperative velopharyngeal gap size from nasoendoscopy; and preoperative and postoperative speech outcomes were collected.

Results:

Total of 36 velocardiofacial syndrome patients with preoperative objective data and postoperative speech outcomes were identified. Preoperative velopharyngeal gap showed significant correlation with thickness of levator veli palatini (correlation coefficient: 0.297/0.397, P = .02/.03) and gap size showed correlation with postoperative speech improvement (0.347/0.413, P = .04/.02). However, muscle thickness showed no correlation with speech outcomes (0.046/0.037, P = .77/.86).

Conclusion:

Thinned levator veli palatini muscle in velocardiofacial syndrome patients are related to widened velopharyngeal gap and production of hypernasal speech, and can give negative impact on postoperative surgical outcome of pharyngeal flap surgery.

Test-retest repeatability of human speech biomarkers from static and real-time dynamic magnetic resonance imaging

Static anatomical and real-time dynamic magnetic resonance imaging (RT-MRI) of the upper airway is a valuable method for studying speech production in research and clinical settings. The test-retest repeatability of quantitative imaging biomarkers is an important parameter, since it limits the effect sizes and intragroup differences that can be studied. Therefore, this study aims to present a framework for determining the test-retest repeatability of quantitative speech biomarkers from static MRI and RT-MRI, and apply the framework to healthy volunteers. Subjects (n = 8, 4 females, 4 males) are imaged in two scans on the same day, including static images and dynamic RT-MRI of speech tasks. The inter-study agreement is quantified using intraclass correlation coefficient (ICC) and mean within-subject standard deviation (σ_e). Inter-study agreement is strong to very strong for static measures (ICC: min/median/max 0.71/0.89/0.98, σ_e: 0.90/2.20/6.72 mm), poor to strong for dynamic RT-MRI measures of articulator motion range (ICC: 0.26/0.75/0.90, σ_e: 1.6/2.5/3.6 mm), and poor to very strong for velocities (ICC: 0.21/0.56/0.93, σ_e: 2.2/4.4/16.7 cm/s). In conclusion, this study characterizes repeatability of static and dynamic MRI-derived speech biomarkers using state-of-the-art imaging. The introduced framework can be used to guide future development of speech biomarkers. Test-retest MRI data are provided free for research use.

Examining a New Method to Studying Velopharyngeal Structures in a Child With 22q11.2 Deletion Syndrome

PURPOSE

To date, no studies have imaged the velopharynx in children with 22q11.2 deletion syndrome (22q11.2 DS) without the use of sedation. Dysmorphology in velopharyngeal structures has been shown to have significant negative implications on speech among these individuals. This single case study was designed to assess the feasibility of a child-friendly magnetic resonance imaging (MRI) scanning protocol in this clinically challenging population and to determine the utility of this MRI protocol for future work in this area.

METHOD

One 6-year-old White girl diagnosed with 22q11.2 DS was imaged using a child-friendly, nonsedated MRI protocol. Quantitative and qualitative measures of the velopharyngeal area and associated structures were evaluated, and comparisons were made to age-matched control subjects with normal velopharyngeal anatomy.

RESULTS

MRI data were successfully obtained using the child-friendly scanning protocol in the subject in the present study. Quantitative and qualitative differences of the levator muscle and associated velopharyngeal structures were noted. Using these MRI and structural analyses methods, insights related to muscle morphology can be obtained and considered as part of the research and clinical examination of children with 22q11.2 DS.

CONCLUSION

The imaging protocol described in this study presents an effective means to counteract difficulties in imaging young children.