Injection Pharyngoplasty With a Hyaluronic Acid and Dextranomer Copolymer to Treat Velopharyngeal Insufficiency in Adults

Efficacy of Posterior Pharyngeal Wall Injection for Velopharyngeal Dysfunction in Adults

OBJECTIVE(S)

Posterior pharyngeal wall (PPW) injection is often employed to treat velopharyngeal deficiency (VPD). We sought to analyze the impact of PPW injection on severity of dysphagia and dysphonia.

METHODS

Retrospective chart review was conducted of patients undergoing PPW injection from 2018 to 2023 at a tertiary laryngology center. Effects on Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), soft palate closure on modified barium swallow, and auditory-perceptual measures of hypernasality and audible nasal air emission were analyzed.

RESULTS

67 PPW injections were performed in 29 patients (11 female). Mean age was 59.4 ± 17.0 years. Etiologies were head and neck cancer (n = 23) and neurologic conditions (n = 6). 30 PPW injections were performed concurrent with intervention on the upper esophageal sphincter (25 dilations, 3 myotomies, 2 botulinum toxin injections), and 8 with a glottic procedure (6 vocal fold injections, 2 thyroplasties). Change scores were 3.87 (-6.85 to -0.89, p = .012) for VHI-10 and -3.00 (-4.75 to -1.25, p = 0.001) for EAT-10. These were statistically different from 0 for the whole cohort but not in the subset of patients undergoing concurrent voice and/or swallow surgery. Soft palate closure scores tended to be better (but not statistically significant) on MBS after PPW injection. Hypernasality and audible nasal air emission both improved after injection.

CONCLUSION

PPW injection appears to have a therapeutic effect on dysphagia/dysphonia in patients with VPD; however, many patients have multifactorial impairment. Additional study is needed to determine benefit of PPW when performed in conjunction with other procedures in this complex patient population.

LEVEL OF EVIDENCE

Level 4 (Case series) Laryngoscope, 2024.

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 3: Objective Assessment and Surgical Decision-Making

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. After an auditory-perceptual speech evaluation by a speech-language pathologist, objective assessment of the VP port is required to determine the need for surgical intervention. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 3, the authors focus on the modalities for objective VP port assessment, including both direct and indirect methods. Direct imaging techniques such as videofluoroscopy, nasoendoscopy, and MRI are detailed for their strengths and limitations in visualizing VP port function and preoperative planning. Indirect assessments, including nasometry and aerodynamic measurements, are also briefly discussed. The decision-making process for surgical intervention is explored, emphasizing factors such as the severity and etiology of VPD, VP closure patterns, palatal length, orientation of the levator veli palatini, and other patient-specific considerations. The authors review the surgical options for repair including palatoplasty procedures (Furlow palatoplasty, straight-line intravelar veloplasty, and palatal lengthening buccal myomucosal flaps) and pharyngoplasty procedures (posterior pharyngeal flaps and sphincter pharyngoplasty), highlighting their indications, techniques, and potential complications. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.

An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis

BACKGROUND

Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature.

METHODS

This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications.

RESULTS

The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases.

CONCLUSIONS

Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.

What We Learned from Performing the Inverse Malek Procedure to Repair Bilateral Cleft Lips and Palates: A Single-Center Retrospective Study

Background: This study reviews the surgical and functional outcomes of children diagnosed with a bilateral cleft lip and palate and treated by the same surgical team following specific surgical protocols 18 years after surgery and during the follow-up. Methods: Based on a single-center retrospective design, demographic and surgical data were gathered by the authors from international institutions. Most of the data were quantitative in nature, and descriptive statistical and non-parametric tests were employed for analysis. All children born with a bilateral cleft from 1982 to 2002 were considered. Children affected by a syndrome were excluded. Complications and speech results were the main items measured. Results: Thirty patients were selected; 73.3% were treated using the inverse Malek procedure, and 26.7% underwent a modified two-stage procedure. Seventy percent developed an oronasal fistula. An alveolar bone graft was performed in 83%, and 53.3% underwent Le Fort osteotomy. Thirty-six percent required a pharyngeal flap, with good speech results. The median number of times general anesthesia was used among all the interventions considered was 5.5 (4.25-6). Conclusions: This study presents the long-term results of using the inverse Malek procedure to treat children with a bilateral cleft lip and palate. It is shown that this is related to a high risk of developing a fistula, but has good long-term speech results.

Surgical Management of Velopharyngeal Dysfunction

Velopharyngeal dysfunction (VPD) is caused by inadequate closure of the velopharyngeal port. VPD can hinder a child's ability to communicate and can impact his/her quality of life. Evaluation of children with VPD is often completed in a multidisciplinary setting and often involves studies that allow for the visualization of the velopharyngeal closure during voluntary speech (ie, nasopharyngoscopy). Multiple surgical options exist for the treatment of VPD including pharyngeal flap, sphincter pharyngoplasty, buccal myomucosal flaps, Furlow palatoplasty, palate re-repair, intravelar veloplasty, and injection pharyngoplasty. Each speech surgery has its unique benefits and drawbacks and the decision on which surgery to recommend should be tailored to each patient's specific needs and weighing the risk/benefit profile for their specific surgeries.

Mitigating Infectious Complications of Injection Pharyngoplasty with Calcium Hydroxyapatite for Velopharyngeal Insufficiency: Retropharyngeal Abscess and Osteomyelitis

Velopharyngeal insufficiency is a complex condition with various treatment options. In this case, a patient with a cleft palate who was treated for velopharyngeal insufficiency with calcium hydroxyapatite injection pharyngoplasty developed persistent cervical pain on postoperative day 6. CT imaging showed a hypodense structure in the right retropharyngeal tissue, and cultures tested positive for Streptococcus intermedius and Staphylococcus aureus. An MRI later revealed skull base osteomyelitis. The infection was controlled via surgical intervention and antibiotics. This case highlights potential severe complications from injection pharyngoplasty and it underscores the importance of early recognition and management of infectious complications.

Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency

BACKGROUND

Velopharyngeal insufficiency (VPI) can cause resonance, speech and feeding problems. While reconstructive palatoplasty and surgical pharyngoplasty techniques are the mainstay of treatment for severe VPI, injection augmentation pharyngoplasty offers a minimally invasive approach in patients with mild-to-moderate VPI.

METHODS

We conducted a systematic review of the literature available on PubMed and Embase from 1990 to 2019 including studies that addressed VPI, incompetence, or dysfunction managed with injection augmentation. Patient demographics, etiology of VPI, injection material, volume of injection, number of injections, complications and both subjective and objective outcomes were recorded.

RESULTS

Twenty-nine studies met our inclusion criteria encompassing 587 patients, ages 3-75 years (mean = 16) who underwent injection pharyngoplasty. Injection materials included glutaraldehyde cross-linked (GAX) collagen (n = 5), calcium hydroxyapatite (n = 36), dextranomer and hyaluronic acid (n = 72) and autologous fat (n = 471). Follow-up averaged 15.4 months (range = 2-60 months). Functional improvements in nasality were recorded in a large proportion of patients (0.79, 95% CI 0.75 to 0.82). However, a greater proportion of patients in the synthetic materials group demonstrated either reduced or resolved hypernasality compared with those receiving autologous fat injections (χ2 = 7.035, n = 91/103 vs. 255/338, p = 0.008). Complete velopharyngeal gap closure post-injection was achieved at a higher frequency with injection of synthetic materials compared with autologous fat (χ2 = 11.270, n = 61/69 vs. 58/91 p = 0.001).r CONCLUSION: Injection pharyngoplasty offers a minimally invasive alternative intervention for treatment of VPI secondary to small velopharyngeal gaps. Patients treated with synthetic materials experienced a greater improvement in velopharyngeal closure and a corresponding improvement in resonance balance.