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Ha JH, Lee H, Kwon SM, Joo H, Lin G, Kim DY, Kim S, Hwang JY, Chung JH, Kong HJ. Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates. J Craniofac Surg 2023; 34:2369-2375. [PMID: 37815288 PMCID: PMC10597411 DOI: 10.1097/scs.0000000000009560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 05/16/2023] [Indexed: 10/11/2023] Open
Abstract
Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.
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Affiliation(s)
- Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Biomedical Research Institute, Seoul National University Hospital
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul
| | - Haeyun Lee
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Production Engineering Research Team, SAMSUNG SDI, Yongin-si, Gyeonggi-do Province
| | - Seok Min Kwon
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine
| | - Hyunjin Joo
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
| | - Guang Lin
- Department of Aesthetic and Plastic Surgery, The First Affiliated Hospital ZHEJIANG University School of Medicine, Hangzhou, China
| | - Deok-Yeol Kim
- Department of Plastic Surgery, CHA Bundang Medical Center, and CHA Institute of Aesthetic Medicine, Seongnam-si, Gyeonggi-do Province
| | - Sukwha Kim
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Department of Plastic Surgery, CHA Bundang Medical Center, and CHA Institute of Aesthetic Medicine, Seongnam-si, Gyeonggi-do Province
| | - Jae Youn Hwang
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu
- Interdisciplinary Studies of Artificial Intelligence, Daegu Gyeongbuk Institute of Science and Technology, Daegu
| | - Jee-Hyeok Chung
- Division of Pediatric Plastic Surgery, Seoul National University Children’s Hospital
| | - Hyoun-Joong Kong
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Department of Transdisciplinary Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul, Korea
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Naveau A, Kret M, Plaire V, Delorme O, Marchi S, de Bataille C, Destruhaut F, Arrive E, Bou C. Efficacy of a new membrane obturator prosthesis in terms of speech, swallowing, and the quality of life of patients with acquired soft palate defects: study protocol of the VELOMEMBRANE randomized crossover trial. Trials 2022; 23:221. [PMID: 35303932 PMCID: PMC8931575 DOI: 10.1186/s13063-022-06163-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Soft palate defects created during oral cancer surgery may prevent complete palatal closure and trigger palatopharyngeal insufficiency. One current treatment employs a rigid obturator prosthesis; an extension of acrylic resin at the level of the hard palate ensures surface contact with the remaining musculature. Unfortunately, airflow escape often causes hypernasality, compromises speech intelligibility, and creates swallowing problems (including leakage of food and fluid into the nasal airway). We plan to test a new removable denture featuring a thick dental dam that serves as a membrane obturator. The principal objective of the clinical trial is a comparison of speech handicap levels after 1 month in patients with acquired velar insufficiencies who wear either the new device or a conventional, rigid obturator. The secondary objectives are between-device comparisons of the swallowing handicaps and the health-related qualities of life. Methods The VELOMEMBRANE trial is a superiority, open-labeled, two-way, random crossover clinical trial. Adult patients exhibiting velar or palatovelar substance loss after tumor excision and who are indicated for rigid obturator-mediated prosthetic rehabilitation will be recruited in two teaching hospitals in France. Fourteen participants will be randomly allocated to wear both prostheses for 1-month periods in either order. The new membrane obturator is a removable resin prosthesis incorporating a rigid extension that holds a dental dam to restore the soft palate. The primary outcome will be the extent of phonation-related disability (the overall score on the Voice Handicap Index [VHI]). The secondary outcomes will be the Deglutition Handicap Index and health-related quality of life scores of the European Organization for Research and Treatment of Cancer (EORTC). Discussion High-quality evidence will be provided to document the utility of a new medical device that may greatly improve the management and quality of life of patients with acquired velar insufficiency. Trial registration ClinicalTrials.govNCT04009811. Registered on 4 July 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06163-6.
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Affiliation(s)
- Adrien Naveau
- CHU de Bordeaux, Pôle de Médecine et Chirurgie Bucco-Dentaire, 33000, Bordeaux, France. .,Université de Bordeaux, UFR des Sciences Odontologiques, 33076, Bordeaux, France. .,INSERM, Bio-ingénierie Tissulaire BioTisU1026, 33076, Bordeaux Cedex, France.
| | - Marion Kret
- CHU de Bordeaux, USMR, Pôle Santé publique, 33076, Bordeaux, France
| | - Valérie Plaire
- CHU de Bordeaux, Pôle de Médecine et Chirurgie Bucco-Dentaire, 33000, Bordeaux, France
| | | | | | - Caroline de Bataille
- Université de Toulouse, Faculté de Chirurgie Dentaire, 31062, Toulouse, France.,CHU de Toulouse, Hôpital de Rangueil, 31059, Toulouse Cedex, France
| | - Florent Destruhaut
- Université de Toulouse, Faculté de Chirurgie Dentaire, 31062, Toulouse, France.,CHU de Toulouse, Hôpital de Rangueil, 31059, Toulouse Cedex, France.,Evolution and Oral Health Laboratory (EvolSan), Paul Sabatier University, Toulouse, France
| | - Elise Arrive
- CHU de Bordeaux, Pôle de Médecine et Chirurgie Bucco-Dentaire, 33000, Bordeaux, France.,Université de Bordeaux, UFR des Sciences Odontologiques, 33076, Bordeaux, France
| | - Christophe Bou
- CHU de Bordeaux, Pôle de Médecine et Chirurgie Bucco-Dentaire, 33000, Bordeaux, France.,Université de Bordeaux, UFR des Sciences Odontologiques, 33076, Bordeaux, France
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Cheng X, Bo Z, Yin H, Yang K, Li J, Shi B. Age and Preoperative Velar Closure Ratio Are Significantly Associated With Surgical Outcome of Furlow Double-Opposing Z-Plasty in Palatal Re-Repair. J Oral Maxillofac Surg 2019; 78:431-439. [PMID: 31654644 DOI: 10.1016/j.joms.2019.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE The patient selection criteria for Furlow double-opposing Z-plasty in palatal re-repair remain obscure. This study investigated whether patients' preoperative characteristics significantly affected the surgical outcome of Furlow double-opposing Z-plasty in palatal re-repair. MATERIALS AND METHODS We designed and implemented a case-control study nested in a cohort, which could be divided into 2 stages. In the first stage, a retrospective cohort study was performed to collect basic information and the preoperative status of the patients who would undergo Furlow double-opposing Z-plasty to correct velopharyngeal insufficiency after primary cleft palate repair. Eight predictor variables were included: age, gender, primary surgical technique, velopharyngeal closure pattern, velar movement, lateral pharyngeal wall movement, levator muscle orientation, and preoperative velar closure ratio. The outcome variable was postoperative velopharyngeal function described as velopharyngeal competence or velopharyngeal insufficiency. In the second stage, a case-control analysis was performed to explore the potential factors affecting the surgical outcome. Univariate and multivariate analyses were applied to examine the relationship between the predictor variables and surgical outcome. RESULTS The sample was composed of 83 patients and resulted in 54 velopharyngeal competence outcomes and 29 velopharyngeal insufficiency outcomes after surgery. Two predictors showed statistical significance: age and preoperative velar closure ratio. The possibility of postoperative velopharyngeal insufficiency in patients older than 14.5 years was 6 times higher than that in patients younger than 14.5 years. The possibility of postoperative velopharyngeal insufficiency in patients with preoperative velar closure ratios of 0.9 or greater was one fifth that in patients with preoperative velar closure ratios between 0.8 and less than 0.9. CONCLUSIONS The results of this study suggest that age and preoperative velar closure ratio are significantly associated with postoperative velopharyngeal insufficiency. Age was a risk factor in achieving good surgical outcomes, and the preoperative velar closure ratio remained a protective factor.
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Affiliation(s)
- Xu Cheng
- Chief Resident, State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Zhenyan Bo
- Medical Statistician, Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Heng Yin
- Associate Professor, State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ke Yang
- Oral Surgery Resident, Stomatological Hospital of Chongqing Medical University, Chongqing, China
| | - Jingtao Li
- Associate Professor, State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- Department Head and Professor, State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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The Double Opposing Z-Plasty Plus or Minus Buccal Flap Approach for Repair of Cleft Palate: A Review of 505 Consecutive Cases. Plast Reconstr Surg 2017; 139:735e-744e. [PMID: 28234851 DOI: 10.1097/prs.0000000000003127] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard methods of cleft palate repair rely on existing palatal tissue to achieve closure. These procedures often require relaxing incisions, causing scars and growth restriction, and may result in insufficient palatal length and suboptimal positioning of the velar musculature. The Furlow double opposing Z-plasty improves palatal length and repositions the velar musculature; however, relaxing incisions may still be needed. The addition of buccal flaps to the Furlow repair obviates the need for relaxing incisions and allows the Furlow repair to be used in wide clefts. METHODS A retrospective review was performed on 505 patients; all patients were treated with the double opposing Z-plasty plus or minus buccal flap approach. Outcomes included nasal resonance, secondary speech surgery, and postoperative complications. A comparison was made between patients treated with double opposing Z-plasty alone and those treated with double opposing Z-plasty plus buccal flaps. RESULTS The average nasal resonance score was 1.38 and was equivalent in both the double opposing Z-plasty alone and with buccal flap groups, despite significantly more wide clefts in the buccal flap group (56 percent versus 8 percent). The secondary surgery rate for velopharyngeal insufficiency was 6.6 percent and the fistula rate was 6.1 percent. The large fistula rate (>2 mm) was 2.7 percent. CONCLUSIONS The double opposing Z-plasty plus or minus buccal flap approach is a useful alternative to standard palate repairs. Speech outcomes were excellent, even in wider clefts, and postoperative complications were minimal. Buccal flaps allow the benefits of the Furlow repair to be applied to any size cleft, without the need for relaxing incisions. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Fukushiro AP, Ferlin F, Yamashita RP, Trindade IEK. Influence of pharyngeal flap surgery on nasality and nasalance scores of nasal sounds production in individuals with cleft lip and palate. Codas 2016; 27:584-7. [PMID: 26691623 DOI: 10.1590/2317-1782/20152014088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/03/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To verify the influence of pharyngeal flap surgery on the management of velopharyngeal insufficiency on nasality and speech nasalance on nasal sound production in individuals with cleft lip and palate. METHODS Prospective study in 159 individuals with repaired cleft palate ± lip, of both genders, aged 6 to 57 years old. All the participants presented residual velopharyngeal insufficiency and were submitted to pharyngeal flap surgery. Perceptual speech evaluation and nasometric assessment were performed before and after (14 months on average) the pharyngeal flap surgery. Hyponasality was rated as absent or present, and nasalance scores were determined by means of nasometer using nasal stimuli, with a cutoff score of 43% used as the lowest limit of normality. Nasality and nasalance were compared before and after surgery (p < 0.05). RESULTS On the basis of correlation between both the methods used, perceptual hyponasality was observed in 14% of the individuals, whereas nasalance scores indicating hyponasality (< 43%) were obtained in 25% of the patients after surgery. CONCLUSION Pharyngeal flap surgery influenced the production of nasal sounds, causing hyponasality in a significant proportion of individuals. The presence of this speech symptom can also be an indicator of upper airway obstruction caused by pharyngeal flap, which should be investigated objectively and prudently postoperatively.
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Affiliation(s)
- Ana Paula Fukushiro
- Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Flávia Ferlin
- Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Renata Paciello Yamashita
- Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Inge Elly Kiemle Trindade
- Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, São Paulo, SP, Brazil
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Hodgins N, Hoo C, McGee P, Hill C. A survey of assessment and management of velopharyngeal incompetence (VPI) in the UK and Ireland. J Plast Reconstr Aesthet Surg 2015; 68:485-91. [DOI: 10.1016/j.bjps.2014.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 10/31/2014] [Accepted: 12/08/2014] [Indexed: 11/16/2022]
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Ezzat AEM, Khalifa RA, Akel MM, El-Shenawy HM. Functional and speech outcomes of superiorly based flap pharyngoplasty combined with radical intravelar veloplasty. JOURNAL OF CLEFT LIP PALATE AND CRANIOFACIAL ANOMALIES 2015; 2:41-48. [PMID: 26005709 DOI: 10.4103/2348-2125.150746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate functional and speech outcomes of superiorly based pharyngeal flap (SBF) pharyngoplasty combined with radical intravelar veloplasty (RIVVP) for the management of velopharyngeal insufficiency (VPI) following surgically repaired cleft palate. DESIGN A case series with chart review. The study was conducted in academic tertiary care medical centre. PATIENTS AND METHODS Fifteen patients with VPIs following surgically repaired cleft palate were managed between May 2011 and August 2014, with SBF pharyngoplasty combined with RIVVP. RESULTS We found that the speech defects improved by a success rate of 93.4%; the VP function became normal (circular pattern of closure) in 80% of patients and the postoperative overall success rate of VP competence grades was 93.4%. Moreover, we found that the overall incidence of complications were 33.3%. CONCLUSION By doing SBF pharyngoplasty combined with RIVVP the surgical procedure was satisfactory in both functional and speech outcomes.
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Affiliation(s)
- Abdelrahman E M Ezzat
- Department of ENT, Phonatric unite of ENT department, Faculty of Medicine, Al-Azhar University, Cairo
| | - Rana A Khalifa
- Department of ENT, Phonatric unite of ENT department, Faculty of Medicine, Al-Azhar University, Cairo
| | - Mabrouk M Akel
- Department of Pediatric Surgery, Faculty of Medicine, Al-Azhar University, Cairo
| | - Hanna M El-Shenawy
- Department of Oral Surgery and Medicine, National Research Center, Dokki, Giza, Egypt
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Hartzell LD, Kilpatrick LA. Diagnosis and Management of Patients with Clefts. Otolaryngol Clin North Am 2014; 47:821-52. [DOI: 10.1016/j.otc.2014.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wermker K, Lünenbürger H, Joos U, Kleinheinz J, Jung S. Results of speech improvement following simultaneous push-back together with velopharyngeal flap surgery in cleft palate patients. J Craniomaxillofac Surg 2014; 42:525-30. [DOI: 10.1016/j.jcms.2013.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/15/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022] Open
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Bohm LA, Padgitt N, Tibesar RJ, Lander TA, Sidman JD. Outcomes of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency. Otolaryngol Head Neck Surg 2013; 150:216-21. [DOI: 10.1177/0194599813513715] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To compare surgical outcomes between pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty in the management of pediatric velopharyngeal insufficiency. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods After exclusion of children with velocardiofacial syndrome, 96 patients who underwent surgical intervention between 2008 and 2012 were identified. Surgical interventions were categorized as pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty. Main outcome measures included perceptual speech analyses, complications, and surgical revision rates. Results Of the 96 reviewed patients, 38 (39.6%) underwent pharyngeal flap, 20 (20.8%) sphincter pharyngoplasty, and 38 (39.6%) combined Furlow palatoplasty and sphincter pharyngoplasty. Choice of surgical intervention was based on patient characteristics, observed palatal length, and formal speech assessments. There were no differences in patient demographics or preoperative perceptual speech analysis scores among the 3 surgical groups. The mean speech improvement was significantly greater in both the pharyngeal flap ( P = .031) and combined procedure ( P = .013) compared with sphincter pharyngoplasty alone, but no differences were observed between the pharyngeal flap and combined procedure ( P = .797). There were no differences in complications among the 3 surgical interventions ( P = .220). The combined procedure required significantly less surgical revisions than the pharyngeal flap ( P = .019). Conclusion Combined Furlow palatoplasty and sphincter pharyngoplasty is an effective procedure for the management of pediatric velopharyngeal insufficiency and may result in superior speech outcomes and lower revision rates than sphincter pharyngoplasty and pharyngeal flap, respectively.
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Affiliation(s)
- Lauren A. Bohm
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Noëlle Padgitt
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Robert J. Tibesar
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Timothy A. Lander
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - James D. Sidman
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Askar SM, Abou-Elsaad TS. A speech nasoendoscopy-based surgeon’s decision for correction of velopharyngeal insufficiency following adenotonsillectomy. Eur Arch Otorhinolaryngol 2013; 271:391-8. [DOI: 10.1007/s00405-013-2572-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
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Spruijt NE, ReijmanHinze J, Hens G, Vander Poorten V, Mink van der Molen AB. In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review. PLoS One 2012; 7:e34332. [PMID: 22470558 PMCID: PMC3314640 DOI: 10.1371/journal.pone.0034332] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 02/26/2012] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Nicole E. Spruijt
- Department of Plastic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Judith ReijmanHinze
- Department of Otorhinolaryngology, Head and Neck Surgery, Free University Medical Center, Amsterdam, The Netherlands
| | - Greet Hens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Leuven, Belgium
| | - Vincent Vander Poorten
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Leuven, Belgium
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Kummer AW, Clark SL, Redle EE, Thomsen LL, Billmire DA. Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals. Cleft Palate Craniofac J 2012; 49:146-52. [DOI: 10.1597/10-285] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.
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Affiliation(s)
- Ann W. Kummer
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati, Cincinnati, Ohio
| | - Stacey L. Clark
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin E. Redle
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leisa L. Thomsen
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A. Billmire
- University of Cincinnati, Cincinnati, Ohio
- Division of Pediatric Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Nasometric and aerodynamic outcome analysis of pharyngeal flap surgery for the management of velopharyngeal insufficiency. J Craniofac Surg 2011; 22:1647-51. [PMID: 21959405 DOI: 10.1097/scs.0b013e31822e5f95] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of pharyngeal flap surgery (PFS) for the management of velopharyngeal insufficiency in cleft lip/palate patients and to assess the impact of age at surgery, surgeon's skills, and postoperative speech therapy on the outcomes. METHODS Prospective preoperative and postoperative assessments were performed on 240 patients aged 6 to 57 years using nasometry and pressure-flow studies.This study was carried out in a quaternary hospital.This study was superiorly based on PFS.Speech nasalance scores were assessed by nasometry and velopharyngeal orifice area assessed by pressure-flow technique, 2 days before and 1 year after PFS, on average. Differences were considered significant when P < 0.05. RESULTS Significant reduction in nasalance scores was observed in 68% of the cases, and improvement of velopharyngeal area was observed in 66%. Rates of 55% and 48%, respectively, were observed when complete resolution was considered. Higher success rates were observed in children (81%) compared with other age groups analyzed and in patients who had concluded postoperative speech therapy (86%). Results did not differ among surgeons. CONCLUSIONS Pharyngeal flap surgery was shown to be effective in reducing nasalance scores and velopharyngeal area during speech for a significant number of patients. Complete resolution was observed in smaller number of cases. Age at surgery and postoperative speech therapy were relevant factors for treatment success.
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Abstract
Separation of the nasal and oral cavities by dynamic closure of the velo-pharyngeal port is necessary for normal speech and swallowing. Velo-pharyngeal dysfunction (VPD) may either follow repair of a cleft palate or be independent of clefting. While the diagnosis of VPD is made by audiologic perceptual evaluation of speech, identification of the mechanism of the dysfunction requires instrumental visualization of the velo-pharyngeal port during specific speech tasks. Matching the specific intervention for management of VPD with the type of dysfunction, i.e. differential management for differential diagnosis, maximizes the result while minimizing the morbidity of the intervention.
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Affiliation(s)
- Jeffrey L Marsh
- Department of Plastic Surgery, St. Louis University School of Medicine, St. Louis MO, USA
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Rikihisa N, Udagawa A, Yoshimoto S, Ichinose M, Kimura T, Shimizu S. Treatment of velopharyngeal inadequacy in a patient with submucous cleft palate and myasthenia gravis. Cleft Palate Craniofac J 2009; 46:558-62. [PMID: 19929094 DOI: 10.1597/08-049.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the clinical course and management of a patient with submucous cleft palate who developed myasthenia gravis (MG) as an adult and suffered recurrent hypernasality. Few reports have described MG patients undergoing pharyngeal flap surgery for velopharyngeal incompetence, and these have described only slight speech improvement in such patients. DESIGN Case report. PATIENT The patient underwent primary pushback palatoplasty and superiorly based pharyngeal flap surgery for submucous cleft and short palate at age 7. Hypernasality showed major improvement after initial surgery. At age 19, the patient developed MG that triggered the recurrence of velopharyngeal incompetence. INTERVENTION After MG was treated, revision pushback palatoplasty was performed for velopharyngeal incompetence when the patient was 24 years old. Preoperatively and postoperatively, the patient was evaluated by the same speech-language-hearing therapists, each with at least 5 years of clinical experience in cleft palate speech. RESULTS After the second pushback palatoplasty, hypernasality and audible nasal air emission during speech decreased to mild. CONCLUSION Primary pushback palatoplasty and pharyngeal flap surgery were performed for the submucous cleft palate. Revision pushback palatoplasty improved velopharyngeal inadequacy induced by MG. Decreased perceived nasality positively influenced the patient's quality of life. Combined pushback palatoplasty and pharyngeal flap surgery is thus an option in surgical treatment for velopharyngeal inadequacy to close the cleft and the velopharyngeal orifice in cases of cleft palate and MG.
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Affiliation(s)
- Naoaki Rikihisa
- Department of Plastic and Aesthetic Surgery, Chiba University Hospital, Japan.
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Velopharyngeal insufficiency: current concepts in diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2008; 16:530-5. [DOI: 10.1097/moo.0b013e328316bd68] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pegoraro-Krook MI, Dutka-Souza JDCR, Marino VCDC. Nasoendoscopy of velopharynx before and during diagnostic therapy. J Appl Oral Sci 2008; 16:181-8. [PMID: 19089215 PMCID: PMC4327691 DOI: 10.1590/s1678-77572008000300004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 01/22/2007] [Accepted: 03/07/2008] [Indexed: 11/22/2022] Open
Abstract
Nasoendoscopy is an important tool for assessing velopharyngeal function. The purpose of this study was to analyze velar and pharyngeal wall movement and velopharyngeal gap during nasoendoscopic evaluation of the velopharynx before and during diagnostic therapy. Nasoendoscopic recordings of 10 children with operated cleft lip and palate were analyzed according to the International Working Group Guidelines. Ratings of movement of velum and pharyngeal walls, and size, location and shape of gaps were analyzed by 3 speech-language pathologists (SLPs). Imaging was obtained during repetitions of the syllable /pa/ during a single nasoendoscopic evaluation: (a) before diagnostic therapy, and (b) after the children were instructed to impound and increase intraoral air pressure (diagnostic therapy). Once the patients impounded and directed air pressure orally, the displacement of the velum, right, left and posterior pharyngeal walls increased 40, 70, 80, and 10%, respectively. Statistical significance for displacement was found only for right and left lateral pharyngeal walls. Reduction in gap size was observed for 30% of the patients and other 40% of the gaps disappeared. Changes in gap size were found to be statistically significant between the two conditions. In nasoendoscopic assessment, the full potential of velopharyngeal displacement may not be completely elicited when the patient is asked only to repeat a speech stimulus. Optimization of information can be done with the use of diagnostic therapy's strategies to manipulate VP function. Assuring the participation of the SLP to conduct diagnostic therapy is essential for management of velopharyngeal dysfunction.
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Affiliation(s)
- Maria Inês Pegoraro-Krook
- Department of Speech Pathology and Audiology, Bauru School of Dentistry and Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, SP, Brazil.
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Mink van der Molen AB, Janssen K, Specken TFJMC, Stubenitsky BM. The modified Honig velopharyngoplasty - a new technique to treat hypernasality by palatal lengthening. J Plast Reconstr Aesthet Surg 2008; 62:646-9. [PMID: 18249165 DOI: 10.1016/j.bjps.2007.12.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Revised: 07/25/2007] [Accepted: 12/17/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Palatal lengthening by pushback with a pharyngeal flap is a commonly used operative technique for the treatment of velopharyngeal insufficiency. The conventional Honig velopharyngoplasty uses full thickness mucoperiosteal flaps for the oral lining of the defect. PURPOSE A modification is described using only mucosal flaps, thus preserving the periosteum and the palatine arteries. Vascularisation of the hard palate is preserved and bone is not exposed, avoiding potential detrimental scar formation overlying the hard palate, which may affect normal outgrowth of the maxilla. STUDY DESIGN Eight patients with persisting hypernasality were included. Velopharyngeal closure was evaluated by nasendoscopy, nasometry and a Dutch speech test for cleft patients. RESULTS Hypernasality was corrected in all cases. One patient developed a light hyponasality. In four patients the overall speech normalised and in the remaining four cases small errors persisted, but speech was well understandable. CONCLUSION The procedure yields satisfactory speech results in this preliminary study, comparable to the conventional Honig velopharyngeaplasty. Long term follow up regarding maxillary growth and comparative studies with other operative techniques are now warranted.
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Ragab A. Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2007; 71:793-800. [PMID: 17343926 DOI: 10.1016/j.ijporl.2007.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2006] [Revised: 01/24/2007] [Accepted: 01/30/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Several surgical techniques are available for the treatment of velopharyngeal insufficiency (VFI). Each method has its own complications and non-dynamic roles. So the aim of this study was to present a novel physiological surgical technique designed by the author for reconstruction of the velopharyngeal sphincter in VFI. METHODS This prospective study included six patients with VFI (two males and four females) with ages from 5 to 20 years (mean: 12.50 years). Speeches, nasopharyngeal and oral endoscopies for velopharyngeal valve closure were measured according to a 5-point scale where 0 was equivalent to normal and 4 meant a severe (constant) deviation. They were scheduled for cerclage sphincter pharyngoplasty after failure of appropriate speech therapy. Under general anaesthesia and the patient in semiflower's position; two level cerclages (1-0 polypropylene suture materials) were inserted behind the muscles of the velopharynx. The first at the level of junction of posterior and middle one-thirds of the soft palate passing through soft palate, left lateral pharyngeal wall, posterior pharyngeal wall, right lateral pharyngeal wall and the soft palate. The second was at 3mm in front of the latter. The surgical technique was described in details. RESULTS Before surgery five patients (83.3%) had sever hypernasality (rating scale 3). After the cerclage operation and speech therapy four patients (66.6%) significantly improved to normal nasality (rating scale 0) and the remaining two patients improved to mild and moderate hypernasality (rating scale 1 and 2), respectively (p<0.05). By endoscopy the closing activity was (rating scale 3) in five patients (83.3%) and (rating scale 2) in one patient (18%). After the cerclage operation and speech therapy five patients (83.3%) changed significantly to complete closure (rating scale 0) and to (rating scale 1) in one patient (p<0.05). CONCLUSIONS Cerclage sphincter pharyngoplasty is a new procedure designed by the author in VFI. It helps the velopharynx to function physiologically in three-dimensional patterns without dependency on the type of closure. Also it is an easy technique; without tissue flaps transfer, upper airway obstruction or hyponasality.
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Affiliation(s)
- Ahmed Ragab
- ORL department, Menoufiya University Hospital, Egypt.
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Dudas JR, Deleyiannis FWB, Ford MD, Jiang S, Losee JE. Diagnosis and Treatment of Velopharyngeal Insufficiency. Ann Plast Surg 2006; 56:511-7; discussion 517. [PMID: 16641626 DOI: 10.1097/01.sap.0000210628.18395.de] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure. PATIENTS AND METHODS A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure. RESULTS All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04). CONCLUSIONS Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.
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Affiliation(s)
- Jason R Dudas
- Division of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Dailey SA, Karnell MP, Karnell LH, Canady JW. Comparison of resonance outcomes after pharyngeal flap and furlow double-opposing z-plasty for surgical management of velopharyngeal incompetence. Cleft Palate Craniofac J 2006; 43:38-43. [PMID: 16405372 DOI: 10.1597/04-118r.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The purpose of this study was to test the hypothesis that no significant difference exists in the speech outcomes between patients with severe velopharyngeal incompetence (VPI) who receive a pharyngeal flap and patients with less severe VPI who receive a Z-plasty for management of VPI. DESIGN This retrospective study from 1993 to 2002 included a review of pre- and postoperative perceptual speech and resonance assessments of patients with marginal VPI who received a Furlow double-opposing Z-plasty and patients with VPI who received a pharyngeal flap. SETTING All patients had surgical management of VPI at the Cleft Palate-Craniofacial Clinic at University of Iowa Hospitals and Clinics. RESULTS Both groups benefited from surgery with significant reduction in perceived hypernasality (p < .001). Comparison of postoperative assessments indicated no difference between the groups in hypernasality or hyponasality ratings. Neither group had a significant increase in hyponasality. CONCLUSION Both pharyngeal flap and double-opposing Z-plasty proved equally effective at reducing hypernasality when the selection of the surgical procedures was based on preoperative ratings of perceived hypernasality and evaluation of velopharyngeal physiology. Severity of the VPI is an important factor when considering surgical management of VPI. Thorough preoperative evaluations of patients with VPI are essential in appropriate treatment planning.
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Affiliation(s)
- Scott A Dailey
- University of Iowa Hospitals and Clinics, Department of Otolaryngology-Head and Neck Surgery, Iowa 52242-1078, USA.
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Rowe MR, D'Antonio LL. Velopharyngeal dysfunction: evolving developments in evaluation. Curr Opin Otolaryngol Head Neck Surg 2005; 13:366-70. [PMID: 16282766 DOI: 10.1097/01.moo.0000186204.53214.62] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Otolaryngologists are increasingly being called upon to assist in the differential diagnosis of velopharyngeal valving disorders for speech, assisting in treatment planning and the assessment of treatment outcomes. RECENT FINDINGS The most commonly used methods for direct visualization of velopharyngeal function remain nasendoscopy and videofluoroscopy. Literature supporting the use of either nasendoscopy followed by videofluoroscopy or the reverse can be found. Several studies also suggest that magnetic resonance imaging can make important contributions to the evaluation of velopharyngeal anatomy and function. The routine use of magnetic resonance imaging for evaluating the velopharynx is neither practical nor probable at the present time. Although magnetic resonance imaging may be as effective as videofluoroscopy or nasendoscopy, the cost of magnetic resonance imaging and the radiation exposure of videofluoroscopy will likely dictate that nasendoscopy continues to be the most common technique for evaluating velopharyngeal function during speech. Several recent studies have documented the use of instrumental assessment of velopharyngeal function for assigning patients to a given surgical procedure, predicting surgical success or complications, and evaluating treatment outcomes. SUMMARY There are still discussions and conflicting results regarding the best method for evaluating velopharyngeal function. Opinions conflict regarding the various methods, which suggests that no single method is best. The decision regarding the most appropriate evaluation protocol should be guided by the information that the clinician is attempting to obtain and the relative benefits and risks of each method. Increasingly, these evaluation methods are used by the otolaryngologist to assist in the differential diagnosis of velopharyngeal valving disorders, the assignment of patients to various treatment options, and the evaluation of treatment outcomes.
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Affiliation(s)
- Mark R Rowe
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Loma Linda University and Children's Hospital, Loma Linda, CA 92354, USA
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Perkins JA, Lewis CW, Gruss JS, Eblen LE, Sie KCY. Furlow Palatoplasty for Management of Velopharyngeal Insufficiency: A Prospective Study of 148 Consecutive Patients. Plast Reconstr Surg 2005; 116:72-80; discussion 81-4. [PMID: 15988249 DOI: 10.1097/01.prs.0000169694.29082.69] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objectives of the study were to describe speech outcomes in a large series of patients undergoing Furlow palatoplasty for management of velopharyngeal insufficiency and to test whether preoperative velopharyngeal gap size and other patient characteristics significantly affect those outcomes. METHODS Data collected included age at the time of surgery, surgeon, type of cleft, syndrome diagnosis, preoperative velopharyngeal gap size as determined by videonasendoscopy, and preoperative and postoperative perceptual speech assessments. Descriptive statistics were generated and ordinal logistic regression on the outcome variable, postoperative velopharyngeal insufficiency severity score, was performed. RESULTS In this series of 154 patients, 148 had complete perceptual speech data. Of these 148 patients, 72 percent had improvement in velopharyngeal insufficiency severity after the procedure and 56 percent had complete resolution of velopharyngeal insufficiency. Postoperative insufficiency was scored as none or minimal (i.e., resolution) in 38 of 52 patients (73 percent) with a small preoperative velopharyngeal gap, 26 of 51 patients (51 percent) with a moderate preoperative gap, and four of 21 patients (19 percent) with a large preoperative gap. Preoperative velopharyngeal gap size was significantly associated (p < 0.0001) with postoperative insufficiency on ordinal multivariate logistic regression after controlling for preoperative insufficiency and other covariates. There was not a significant association between syndrome diagnosis, age at Furlow palatoplasty (younger than 5 years versus older), gender, surgeon, or presence of submucous cleft palate and postoperative speech outcome, in either the unadjusted or adjusted analyses. CONCLUSIONS Preoperative velopharyngeal gap size, as determined with nasendoscopy, was significantly associated with postoperative velopharyngeal insufficiency severity after Furlow palatoplasty. Small gap size is associated with a greater likelihood of resolution.
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Affiliation(s)
- Jonathan A Perkins
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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Boseley ME, Hartnick CJ. Assessing the outcome of surgery to correct velopharyngeal insufficiency with the pediatric voice outcomes survey. Int J Pediatr Otorhinolaryngol 2004; 68:1429-33. [PMID: 15488976 DOI: 10.1016/j.ijporl.2004.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2004] [Revised: 06/14/2004] [Accepted: 06/25/2004] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the functional outcome of surgery for velopharyngeal insufficiency (VPI) by administering the pediatric voice outcomes survey (PVOS) to the parents of the affected children. DESIGN Prospective longitudinal study. SETTING Tertiary referral pediatric otolaryngology office. SUBJECTS Twelve children who underwent surgery to correct VPI during the 12-month-period between 1 January 2002 and 31 December 2002. METHODS Parents of the 12 children were administered the PVOS prior to surgery and again 6 weeks post-operatively. The PVOS is a validated instrument designed to measure voice-related quality of life (V-RQOL). The score has been transformed to range from 0 (low V-RQOL) to 100 (high V-RQOL). RESULTS The mean age of the children was 5 years (standard deviation [S.D.], 2.3 years). Seven children underwent sphincteroplasty and five had a superior based pharyngeal flap as a primary procedure. Three children required secondary procedures to correct their underlying VPI and one of those had a third procedure consisting of a posterior wall fat injection. The mean pre-operative PVOS score was 38.3 (S.D., 12) and the mean 6 weeks post-operative score was 72.3 (S.D., 22.7) (paired t-test; P < 0.001). CONCLUSION The PVOS represents a valid clinical tool to measure the functional impact of surgery to correct pediatric velopharyngeal insufficiency.
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Affiliation(s)
- Mark E Boseley
- Brooke Army Medical Center, 3851 Roger Brooke Drive, San Antonio, TX 78234, USA.
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Abstract
PURPOSE OF REVIEW Velopharyngeal insufficiency is a niche within our specialty, but patients with hypernasality present who have never been diagnosed previously. Otolaryngologists should be familiar with current trends in diagnosis and treatment of hypernasality. RECENT FINDINGS Velopharyngeal insufficiency has been associated with genetic conditions and identifiable syndromes. Multiple surgical techniques are available for the treatment of this condition, the results of which vary widely in the literature. There is difficulty in interpreting the success of surgical outcomes on speech intelligibility and resonance because of the heterogeneity of the patient population and the subjective nature of assessing results. More studies are now available for the evaluation of associations of comorbid conditions and their impact on speech results. SUMMARY Velopharyngeal insufficiency must be diagnosed properly. Syndromes and comorbid conditions must be identified. No single specialty can care appropriately for these patients. A team approach is the ideal method of evaluating and managing patients with velopharyngeal insufficiency. Specialists with a particular interest and training in the management of patients with clefts of the palate and velopharyngeal insufficiency must collaborate to obtain the maximal functional outcome for these patients.
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Affiliation(s)
- J Paul Willging
- Department of Otolaryngology--Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical Center, Ohio 45229, USA.
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Marsh JL. Management of Velopharyngeal Dysfunction: Differential Diagnosis for Differential Management. J Craniofac Surg 2003; 14:621-8; discussion 629. [PMID: 14501319 DOI: 10.1097/00001665-200309000-00004] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A single surgeon's 20 year experience in one cleft center with differential diagnosis for differential management of velopharyngeal dysfunction (VPD) is reviewed. The specific diagnostic and functional status of each affected individual is determined to select the method of VPD management. Two types of diagnostic evaluation of velopharyngeal function, perceptual and instrumental, are used to make that determination. There are four broad etiologic categories of VPD: anatomic deficiency, myoneural deficiency, anatomic and myoneural deficiency, and neither anatomical nor myoneural deficiency. The type of VPD management is specific for each etiologic category. The management options are between prosthetic appliances (lift, obturator, "liftorator") and operations (intravelar veloplasty, velar Z-plasty, pharyngeal flap, sphincter pharyngoplasty, posterior pharyngeal wall augmentation). The objective of differential management based on differential diagnosis is to optimize the function of the velopharynx for speech tasks while minimizing the morbidity of the intervention on the upper airway. A personal experience, in the context of an interdisciplinary cleft team, with such an approach over the past 20 years validates the assumption that differential management of VPD based on differential diagnosis can achieve this goal.
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Kummer AW. Velopharyngeal dysfunction: current thinking on the cause, effect, assessment and treatment. Curr Opin Otolaryngol Head Neck Surg 2002. [DOI: 10.1097/00020840-200212000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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