Practical application of flexible fiberoptic nasopharyngoscopy for evaluating velopharyngeal function

Conversion Furlow Palatoplasty and the Use of Preoperative Video Nasendoscopy

OBJECTIVE

To assess outcomes after conversion Furlow palatoplasty with and without routine preoperative flexible fiberoptic video nasendoscopy (FFVN).

DESIGN

Retrospective cohort study.

SETTING

Tertiary Children's Hospital.

PATIENTS

Greater than 3 years of age with cleft palate and velopharyngeal insufficiency (VPI) after straight-line palatoplasty requiring secondary surgery performed with a Furlow palatoplasty.

MAIN OUTCOME MEASURES

The number of children with and without routine FFVN prior to conversion Furlow palatoplasty for VPI after initial straight-line palatoplasty. Groups were compared for surgical timing, speech outcomes, and need for additional surgery after conversion Furlow palatoplasty.

RESULTS

Fifty-eight patients underwent preoperative FFVN versus 29 without. Mean age at FFVN was 73.8 (SD 34) months. Mean age for secondary palatal surgery by conversion Furlow palatoplasty was 81.5 (SD 34.8) months with FFVN versus 73.4 (SD 34.0) months without FFVN. There was a significant difference (P < .001) for VPI diagnosis and time to surgery between the groups. Preoperative hypernasality ratings were similar between groups. Postoperatively 65.5% of FFVN and non-FFVN patients corrected to normal resonance. Only 6.9% of all patients rated moderate-severe hypernasality after surgery compared to 42.5% preoperatively. Of total, 5.7% of patients had unchanged hypernasality and only 1 patient rated worse. Seven patients ultimately required additional surgery in attempt to normalize their resonance.

CONCLUSIONS

Routine preoperative FFVN does not offer any advantage for improved outcomes in children undergoing conversion Furlow palatoplasty after straight-line repair. Routine preoperative FFVN was associated with increased time to surgery after diagnosis of VPI compared to those without FFVN.

Airflow of the Two-Port Velopharyngeal Closure: Study Using Computational Fluid Dynamics

Posterior pharyngeal flap palatoplasty is used to restore the function of velopharyngeal (VP) closure, after which 2 ports remain between the nasal and oral cavity. The authors hypothesized that the airflow dynamics of the upper airway is different in PPF patients compared to health subjects, who only has 1 movable port. Twenty adults who have multislice spiral computed tomography scan were included in this study. Two cylinders (radius, 2.00 mm; height, 4.5 mm) were used to recapitulate the 2-port VP structure after PPF palatoplasty. The areas of ports were modified by changing the radius of 2 cylinders. Real-time computational fluid dynamics simulation was used to capture the airflow velocity and pressures through the 2 ports. The airflow velocity and pressure of upper airway were recorded as the total areas of 2 VP ports increased. The total orifice areas of the 2-port VP closure for 4 VP conditions, including adequate closure, adequate/borderline closure, borderline/inadequate closure, and inadequate closure, were demonstrated. Significant differences between the 2-port VP function for demonstrating PPF reconstruction and the 1-port VP function were found. Airflow dynamics is dependent on the VP structure. The 2-port airflow model for mimicking VP closure after PPF palatoplasty demonstrated airflow characteristics that were significantly different from the 1-port model in normal VP closure.

Surgical Management of Velopharyngeal Insufficiency Due to Unilateral Oropharyngeal Agenesis in a Patient With Stickler Syndrome

Velopharyngeal insufficiency (VPI) results from defects interfering with closure of the velopharyngeal port. It can lead to many issues ranging from nasal regurgitation to severe speech abnormalities. Treatment is tailored to patient-specific etiology and severity, often involving surgical correction. A rare, and therefore seldom, described cause of VPI is isolated unilateral agenesis of the soft palate. We describe the case of a 2-year-old patient with Stickler syndrome possessing a unique anatomic presentation of this pathology, managed successfully with a unilateral pharyngeal flap.

Reconstruction of an idiopathic hemipalatal hypoplasia: report of a case

Idiopathic hemipalatal hypoplasia is rare and leads to speech problems and the regurgitation of fluids, and the reconstruction of asymmetrical velopharyngeal incompetence is a challenge to the cleft surgeon. We present a case in a 5-year-old boy, and introduce the one-stage surgical technique that we used to resolve it.

Velopharyngeal incompetence in patients with cleft palate, flexible video pharyngoscopy and perceptual speech assessment: a correlational pilot study

Objectives:

To assess the role of video endoscopy in evaluating velopharyngeal incompetence and investigate a possible relationship between velopharyngeal incompetence type and speech defect in cleft palate patients.

Methods:

A prospective study of 28 pre- or post-operative cleft palate patients with speech defects who attended Plastic Surgery–Cleft Palate and ENT out-patient clinics was performed. The velar defect type was determined using a flexible endoscope and findings were video recorded. Speech pathology was assessed using the cleft palate audit protocol for speech.

Results:

A significant, clinically relevant relationship was noted between the perceived characteristics of hypernasality and velopharyngeal insufficiency type. Hypernasal speech was a definite clinical indicator of velopharyngeal incompetence, and the type 1 velopharyngeal defect was most common. Type 1 velopharyngeal coronal-type dysfunction was strongly associated with hypernasality (p < 0.05). When speech substitution was noted, type 2 velopharyngeal (or sagittal) incompetence could be predicted (p < 0.05).

Conclusion:

In the management of cleft palate patients, it is important that surgical correction of the defect and achieving velopharyngeal competency for speech are performed simultaneously. Pre-operative velopharyngeal endoscopy with speech assessment will define the anatomical and functional bases for velopharyngeal correction and assist in planning and tailoring the pharyngeal flap.

A Very Rare Cause of Asymmetric Velopharyngeal Incompetence: Unilateral Palate Hypoplasia

Asymmetric velopharyngeal incompetence (VPI) may be caused by neuromuscular disorders, trauma, tumor resection, cleft palate, or unilateral hypoplasia of the velum and pharynx. However, VPI due to isolated unilateral hypoplasia is extremely rare. In this case report, a 4-year-old girl with unilateral palate hypoplasia and her two-staged management is presented. The speech quality of the patient improved noticeably after these procedures. The first stage allowed us to make the second stage pharyngeal flap more conservatively than possible in a one-stage procedure. We think that this two-step procedure could be an alternative to other methods in the treatment of asymmetric VPI.

Conscious sedation in pediatric speech endoscopy

OBJECTIVE

Speech nasoendoscopy is one of the gold standards for evaluating velopharyngeal insufficiency. The vast majority of pediatric patients are able to tolerate this procedure within the clinic under local anesthetic. However, a select group of pediatric patients is unable to cooperate with the examination. Conscious sedation is commonly used in pediatrics to aid in patient tolerance and cooperating with selected procedures. Conscious sedation has never been reported in the literature for use in speech endoscopy. The purpose of this study is to describe a technique for performing sedated speech endoscopy and to review our experience with sedated speech endoscopy in a selected group of patients who were unable to cooperate with examination under local anesthesia alone.

METHODS

A retrospective chart review was performed of pediatric patients between the ages of 2 and 15 who underwent conscious sedation for the speech nasoendoscopy. All examinations were performed at a tertiary care pediatric hospital. Sedation agent, tolerance of procedure, success of procedure, and complications associated with the procedure were recorded.

RESULTS

Fifty-seven sedated speech endoscopies were evaluated. Adequate examinations were obtained in 93% of patients overall and 100% of the patients evaluated while sedated with nitrous oxide. Complication rates and post-endoscopy speech management are reported.

CONCLUSIONS

Sedated speech endoscopy is a promising modality for evaluating velopharyngeal insufficiency in the pediatric population that may not otherwise be able to cooperate with examination in the clinic.

Evaluation of dynamic magnetic resonance imaging in assessing velopharyngeal insufficiency during phonation

BACKGROUND

Velopharyngeal insufficiency (VPI) expresses the structural and neuromuscular disorder of soft palate and pharyngeal walls inhibiting the normal functions of velopharyngeal (VP) sphincter mechanism. In this study, efficacy of dynamic magnetic resonance imaging in the diagnosis of VPI is investigated.

MATERIALS AND METHODS

A total of 32 cases, 16 controls and 16 cleft palates, were included in this study. T1 fast spin echo-weighted imaging during rest, dynamic investigations with True-fast imaging with steady-state precession sequence during /sss/ and /mmm/ phonations were performed.

RESULTS

During /sss/ phonation, complete closure was observed in the control group, whereas mean VP opening was 4.11 cm2 preoperatively and 0.21 cm2 postoperatively in the cleft palate group. In the postoperative period, only 3 patients did not have complete closure. In the second operations, performed 6 months later, only muscle repair was done. All 3 had complete closure.

CONCLUSIONS

In cleft palate cases with delayed diagnosis, appropriate application of muscle repair will be sufficient for anatomic repair of VPI without any extra procedures. In addition, dynamic magnetic resonance imaging is an objective, noninvasive, reliable, and effective modality that may be used in the diagnosis and treatment of VPI without any extra investigations.

The contribution of electromyography to the diagnostics of some rare palatal anomalies

The paper presents the electromyographic (EMG) findings of the soft palate in three patients: a patient with Mohr syndrome and cleft palate, a patient with palatal asymmetry and rhinolalia and a patient with vertical oro-ocular facial cleft with marked asymmetry of the cleft palate. In the first patient, electrical silence was registered in one half of the palate. In the second patient, moderate loss of active motor units was registered in the hypoplastic part of the palate. In the third patient, in spite of asymmetry, the EMG finding was normal on both sides of the palate.

Velopharyngeal Incompetence:

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.

Management of Velopharyngeal Dysfunction: Differential Diagnosis for Differential Management

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.

Analysis of speech characteristics in children with velocardiofacial syndrome (VCFS) and children with phenotypic overlap without VCFS

OBJECTIVE

To address two questions of theoretical importance regarding the profile and course of communication impairment associated with velocardiofacial syndrome (VCFS): (1) do speech characteristics of children with VCFS differ from a group of children with some of the phenotypic characteristics of VCFS who do not have the syndrome, and (2) do younger children with VCFS demonstrate speech patterns that differ from older children with VCFS?

DESIGN

Prospective, cross-sectional study comparing two groups of children at two age levels.

PATIENTS

Thirteen children with VCFS and eight children with some of the phenotypic features of VCFS who did not have the syndrome. Children ranged in age from 3 to 10 years.

MAIN OUTCOME MEASURE

(1) Broad phonetic transcription of speech yielding measures of number of consonant types, Percent Consonant Correct, and percentage of glottal stops used; and (2) composite ratings of velopharyngeal function made from perceptual, aerodynamic, and endoscopic evaluations.

RESULTS

Younger children with VCFS demonstrated greater speech impairment than older children with VCFS or the children without VCFS, such as smaller consonant inventories, greater number of developmental errors, greater severity of articulation disorder, and higher frequency of glottal stop use. The relationship between ratings of velopharyngeal function and the speech variables analyzed was not straightforward.

CONCLUSIONS

Some young children with VCFS demonstrated speech impairment that is qualitatively and quantitatively different from older children with VCFS or children without VCFS. This finding supports the hypothesis that some children with VCFS demonstrate a profile of speech production that is different from normal but also may be specific to the syndrome.

Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art

Surgical management of velopharyngeal insufficiency by attachment of posterior pharyngeal flap or construction of sphincter pharyngoplasty is reviewed. Posterior pharyngeal flap surgery is well established, with a long history dating back to the 19th century. Flaps have been based superiorly, inferiorly, or laterally. There have been reports of airway obstruction and obstructive sleep apnea associated with posterior pharyngeal flap surgery. The concept of surgical creation of a dynamic sphincter pharyngoplasty to provide velopharyngeal closure was first introduced by Hynes in 1950. Hynes and others have proposed several subsequent anatomic modifications. Airway dysfunction has also been reported following sphincter pharyngoplasty, but may not be as frequent or severe as with posterior pharyngeal flap. While several studies have compared posterior pharyngeal flap and sphincter pharyngoplasty in terms of speech outcome or complications, there is not, as yet, a consensus regarding the specific choice of one versus the other for surgical management of velopharyngeal insufficiency.

Sphincter pharyngoplasty for the surgical management of speech dysfunction associated with velocardiofacial syndrome

There are no reports in the literature that document the effectiveness of sphincter pharyngoplasty as a surgical alternative to pharyngeal flap for management of velopharyngeal dysfunction in patients with velocardiofacial syndrome. A retrospective review of patients with velocardiofacial syndrome was undertaken at our tertiary cleft care centre. All patients were managed between 1984 and 1996 at the Cleft Palate and Craniofacial Deformities Institute, St Louis Children's Hospital. Subjects (n = 19) underwent velopharyngeal surgical management on the basis of perceptual speech evaluations and instrumental assessments of inadequate velopharyngeal closure. All patients had a molecular diagnosis of velocardiofacial syndrome based on fluorescent in situ hybridisation analysis of peripheral blood lymphocytes and independent evaluation by a medical geneticist. Surgical outcome was classified as successful if perceptual speech assessment indicated elimination of hypernasality, nasal emission and turbulence, and instrumental assessment indicated 100% velopharyngeal closure. Results showed that 18 of 19 patients were managed successfully with sphincter pharyngoplasty. Our data corroborate that sphincter pharyngoplasty is a reasonable alternative to pharyngeal flap in patients with velopharyngeal dysfunction secondary to velocardiofacial syndrome.

The evaluation of velopharyngeal function using flexible nasendoscopy

Nasendoscopy is an essential tool in assessing the dynamic function and structure of the velopharyngeal sphincter during speech and swallowing. Flexible fibre-optic nasendoscopy has been used by the cleft palate team at Withington Hospital, Manchester since 1989. Seventy-six patients were referred between 1989 and 1994 for evaluation of velopharyngeal function during speech. Flexible nasendoscopic evaluation was attempted in 50 patients, and successfully carried out in 43 patients. The age range was four years to 77 years (mean 21 years). The patients were divided into two groups: Group 1 consisting of patients with cleft palate and Group 2 comprised of patients with non-overt cleft palate-related velopharyngeal dysfunction of various aetiologies; such as, submucous cleft, post-tonsillectomy, post-adenoidectomy, neurological and post-traumatic. Based on the findings on nasendoscopy, videofluoroscopy and clinical speech/voice analysis the following treatment options were recommended: 17 (40 per cent) for pharyngoplasty, five (11 per cent) for revision pharyngoplasty, 15 (35 per cent) for speech therapy, four for an obturator and one for tonsillectomy. Two previously undetected submucous clefts were diagnosed.

Tonsillectomy in children with or at risk for velopharyngeal insufficiency: effects on speech

Recent case reports have challenged the notion that tonsillectomy is contraindicated in patients with or at risk for velopharyngeal insufficiency. The purpose of this study was to quantify the effects of tonsillectomy (with or without adenoidectomy) on perceptual speech characteristics, aerodynamic measures, and endoscopic descriptions of velopharyngeal function in a clinical population. Fifteen children 4 to 10 years of age received preoperative and postoperative evaluations. Perceptual speech characteristics improved or remained the same for most variables. There was no statistically significant difference between preoperative and postoperative ratings of hypernasality or frequency and severity of nasal emission. However, ratings of voice quality (pitch and breathiness) were significantly improved after surgery. Aerodynamic measures showed improvement or no change in velopharyngeal function for 12 of 15 children. Endoscopic assessment showed improvement or no change in velopharyngeal closure for 7 of 11 children tested. Cross-method analysis indicated that no single subject showed deterioration in velopharyngeal function in all three measures. The data from this investigation do not support the assumption that tonsillectomy is contraindicated for all children with or at risk for velopharyngeal insufficiency.

Velopharyngeal incompetence after adenotonsillectomy in non-cleft patients

This report discusses 15 non-cleft palate children who developed velopharyngeal incompetence (VPI) after adenotonsillectomy. Eight boys and 7 girls with a mean age of 6.2 years (range 4.3-11 years) were treated between 1970 and 1993. After 2 years conservative management to allow for spontaneous resolution, only (7 children) 47% achieved normal resonance. Speech therapy was employed mainly for those patients with unrelated articulation errors. Fifty-three percent (8 children) required surgery for persistent hypernasality and in 6 a pharyngoplasty was performed and in one child a posterior pharyngeal cartilage graft was inserted. One case is still to have surgical intervention. Half of the non-cleft children who develop VPI after adenotonsillectomy will respond to conservative management.

Evaluation and Treatment of Resonance Disorders

Resonance disorders can be caused by a variety of structural abnormalities in the resonating chambers for speech, or by velopharyngeal dysfunction. These abnormalities may result in hypernasality, hypo- or denasality, or cul-de-sac resonance. Resonance disorders are commonly seen in patients with craniofacial anomalies, particularly a history of cleft palate. The appropriate evaluation of a resonance disorder includes a speech pathology evaluation, and may require a video-fluoroscopic speech study or nasopharyngoscopy assessment. Treatment may include surgery or the use of prosthetic devices, and usually speech therapy. Given the complexity of these disorders in regard to evaluation and treatment, the patient is best served by an interdisciplinary craniofacial anomaly team.

Do palatal lift prostheses stimulate velopharyngeal neuromuscular activity?

The purpose of this investigation was to evaluate the ability of palatal lift prostheses to stimulate the neuromuscular activity of the velopharynx. Nasendoscopic evaluations were audio-videotaped preprosthetic and postprosthetic management for 25 patients who underwent placement of a palatal lift prosthesis for velopharyngeal dysfunction (VPD). These audio-videotapes were presented in blinded fashion and random order to three speech pathologists experienced in assessment of patients with VPD. They rated the tapes on the following parameters: VP gap size, closure pattern, orifice estimate, direction and magnitude of change, and qualitative descriptions of the adequacy of VP closure during speech. VP closure for speech was unchanged in 69% of patients and the number of patients rated as improved or deteriorated was nearly identical at about 15%. Postintervention gap shape remained unchanged in 70% of patients. The extent of VP orifice closure during speech remained unchanged in 57% of patients. Articulations that could impair VP function improved in 30% of patients, deteriorating in only 4%. Results of this study neither support the concept that palatal lift prostheses alter the neuromuscular patterning of the velopharynx, nor provide objective documentation of the feasibility of prosthetic reduction for weaning.

Treatment of asymmetric velopharyngeal insufficiency with skewed pharyngeal flap

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view video-fluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or iatrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

Successful nasoendoscopic and aerodynamic examinations of children with speech/voice disorders

An 8-year retrospective analysis of aerodynamic and nasoendoscopic examinations of children with a variety of speech and voice disorders shows that these examinations can be completed with a high rate of success. Moreover, the examinations were achieved with relative ease in children as young as 2 years old. Several clinicians were involved in the examinations, illustrating the viability of the methods. It is suspected that the failures to complete the examinations relate more to the examiners' methods and skills than to the child's tolerance of the instrumentation.

Results of a survey of cleft palate teams concerning the use of nasendoscopy

A national survey was conducted concerning methods used for the evaluation of velopharyngeal function with emphasis on the role of nasendoscopy. Forty-five percent of questionnaires were returned. Ninety percent of the responding teams indicated that nasendoscopy was available. Sixty-one percent agreed that endoscopy was an important clinical tool and not solely a research tool. The majority (59%) considered 3 to 5 years of age to be the youngest, appropriate age for referral. Ninety percent agreed that nasendoscopy was indicated for difficult diagnostic problems and 41% reported endoscopic studies were appropriate for all patients for whom secondary palatal management is planned. The results of this survey suggest that endoscopic assessment of velopharyngeal function is used routinely as an adjunct to the perceptual evaluation of speech and has become the standard of care among cleft palate teams for difficult diagnostic cases. However, the data also indicate that increased availability does not necessarily assure optimal use.

Radiographic demonstration of oronasal fistulas in patients with cleft palate with the use of barium sulfate contrast

The purpose of this investigation was to determine the overlapping and unique contributions that radiographic techniques might provide for accurate characterization of hard palate fistulas associated with cleft palate. Five subjects with oronasal fistulas were selected for radiographic imaging, and their informed consent was obtained. Results indicated that radiographs with contrast can provide important supplemental and unique information. Qualitative descriptions of the inferior-superior course and location, and the size of the narrowest aperture could be obtained from the combination of maxillary occlusal, posteroanterior tomographic, and lateral tomographic projections. This information could not be obtained from the common clinical methods in use to describe fistulas. This technique can provide valuable information to all members of a multidisciplinary cleft palate team to document palatal fistulas for both clinical and research purposes.

Navigation of the nose with flexible fiberoptic endoscopy

The introduction of flexible fiberoptics into medicine revolutionized the evaluation and treatment of velopharyngeal dysfunction. In this paper, rigid endoscopy and flexible fiberoptic scopes are discussed, including their respective advantages and disadvantages. Anesthetic and anatomic considerations relative to the endoscopic procedure are presented. Transnasal endoscopy permits documentation of static and dynamic anatomy, information that may be fundamental for the understanding and treatment of patients with velopharyngeal dysfunction.