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Ghanem AM, Borg TM, Youssef G, Ridout D, Gilleard O, Birch M, Sell D, Sommerlad BC. Surgical Management of Submucous Cleft Palate by Radical Muscle Dissection Veloplasty: Speech Outcomes in Patients with 22q11.2 Deletion Syndrome. Cleft Palate Craniofac J 2024; 61:498-507. [PMID: 36624582 DOI: 10.1177/10556656221150707] [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] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate the benefit of anatomical muscle dissection repair for velopharyngeal insufficiency (VPI) in patients with submucous cleft palate (SMCP) with 22q11.2 deletion syndrome. DESIGN Retrospective blinded randomised analysis of a surgeon's management over 10 years. SETTING The study was performed at a specialised Paediatric hospital in the United Kingdom. PATIENTS Children with SMCP and 22q11.2 deletion syndrome. INTERVENTIONS All participants underwent radical muscle dissection veloplasty. OUTCOMES MEASURED Pre- and post- operative measurements included severity of anatomical defect, speech samples and lateral images which were digitised, randomised then externally and blindly analysed using validated techniques. Stata software was used to perform statistical analysis. RESULTS 57 children with 22q11.2 deletion syndrome were included in this analysis. Intra-operatively, the majority of cases were identified as SMCP Grade I anomalies. Post-operatively, a statistically significant improvement in hypernasality, resting palate length, palate length at maximum closure, palate excursion and gap size at maximum closure was observed. Secondary surgery was performed for 59% of patients by ten years. CONCLUSION Muscle dissection repair improves hypernasality, palate closure function and the closure gap in patients with 22q11.2 deletion syndrome. Although over 50% of patients may require further surgery, muscle dissection repair should be a first step due to its utility at a younger age, when invasive investigations are impossible, its lower morbidity, speech and language benefits or altering the plans for less obstructive secondary surgery when it lead to reduced velo-pharyngeal gap and improved palate mobility even when adequate velo-pharyngeal closure was not achieved.
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Affiliation(s)
| | - Tiffanie-Marie Borg
- Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesborough, UK
- Academic Plastic Surgery Group, Barts and the London School of Medicine, London, UK
| | - Gehad Youssef
- Milner Therapeutics Institute, Cambridge University, Cambridge, UK
| | | | - Onur Gilleard
- Plastic and Reconstructive Surgery, Barts Health, London, UK
| | - Malcolm Birch
- Director of Clinical Physics, Barts Health, London, UK
| | - Debbie Sell
- Great Ormond Street Hospital for Children, NHS Trust, London, UK
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Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2023; 81:E120-E146. [PMID: 37833020 DOI: 10.1016/j.joms.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Charters E, Pelham C, Novakovic D, Madill C, Clark J. Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 25:540-548. [PMID: 35975948 DOI: 10.1080/17549507.2022.2104927] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Following transoral robotic surgery (TORS) for oropharyngeal carcinoma (OPC), velopharyngeal incompetence (VPI) is a known consequence that may contribute to swallowing and speech disorders. As the incidence of OPC increases affecting a younger demographic, a better understanding of VPI is required to support speech and swallowing rehabilitation. METHOD A scoping review was conducted using Arskey & O'Malley's framework. Studies were identified from five databases between 2007 and 2020. The methodological quality was measured with the RevMan Risk of Bias Tool by two independent evaluators. RESULT A total of seven studies met the inclusion criterion. There was a combined total of 306 participants, their average age was 59.2 years. A high risk of bias and degree of heterogeneity across all seven cohort studies was observed. Validated and instrumental evaluations of VPI were present in two papers, with the majority only reporting the presence or absence of VPI. The incidence of VPI reported in each study ranged from 0 to 53%, (median 3.5%). CONCLUSION There are few high-quality studies and considerable heterogeneity in the terminology, inclusion criteria and measurement of VPI. Instrumentation, to date, has been rarely used but is necessary for a normed and validated approach to VPI. Based on this review, there is considerable need for larger studies which instrumentally and longitudinally assess VPI as a consequence of TORS, in order to guide patient education and management prior to, and following their surgery.
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Affiliation(s)
- Emma Charters
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Claire Pelham
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Daniel Novakovic
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
| | - Cate Madill
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jonathan Clark
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
- Sydney Head and Neck Cancer Institute, Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, Australia
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, Australia
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Tse RW, Sie KC, Tollefson TT, Jackson OA, Kirshner R, Fisher DM, Bly R, Arneja JS, Dahl JP, Soldanska M, Sitzman TJ. Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations. Cleft Palate Craniofac J 2023:10556656231181359. [PMID: 37441787 PMCID: PMC10787042 DOI: 10.1177/10556656231181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.
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Affiliation(s)
- Raymond W Tse
- Craniofacial and Pediatric Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Plastic Surgery, University of Washington, Seattle, WA, USA
| | - Kathleen C Sie
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Travis T Tollefson
- Otolaryngology Head and Neck Surgery, University of California, Davis, Sacramento, CA, USA
| | - Oksana A Jackson
- Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Kirshner
- Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David M Fisher
- Plastic Surgery, The Hospital for Sick Children, Toronto, ON, USA
- Plastic Surgery, University of Toronto, Toronto, ON, USA
| | - Randall Bly
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Jugpal S Arneja
- Plastic Surgery, BC Children's Hospital, Vancouver, BC, USA
- Plastic Surgery, University of British Columbia, Vancouver, BC, USA
| | - John P Dahl
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | | | - Thomas J Sitzman
- Plastic Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Konstantinidou S, Hall A, Pinkstone M, Cochrane L. Paediatric velopharyngeal insufficiency following adenotonsillar surgery. Int J Pediatr Otorhinolaryngol 2021; 149:110847. [PMID: 34293625 DOI: 10.1016/j.ijporl.2021.110847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/10/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Paediatric velopharyngeal insufficiency (VPI) is a known but rare complication following adenotonsillar surgery that can have significant adverse effects on the communication as well as psychological well-being of the patient and their family. We sought to assess risk factors, aetiology, assessment and management of these patients through a dedicated multidisciplinary clinic. METHODS Retrospective data collection was performed for patients seen in the Great Ormond Street Hospital for Children multidisciplinary VPI clinic from the 1st of January 2015 until 30th of April 2020. Paediatric patients with previous adenotonsillar surgery and no evidence of cleft palate or speech and language disorder were included in the study. RESULTS 29 patients met the inclusion criteria, with 16 having previous adenotonsillectomy and 13 isolated adenoidectomy. In our VPI clinic, patients were seen on average for 4.9 occasions over a 38.3-month period. Clinical assessment was conducted using GOS.SP.ASS '98 speech assessment tool, speech videofluoroscopy and nasoendoscopy, as per individual needs. The main cause of post-adenoidectomy VPI was identified in 72.5% of the cases. Speech videofluoroscopy was performed in 27 cases. Associated anatomic features identified included deep pharynx (37%), long palate (22.2%) and variable levator position. Severe hypernasality was noted in 3 patients, while in 20 cases moderate or mild hypernasality was found. There were no patients with normal speech. Ten patients were treated with speech therapy alone, whereas surgical intervention was required in seventeen cases. In the population who received treatment and had adequately recorded follow-up, improvement in speech was noted in 86.9%, with 30.4% having oral resonance on last review. Of the patients with severe hypernasality, all improved but had some persistent hyper nasality on last clinic review. CONCLUSIONS We present our multidisciplinary management of post adenoidectomy VPI. Through the investigations in our dedicated specialist VPI clinic, the cause of VPI was found more frequently than in previous reports in the literature. Intense treatment is usually required with lengthy follow-up and multiple attendances in VPI clinic. Main modalities of management include SLT, surgery and speech prostheses. Most patients' speech will improve with intervention. We highlight the importance of early recognition, referral and a multi-disciplinary approach in treating this condition. We advise ENT surgeons to ensure patients are adequately aware of this complication given its potential impact.
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Affiliation(s)
| | - Andrew Hall
- Great Ormond Street Hospital for Children, London, UK; Noah's Ark Children's Hospital for Wales, Cardiff, UK
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Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function. J Craniofac Surg 2021; 33:491-495. [PMID: 34260449 DOI: 10.1097/scs.0000000000007940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.
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Steinberg B, Caccamese J, Costello BJ, Woerner J. Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2019; 75:e126-e150. [PMID: 28728728 DOI: 10.1016/j.joms.2017.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Trudel M, Laframboise R, Leclerc JE. Musculo-mucous web velum and velopharyngeal dysfunction associated with 8q22.1-22.2 microduplication. Int J Pediatr Otorhinolaryngol 2018; 104:134-137. [PMID: 29287853 DOI: 10.1016/j.ijporl.2017.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/18/2017] [Accepted: 11/14/2017] [Indexed: 11/18/2022]
Abstract
This report presents a rare case of isolated non-cleft velopharyngeal dysfunction (VPD). An eight-year-old child presented 1. a phenotypically unique band-gap pattern of the velar musculature with anteroposterior insertion; 2. a mosaic partial trisomy on chromosome 19 as well as microduplications on chromosomes 8 and 22. Following cytogenetic analysis, microduplication on chromosome 8 was found in another member of her family. A family history of VPI with hypernasality and nasal regurgitation was reported over three different generations on the patient's maternal side. Since only one case of velum malformation is found in this family, we cannot conclude to a link between the palatal anomaly or VPD and the DNA rearrangements.
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Affiliation(s)
- Mathieu Trudel
- Department of Otolaryngology - Head & Neck Surgery, Laval University, Quebec City, Canada
| | - Rachel Laframboise
- Department of Pediatrics - Medical Genetics Division, Centre Hospitalier Universitaire de Québec, Canada
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Nasoseptal flap for palatal reconstruction after hemi-maxillectomy: case report. The Journal of Laryngology & Otology 2017; 132:83-87. [PMID: 29151373 DOI: 10.1017/s002221511700233x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Palatal reconstruction following maxillectomy is a surgical challenge, and a nasoseptal flap is a feasible approach. This paper reports the first known successful clinical case of a nasoseptal pedicle flap applied for the reconstruction of maxillary bone following hemi-maxillectomy. CASE REPORT This report describes hemi-maxillectomy in a 60-year-old Italian male diagnosed with stage IV squamous cell carcinoma of the left maxilla. Endoscopic transnasal extended medial maxillectomy was performed, followed by a transoral modified midfacial degloving technique for removal of the maxillary bone. The contralateral nasoseptal pedicle flap was used to reconstruct the defect. The case was followed up prospectively for the assessment of flap reception and healing. CONCLUSION The locally accessible nasoseptal flap is a viable alternative for palatal reconstruction; therefore, a second surgical procedure with its associated donor site morbidity can be avoided. Large-scale studies may help in establishing the cosmetic and functional outcomes.
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Bruneel L, Van Lierde K, Bettens K, Corthals P, Van Poel E, De Groote E, Keppler H. Health-related quality of life in patients with cleft palate: Validity and reliability of the VPI Effects on Life Outcomes (VELO) questionnaire translated to Dutch. Int J Pediatr Otorhinolaryngol 2017; 98:91-96. [PMID: 28583513 DOI: 10.1016/j.ijporl.2017.04.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/28/2017] [Accepted: 04/30/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Disease-specific health-related quality of life (HRQOL) questionnaires provide the clinician with important information regarding the impact of the disease on functioning and well-being. For patients with velopharyngeal insufficiency (VPI), the VPI Effects on Life Outcomes (VELO) questionnaire was developed and validated in English by Skirko et al. (2012). However, a valid and reliable Dutch translation of this questionnaire is not available yet. METHODS The English questionnaire was translated to Dutch following a forward-backward translation procedure. A linguistic validation and the evaluation of the internal consistency (Cronbach's α) of this Dutch version were performed based on the responses of 39 parents of patients with cleft (lip and) palate (mean age: 6.8 years) (parent report) and the responses of 14 patients older than 8 years (mean age: 9.5 years) (child report). Additionally, the concurrent validity was assessed by comparing the scores on the parent report to those on the pediatric voice handicap index. Furthermore, the validity of the parent proxy assessment and the relationship between age and responses on the VELO questionnaire were investigated. Based on the responses of an age and gender matched control group without cleft palate, the discriminant validity was evaluated. RESULTS The parent report was easy to complete for all parents. Nine of the fourteen (64%) patients were able to complete the child report independently. The median scores on the parent report and the child report were 82.7 and 95.1 respectively. The patient group had a significantly worse perception of HRQOL compared to the control group (p < 0.001; p = 0.029). There were no significant differences between the responses of the parent and their child's (p = 0.345). A significant positive correlation was found between the score on the parent report and the age of the patients (p = 0.001). Furthermore, a significant negative correlation was found between the parent report and the P-VHI (p < 0.001). Cronbach's α was 0.955 and 0.817 for the parent report and the child report respectively. CONCLUSION The Dutch VELO questionnaire is a valid, reliable and user-friendly tool that provides important information about HRQOL in patients with cleft (lip and) palate.
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Affiliation(s)
- Laura Bruneel
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium.
| | - Kristiane Van Lierde
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium; Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Kim Bettens
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium
| | - Paul Corthals
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium; Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Esther Van Poel
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium
| | - Evelien De Groote
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium
| | - Hannah Keppler
- Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium
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Glade RS, Deal R. Diagnosis and Management of Velopharyngeal Dysfunction. Oral Maxillofac Surg Clin North Am 2016; 28:181-8. [DOI: 10.1016/j.coms.2015.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sinclair CF, Simonyan K, Brin MF, Blitzer A. Negative dystonia of the palate: a novel entity and diagnostic consideration in hypernasal speech. Laryngoscope 2015; 125:1426-32. [PMID: 25646795 PMCID: PMC4718549 DOI: 10.1002/lary.25165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/22/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To present the first documented series of patients with negative dystonia (ND) of the palate, including clinical symptoms, functional MRI findings, and management options. STUDY DESIGN Case series ascertained from clinical research centers that evaluated patients with both hyperkinetic and hypokinetic movement disorders. METHODS Between July 1983 and March 2013, data was collected on patient demographics, disease characteristics, functional MRI findings, long-term management options, and outcomes. We sought patients whose clinical examination demonstrated absent palatal movement on speaking, despite normal palatal activity on other activities. RESULTS Five patients (2 males, 3 females) met clinical criteria. All patients presented with hypernasal speech without associated dysphagia. Clinical examination revealed absent palatal movement on speaking despite intact gag reflexes, normal palate elevation on swallowing, and normal cranial nerve examinations. Other cranial and/or limb dystonias were present in four patients (80.0%). Three patients (60.0%) had previously failed oral pharmacologic therapy. Two patients underwent functional magnetic resonance imaging (fMRI) studies, which demonstrated an overall decrease of cortical and subcortical activation during production of symptomatic syllables and asymptomatic coughing. Management included speech therapy (all patients) and palatal lift (2 patients) with limited improvement. Calcium hydroxyapatite injection (1 patient) into the soft palate and Passavants' ridge was beneficial. CONCLUSIONS This is the first report of ND of the palate. Characteristic findings were task-specific absent palatal movement with speech, despite normal movement on swallowing, coughing, and an intact gag reflex, as well as disorder-specific decreased brain activation on functional MRI. A diagnosis of ND of the palate should be considered for patients who present with hypernasal speech. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, Mount Sinai Icahn School of Medicine, New York, New York, U.S.A
- New York Center for Voice and Swallowing Disorders, Mount Sinai Icahn School of Medicine, New York, New York, U.S.A
| | - Kristina Simonyan
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, Mount Sinai Icahn School of Medicine, New York, New York, U.S.A
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Mitchell F Brin
- Department of Neurology, University of California, Irvine, Irvine, California, U.S.A
| | - Andrew Blitzer
- New York Center for Voice and Swallowing Disorders, Mount Sinai Icahn School of Medicine, New York, New York, U.S.A
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
- Department of Otolaryngology, Columbia University College of Physicians and Surgeons, New York, New York, U.S.A
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El-Anwar MW, Amer HS, Elnashar I, Khazbak AO, Khater A. Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function. Laryngoscope 2014; 125:1729-32. [PMID: 25545913 DOI: 10.1002/lary.25106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/03/2014] [Accepted: 12/01/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function. METHODS This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation. RESULTS All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001). CONCLUSION ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.
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Affiliation(s)
- Mohammad Waheed El-Anwar
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hazem Saeed Amer
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ismail Elnashar
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Alaa Omar Khazbak
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Khater
- Audiology Unit, Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Cadaveric study of the posterior pedicle nasoseptal flap: a novel flap for reconstruction of pharyngeal defects and velopharyngeal insufficiency. Plast Reconstr Surg 2014; 132:1269-1275. [PMID: 24165608 DOI: 10.1097/prs.0b013e3182a4c37b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The posterior pedicle nasoseptal flap has been the workhorse for endoscopic reconstruction of medium to large cranial base defects, with excellent outcomes and minimal flap failures. The authors present the anatomical foundations for the use of the nasoseptal flap for reconstruction of soft palate and pharyngeal defects and for surgical treatment of velopharyngeal insufficiency in a cadaveric model. METHODS Posterior pedicle nasoseptal flaps were endoscopically harvested and transposed to the naso/oropharynx in seven cadavers. The reach and relationships of the flap with nasopharyngeal and oropharyngeal structures were documented. RESULTS A total of nine nasoseptal flaps (bilateral in two specimens) were transposed into the nasopharynx and oropharynx. The most anterior aspect of the flap was visualized transorally several millimeters inferior to the soft palate in all specimens. Six flaps were sutured transorally to the posterior pharyngeal wall and three were sutured to defects of the soft palate. The width of a fully harvested flap (entire septal mucosa) was more than twice the width of the posterior nasopharyngeal/oropharyngeal wall in all specimens. Nasoseptal flaps were easily tailored endoscopically and transorally with standard instrumentation to fit the defects. CONCLUSIONS In a cadaveric model, the nasoseptal flap can be transposed into the nasopharynx and upper oropharynx and is a potential alternative for pharyngeal reconstruction and surgical treatment of velopharyngeal insufficiency in patients in whom traditional flaps are not available. The application of this technique for reconstruction of pharyngeal and velar defects is novel, and further studies evaluating clinical outcomes are needed.
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Ockeloen CW, Simpson J, Urquhart J, Davies J, Bowden M, Patrick K, Dore J, Clayton-Smith J. Velopharyngeal insufficiency: high detection rate of genetic abnormalities if associated with additional features. Arch Dis Child 2014; 99:52-7. [PMID: 24146286 DOI: 10.1136/archdischild-2013-304484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To review the clinical and molecular-genetic characteristics of 34 children who were referred to the clinical genetics department with a presenting diagnosis of definite or suspected velopharyngeal insufficiency (VPI, defined as the inability to close off the nasal from the oral cavity during speech) or hyponasal/hypernasal speech. All the patients referred also had additional anomalies and did not therefore comprise the whole VPI population. METHODS Patients were clinically investigated by a clinical geneticist. Fluorescent in situ hybridisation for chromosome 22q11 deletion and/or array comparative genomic hybridisation (array CGH) analysis was performed in all cases. A literature review was performed using the Pubmed online database. RESULTS Microdeletions or microduplications were identified in half of the patients. Six patients (∼18% of total) carried a chromosome 22q11 microdeletion, one patient had a chromosome 22q11 microduplication, and four patients had microdeletions in other chromosomes that were considered likely to be associated with the phenotype. One patient had KBG syndrome. Thus, an underlying genetic abnormality was found in approximately one-third (35%) of our patients. An additional seven patients harboured copy number variations that were considered benign or of unknown significance. CONCLUSIONS We present an overview of patients with VPI or hyponasal/hypernasal speech with additional anomalies and their clinical and genetic findings. In one-third of these patients, an underlying genetic abnormality was identified. This has important implications for family counselling and medical follow-up. Furthermore, we recommend array CGH testing in all patients with VPI and associated anomalies because of the high percentage of copy number variants identified in these patients.
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Affiliation(s)
- Charlotte W Ockeloen
- Department of Human Genetics, Radboud university medical center, Nijmegen , The Netherlands
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Ruda JM, Krakovitz P, Rose AS. A review of the evaluation and management of velopharyngeal insufficiency in children. Otolaryngol Clin North Am 2012; 45:653-69, viii. [PMID: 22588042 DOI: 10.1016/j.otc.2012.03.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This article highlights the most common causes of velopharyngeal insufficiency (VPI), and discusses routine evaluation and treatment algorithms for the management of VPI in children. VPI is a multifactorial condition that occurs commonly in syndromic and non-syndromic children. The most common features of VPI are audible hypernasal speech, facial grimacing, decreased speech intelligibility, nasal regurgitation, and nasal emission from failure to produce oronasal separation. Work-up of VPI typically involves radiologic and endoscopic testing performed with the assistance of a speech-language pathologist. Management of VPI involves initial speech therapy followed by operative repair with sphincter or pharyngeal flap pharyngoplasty, if needed.
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Affiliation(s)
- James M Ruda
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, 170 Manning Drive, Chapel Hill, NC 27599-7070, USA.
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Lam E, Hundert S, Wilkes GH. Lateral Pharyngeal Wall and Velar Movement and Tailoring Velopharyngeal Surgery: Determinants of Velopharyngeal Incompetence Resolution in Patients with Cleft Palate. Plast Reconstr Surg 2007; 120:495-505. [PMID: 17632355 DOI: 10.1097/01.prs.0000267438.18295.e4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After primary palatoplasty, patients with cleft palate may still require secondary surgical procedures to correct residual velopharyngeal incompetence. This study evaluated speech outcomes of patients who underwent differential velopharyngeal surgery based on degree of lateral pharyngeal wall movement and velar movement. METHODS In this retrospective cohort study, 31 patients with cleft palate from 1992 to 2003 underwent tailor-made velopharyngeal surgery with complete preoperative and postoperative speech assessments. All patients were evaluated postoperatively for velopharyngeal incompetence resolution, persistent velopharyngeal incompetence, and hyponasality. RESULTS Velopharyngeal incompetence was resolved in 90 percent of patients. Severe hyponasality occurred as a complication in 16 percent, requiring subsequent division of the pharyngeal flap. Patients with lateral pharyngeal wall movement greater than 25 percent had a significantly greater chance of incompetence resolution compared with those with lateral pharyngeal wall movement less than 25 percent (p < 0.001). Regarding combined lateral pharyngeal wall movement plus velar movement, all groups showed significantly lower velopharyngeal competence scores following surgery (p < 0.001). Patients with lateral pharyngeal wall movement less than 25 percent and velar movement greater than 50 percent had the least successful speech outcome. The data also showed that various types of surgical operations performed on patients with similar combined degrees of lateral pharyngeal wall movement and velar movement can result in equally successful speech outcomes. This finding indicated flexibility in following the treatment algorithm for tailoring velopharyngeal surgery. CONCLUSION The degree of lateral pharyngeal wall movement and velar movement, rather than type of surgical procedure chosen, is a more important determinant of velopharyngeal incompetence resolution in patients with cleft palate.
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Affiliation(s)
- Eugene Lam
- Edmonton, Alberta, Canada From the Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, and Department of Speech Pathology and Audiology, Stollery Children's Hospital, University of Alberta, WC Mackenzie Health Science Center
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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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