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Chernov ES, Taniguchi AN, Nguyen SA, Sutton SR, Pecha PP, Patel KG, Montiel M, Carroll WW. Surgical outcomes and revision rates for velopharyngeal insufficiency (VPI) in syndromic and non-syndromic children: A systematic review and meta-analysis. Am J Otolaryngol 2024; 45:104341. [PMID: 38754293 DOI: 10.1016/j.amjoto.2024.104341] [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: 02/27/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE To evaluate pre- and post-operative resonance, surgical technique, revision rate, and revision indication among syndromic and non-syndromic children with velopharyngeal insufficiency (VPI). MATERIALS AND METHODS A systematic review was conducted through July 2022. Children surgically treated for VPI were included. A meta-analysis of single means, proportions, comparison of proportions, and mean differences with 95 % confidence interval [CI] was conducted. RESULTS Twenty-three articles (n = 1437) were included in the analysis. The most common surgery was Sphincter Pharyngoplasty (SP), 62.6 % [31.3-88.9] for syndromic and 76.3 % [37.5-98.9] for non-syndromic children. Among all surgical techniques, for syndromic and non-syndromic children, 54.8 % [30.9-77.5] and 73.9 % [61.3-84.6] obtained normal resonance post-operatively, respectively. Syndromic patients obtained normal resonance post-operatively in 83.3 % [57.7-96.6] of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty (CPSP), 72.6 % [54.5-87.5] of Pharyngeal Flap (PF), and 45.1 % [13.2-79.8] of Sphincter Pharyngoplasty (SP) surgeries. Non-syndromic patients obtained normal resonance post-operatively in 79.2 % [66.4-88.8] of PF and 75.2 % [61.8-86.5] of SP surgeries. The revision rate for syndromic and non-syndromic patients was 19.9 % [15.0-25.6] and 11.3 % [5.8-18.3], respectively. The difference was statistically significant, 8.6 % [2.9-15.0, p = 0.003]. Syndromic patients who underwent PF were least likely to undergo revision surgery as compared to SP and CPSP, 7.7 % [2.3-17.9] vs. 23.7 % [15.5-33.1] and 15.3 % [2.8-40.7], respectively. CONCLUSIONS Syndromic children had higher revision rates and were significantly less likely to obtain normal resonance following primary surgery than non-syndromic patients. Among syndromic children, PF and CPSP have been shown to improve resonance and reduce revision rates more so than SP alone.
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Affiliation(s)
- Evan S Chernov
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; SUNY Upstate Medical University, School of Medicine, 766 Irving Ave, Syracuse, NY 13210, USA
| | - April N Taniguchi
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Central Florida, School of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
| | - Shaun A Nguyen
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA.
| | - Sarah R Sutton
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Nevada, Reno, School of Medicine, 1664 N Virginia St, Reno, NV 89557, USA
| | - Phayvanh P Pecha
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Krishna G Patel
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Melissa Montiel
- Medical University of South Carolina, Department of Speech Language Pathology, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - William W Carroll
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
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Wang AT, Hseu AF, Staffa SJ, Clark RE, Meara JG, Nuss RC, Ganske IM, Rogers-Vizena CR. Comparative Study of Pharyngeal Flap Outcomes between Children with 22q11.2 Deletion Syndrome and Nonsyndromic Cleft Lip and Palate. Plast Reconstr Surg 2024; 154:151-160. [PMID: 37337330 DOI: 10.1097/prs.0000000000010854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Management of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome is challenging. The authors compared pharyngeal flap outcomes in children with 22q11.2 deletion syndrome to those with nonsyndromic cleft lip and palate (CLP) to assess risk of poor speech outcomes and negative sequelae. METHODS Children with 22q11.2 deletion syndrome or CLP treated with pharyngeal flap through a multidisciplinary VPI clinic between 2009 and 2020 were retrospectively reviewed. Preoperative and postoperative speech assessments, perioperative characteristics, and complications were identified. RESULTS Thirty-six children with 22q11.2 deletion syndrome and 40 with CLP were included. Age at surgery ( P = 0.121), preoperative velopharyngeal competence score ( P = 0.702), and preoperative resonance ( P = 0.999) were similar between groups. Pharyngeal flaps were wider ( P = 0.038) and length of stay longer in the 22q11.2 deletion syndrome group ( P = 0.031). On short-term follow-up 4 months after surgery, similar speech outcomes were seen between groups. At long-term follow-up greater than 12 months after surgery, 86.7% of 22q11.2 deletion syndrome versus 100% of CLP ( P = 0.122) children had improvement in velopharyngeal function; however, fewer children with 22q11.2 deletion syndrome (60.0%) achieved a completely "competent" velopharyngeal competence score compared with those with CLP (92.6%) ( P = 0.016). Nasal regurgitation improved for both groups, with a greater improvement in those with 22q11.2 deletion syndrome ( P = 0.026). Revision rate ( P = 0.609) and new-onset obstructive sleep apnea ( P = 0.999) were similar between groups. CONCLUSIONS Children with 22q11.2 deletion syndrome have improved speech after pharyngeal flap, but they may be less likely to reach normal velopharyngeal function over the long term than those with CLP; however, negative sequelae do not differ. Improvement in nasal regurgitation is a uniquely positive outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
| | - Anne F Hseu
- From Harvard Medical School
- the Departments of Otolaryngology and Communication Enhancement
| | - Steven J Staffa
- From Harvard Medical School
- Surgery
- Anesthesiology, Critical Care, and Pain Medicine
| | | | - John G Meara
- From Harvard Medical School
- Plastic and Oral Surgery, Boston Children's Hospital
| | - Roger C Nuss
- From Harvard Medical School
- the Departments of Otolaryngology and Communication Enhancement
| | - Ingrid M Ganske
- From Harvard Medical School
- Plastic and Oral Surgery, Boston Children's Hospital
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Sink MC, Hopper SJ, Phillips JB, Goza SD, Brown MI, Brown KW, Fernstrum CJ, Humphries LS, Hoppe IC. Patients Requiring Multiple Surgeries for Velopharyngeal Insufficiency: Findings From a 10-Year Retrospective Review. J Craniofac Surg 2024:00001665-990000000-01580. [PMID: 38743261 DOI: 10.1097/scs.0000000000010213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/11/2024] [Indexed: 05/16/2024] Open
Abstract
This study analyzed patients undergoing multiple surgeries for velopharyngeal insufficiency (VPI) and reviewed their preoperative evaluations and techniques selected for subsequent surgeries. A retrospective chart review was performed including patients having undergone multiple surgeries for VPI at the authors' institution between 2012 and 2022. All patients were evaluated and managed at the author's institution under the direction of 4 senior surgeons. The objective of this study was to provide insight into preoperative evaluation, surgical technique selection, and other factors that may contribute to patients who require multiple VPI surgeries. Of 71 patients having undergone surgery for VPI, 8 required at least 1 additional operation for persistent VPI following the initial intervention. Six patients who initially underwent a superiorly based posterior pharyngeal flap (PPF) required additional surgery, and for those patients' subsequent operations, 5 different techniques were used throughout their treatment. Of the remaining 2 patients who had multiple VPI surgeries, 1 initially received autologous fat transfer and 1 initially underwent a furlow palatoplasty. Finally, 0 patients that initially underwent buccal flaps or collagen injection required further unplanned surgical intervention. This study demonstrates the importance of selecting an appropriate surgical approach when operating on patients following a failed VPI surgery. The algorithm developed from these findings emphasizes the importance of properly identifying the anatomical deficiency resulting from the failed intervention. A review of the advantages of nasopharyngoscopy as a preoperative evaluative technique of velopharyngeal form and function when compared to lateral barium video fluoroscopy was also included.
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Affiliation(s)
- Matthew C Sink
- The University of Mississippi Medical Center, School of Medicine
| | - Samuel J Hopper
- The University of Mississippi Medical Center, School of Medicine
| | - John B Phillips
- The University of Mississippi Medical Center, School of Medicine
| | - Shelby D Goza
- The University of Mississippi Medical Center, School of Medicine
| | - Madyson I Brown
- The University of Mississippi Medical Center, School of Medicine
| | | | | | | | - Ian C Hoppe
- The University of Mississippi Medical Center, Jackson, MS
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Esmailzade Moghimi S, Rezaei P, Sadeghi S, Feizi A, Derakhshandeh F. Outcomes of primary repair of cleft palate using sommerled intravelar veloplasty associated with velocardiofacial syndrome. Int J Pediatr Otorhinolaryngol 2024; 179:111940. [PMID: 38588634 DOI: 10.1016/j.ijporl.2024.111940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES Velocardiofacial syndrome, a prevalent microdeletion syndrome occurring in 1 in 2000-4000 live births, is marked by speech and language disorders, notably velopharyngeal dysfunction. This study investigates speech outcomes, nasometric and videofluoroscopic results before and after primary repair of cleft palate using the Sommerlad intravelar veloplasty (SIVV) technique within the Isfahan cleft care team for patients with velocardiofacial syndrome. METHODS Employing a quasi-experimental design, 19 participants with velocardiofacial syndrome, who underwent primary cleft palate repair by the Isfahan cleft care team, were included through convenience sampling. Perceptual and instrumental outcomes were assessed pre-and post-operatively. Statistical analysis encompassed paired t-tests and the non-parametric Wilcoxon signed-rank test (p < 0.05). RESULTS The study identified no statistically significant differences between pre-and post-surgical speech outcome parameters and nasalance scores. Nonetheless, a significant distinction emerged in the velopharyngeal closure ratio based on fluoroscopic evaluation (p = 0.038). CONCLUSION The efficacy of the SIVV technique in treating velopharyngeal dysfunction in velocardiofacial syndrome patients is inconclusive, demanding further research. Post-surgical speech outcomes are influenced by surgical technique, hypotonia, apraxia of speech, and surgery timing. Notably, an elevated velopharyngeal valve closure ratio, though anatomically indicative, does not exclusively predict surgical success.
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Affiliation(s)
- Sarah Esmailzade Moghimi
- Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Faculty of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Rezaei
- Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Sadeghi
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Awat Feizi
- Department of Biostatistics, Faculty of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Derakhshandeh
- Craniofacial and Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Kattimani V, Panneerselvam E, Tiwari R, Panga GSK, Sreeram RR. An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea. J Maxillofac Oral Surg 2023; 22:781-793. [PMID: 38105854 PMCID: PMC10719205 DOI: 10.1007/s12663-023-02051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes. Methods A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist. Results Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic review which assessed the adult age group. Conclusion None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects. Supplementary Information The online version contains supplementary material available at 10.1007/s12663-023-02051-x.
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Affiliation(s)
- Vivekanand Kattimani
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
| | | | - Rahul Tiwari
- Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat India
| | | | - Roopa Rani Sreeram
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
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Pereira VJ, So JYT, Tsang JMK, Choi WS, Tong MCF, Lee KYS. Speech Telepractice and Treatment Intensity in a Cantonese-Speaking Case with 22q11.2 Deletion Syndrome Following Late Diagnosis and Management of Velopharyngeal Dysfunction. Cleft Palate Craniofac J 2023; 60:1505-1512. [PMID: 35678611 DOI: 10.1177/10556656221106042] [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: 11/16/2022] Open
Abstract
This case report explores clinical treatment efficacy in a Cantonese-speaking child with 22q11.2 Deletion Syndrome where diagnosis and management of velopharyngeal dysfunction can be considered late. All treatment sessions were undertaken via telepractice during the peak of the COVID-19 pandemic in Hong Kong. A hybrid of specialized cleft palate speech treatment techniques and traditional treatment approaches in Speech Sound Disorders were utilized. Treatment intensity components including dose, dose form, session duration, and total intervention duration were documented.
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Affiliation(s)
- Valerie J Pereira
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
- Institute of Human Communicative Research, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Janet Y T So
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Joy M K Tsang
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Wing S Choi
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Michael C F Tong
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
- Institute of Human Communicative Research, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Kathy Y S Lee
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
- Institute of Human Communicative Research, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
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Kollara L, Perry JL, Kirschner RE, Fang X, Baylis AL. Assessment of the Velopharyngeal Mechanism at Rest and During Speech in Children With 22q11.2DS: A Cross-Sectional Study. Cleft Palate Craniofac J 2023; 60:1250-1259. [PMID: 35575228 DOI: 10.1177/10556656221100674] [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: 11/16/2022] Open
Abstract
OBJECTIVE Velopharyngeal dysfunction (VPD) associated with 22q11.2 deletion syndrome (22q11.2DS) has a complex etiology. This study had 3 aims: (1) assess differences in velopharyngeal and levator muscle configuration during rest versus sustained speech production (2) compare differences in velopharyngeal changes between children with and without 22q11.2DS (3) examine the relationship between adenoid thickness, pharyngeal depth, and velopharyngeal changes. DESIGN Cross-sectional. METHODS A total of 22 participants, 11 with 22q11.2DS and 11 controls with normal speech and velopharyngeal anatomy (ages 4-12 years), underwent nonsedated MRI at rest and during sustained /i/. Differences in velar and levator muscle contraction across the 2 different conditions were analyzed, using matched paired t-tests. Mean differences across participant groups were examined. Correlation analyses were also conducted. RESULTS When comparing differences between rest and sustained phoneme production (aim 1), significant (P < .05) differences were noted for all velar and levator muscle variables. For differences in velopharyngeal changes between children with and without 22q11.2DS (aim 2), VP ratio and effective VP ratio were noted to be significantly different. Pharyngeal depth and adenoid thickness were correlated with velar and levator muscle change measures and ratios (aim 3). CONCLUSION Results from this study provide quantitative in vivo measurements of the contracted levator muscle and velum in young children with 22q11.2DS. Results demonstrated that VP ratio and EVP ratio are significantly different between children with and without 22q11.2DS and that pharyngeal depth is a strong clinical determinant of VPD in children with 22q11.2DS.
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Affiliation(s)
- Lakshmi Kollara
- School of Communication Sciences and Disorders, College of Health Professions and Sciences, Biionix Cluster, University of Central Florida, Orlando, FL, USA
| | - Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Richard E Kirschner
- Section of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, USA
- Clinical Plastic Surgery, The Ohio State University College of Medicine, Columbus, USA
| | - Xiangming Fang
- Department of Biostatistics, East Carolina University, Greenville, NC, USA
| | - Adriane L Baylis
- Section of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, USA
- Clinical Plastic Surgery, The Ohio State University College of Medicine, Columbus, USA
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Suzzi C, Di Gennaro G, Baylon H, Captier G. A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence. Int Arch Otorhinolaryngol 2023; 27:e351-e361. [PMID: 37125364 PMCID: PMC10147477 DOI: 10.1055/s-0043-1763501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/09/2022] [Indexed: 03/31/2023] Open
Abstract
Abstract
Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options.
Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech.
Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study.
Results Among the patients (median [range] age 7 [4–48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique.
Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.
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Patel KR, Partain M, Ryan DP, Hersh C, Goldenberg P, Hartnick CJ. Carotid artery mobilization prior to pharyngeal flap inset for patients with 22q11.2 deletion syndrome. Int J Pediatr Otorhinolaryngol 2021; 141:110573. [PMID: 33359933 DOI: 10.1016/j.ijporl.2020.110573] [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: 11/15/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/01/2022]
Abstract
The management of velopharyngeal insufficiency (VPI) in patients with 22q11.2 deletion syndrome (22q11DS) poses a significant clinical challenge due to presence of a large velopharyngeal gap and a relatively high rate of internal carotid artery (ICA) medialization. To our knowledge, we are the first group to have successfully managed VPI in a series of seven pediatric patients with 22q11DS with medialized ICAs via a novel surgical technique involving carotid artery mobilization followed by pharyngeal flap insertion. Thus far, we have found this technique to be reliably safe with no significant morbidity and caregivers have reported postoperative improvement in speech, swallowing and nasal regurgitation symptoms. Herein, we provide a detailed description of our novel surgical approach, including an instructional video, for correction of VPI in patients with medialized ICAs, who have previously had limited management options.
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Affiliation(s)
- Krupa R Patel
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Matthew Partain
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Daniel P Ryan
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl Hersh
- Pediatric Airway, Voice and Swallowing Center, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Paula Goldenberg
- Division of Medical Genetics, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
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Outcomes in Velopharyngeal Dysfunction Treatment: Comparing Two Approaches for Pharyngeal Flaps. J Craniofac Surg 2020; 31:2167-2170. [PMID: 33136848 DOI: 10.1097/scs.0000000000006720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The most common surgical intervention to treat velopharyngeal dysfunction in the US is the posterior pharyngeal flap (PPF). In this retrospective study, the authors compare surgical and speech outcomes across 2 PPF surgical approaches: the palatal split (PS) and fish mouth (FM) techniques. METHODS An Institutional Review Board approved retrospective chart review was performed for PPF cases performed by a single surgeon between 2008 and 2016. Overall, 40 patients received the PS technique and 47 received the FM technique. Age at surgery, operative length, length of stay (LOS), revisional surgery, and pain medication administration were measured. Speech outcomes were measured based on the Universal Parameters for Reporting Speech Outcomes and included Speech Language Pathologist ratings of hypo- and hypernasality, speech acceptability, and audible nasal emission. Two sample t-tests and multivariable-mixed effects logistic regression were used to analyze the data. RESULTS Comparing the 2 groups (PS versus FM), there were statistically significant differences among the operative approaches across multiple measures: LOS (32.86 hours versus 26.20 hours, P = 0.01), acetaminophen use (1523.54 mg versus 805.74 mg, P = 0.01), revisional surgery rate (17.5% versus 2.10%, P = 0.02), and degree of postoperative hypernasality (0.61 versus 0.29, P = 0.03). Syndromic patients were more likely to receive the FM technique (PS: 15% versus FM: 29.8%; P = 0.05). The odds ratio for revision surgery with the FM technique was -2.32 (CI: -4.32 to -0.35, P = .04). CONCLUSIONS In this study, the FM technique offered a shorter LOS, lower revision rate, less acetaminophen administration, and more favorable speech outcomes when compared to the PS technique.
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Kimia R, Elden L, Dailey J, Kodavatiganti M, Crowley TB, McGinn DE, Bailey A, Zackai EH, McDonald-McGinn DM, Jackson OA. Magnetic resonance angiography (MRA) in preoperative planning for patients with 22q11.2 deletion syndrome undergoing craniofacial and otorhinolaryngologic procedures. Int J Pediatr Otorhinolaryngol 2020; 138:110236. [PMID: 32890936 DOI: 10.1016/j.ijporl.2020.110236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/28/2020] [Accepted: 06/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with 22q11.2 deletion syndrome (22q11.2DS) have a variety of anatomic anomalies. For surgeons operating in proximity to the retropharynx, the most pertinent is medial displacement of the internal carotid arteries. The purpose of this study is to describe the preoperative use of magnetic resonance angiography (MRA) in surgical planning and update the incidence rate of medial carotid displacement in patients with 22q11.2DS. METHODS This is a retrospective cohort study of patients with a confirmed diagnosis of 22q11.2 deletion and preoperative MRA <18 years old who underwent tonsillectomy, adenoidectomy, Furlow palatoplasty (FPP), posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), or submucosal cleft palate (SMCP) repair between January 1st, 2008 and December 31st, 2019. RESULTS Ninety patients who met the inclusion criteria underwent 133 procedures. The majority identified as Caucasian (84.4%); 52.2% were female. Cervical MRA was more likely to be ordered before a PPF (80.9%) and tonsillectomy (72.7%) over a FPP (47.6%) or adenoidectomy (11.1%). Carotid medialization was visualized in 23 patients (25.6%) and was mild in 11 cases, moderate in 7 cases, and significant in 5 cases. There was no association between sex, race/ethnicity, or genetic diagnosis with carotid medialization. Flap shortening was necessary in 20% of PPF cases to avoid injuring the medialized vessel. CONCLUSION Patients with 22q11.2DS may have higher rates of medialization of the carotid arteries than previously thought. Given the risk for complications in these patients during pharyngeal operations, there may be a critical place for MRA in surgical planning for patients with 22q11.2DS.
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Affiliation(s)
- Rotem Kimia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julia Dailey
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mallika Kodavatiganti
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T Blaine Crowley
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel E McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alice Bailey
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Roche L, Campbell L, Heussler H. Communication in 22q11.2 Deletion Syndrome: a Brief Overview of the Profile, Intervention Approaches, and Future Considerations. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2020. [DOI: 10.1007/s40474-020-00208-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Greenberg M, Caloway C, Hersh C, Ryan D, Goldenberg P, Hartnick C. Pharyngeal flap using carotid artery mobilization in 22q11.2 deletion syndrome with velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2019; 120:130-133. [PMID: 30784809 DOI: 10.1016/j.ijporl.2019.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/02/2019] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION 22q11.2 deletion syndrome is the most common microdeletion syndrome in children. Many patients with this disease develop craniofacial defects including cleft palate, bifid uvula, and velopharyngeal insufficiency. Our study adds to the current body of literature by describing a novel technique of carotid mobilization performed in conjunction with pharyngeal flap surgery in patients with extensive medialization of the carotid artery. METHODS Carotid artery mobilization followed by insertion of a superiorly based pharyngeal flap was performed on two patients, a 10-year-old girl and a 5-year-old boy, with 22q11.2 deletion syndrome concurrent with velopharyngeal insufficiency. RESULTS Neither patient experienced significant post-operative issues. Following the procedure, parents of both patients noted significant speech and voice improvement. Both patients had improvements in VPI Effects On Life Outcome (VELO) scores, nasometry, and production of paragraph passages following surgery. CONCLUSIONS Our study describes a novel surgical treatment for children with 22q11.2 deletion syndrome with significant velopharyngeal insufficiency (VPI). The procedure wherein is characterized by an extensive mobilization of the carotid artery followed by implantation of a pharyngeal flap. This technique resulted in no significant intra-operative bleeding, and was measured to be successful as noted by nasometry scores and changes in pre- and post-op VELO scores.
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Affiliation(s)
- Max Greenberg
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Christen Caloway
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Cheryl Hersh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Daniel Ryan
- Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Paula Goldenberg
- Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA, USA
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Jackson O, Crowley TB, Sharkus R, Smith R, Jeong S, Solot C, McDonald-Mcginn D. Palatal evaluation and treatment in 22q11.2 deletion syndrome. Am J Med Genet A 2019; 179:1184-1195. [PMID: 31038278 DOI: 10.1002/ajmg.a.61152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/21/2018] [Accepted: 02/27/2019] [Indexed: 01/23/2023]
Abstract
Palatal involvement occurs commonly in patients with 22q11.2 Deletion Syndrome (22qDS), and includes palatal clefting and velopharyngeal dysfunction in the absence of overt or submucous clefts. The reported incidence and distribution of palatal abnormalities vary in the literature. The aim of this article is to revisit the incidence and presenting features of palatal abnormalities in a large cohort of patients with 22qDS, summarize the surgical treatments performed in this cohort, and provide an overview of surgical treatment protocols and management guidelines for palatal abnormalities in this syndrome. Charts of 1,121 patients seen through the 22q and You Center at the Children's Hospital of Philadelphia were reviewed for palatal status, demographic factors, deletion size, and corrective surgical procedures. Statistical analysis was performed using Pearson's chi-squared test to identify differences between gender, deletion size, and palatal abnormality. Of the patients with complete evaluations, 67% were found to have a palatal abnormality. The most common finding was velopharyngeal dysfunction in 55.2% of patients, and in 33.3% of patients, this occurred in the absence of palatal clefting. There was no significant difference in the incidence of palatal abnormalities by gender; however, a difference was noted among race (p < 0.01) and deletion sizes (p < 0.01). For example, Caucasian and Asian patients presented with a much higher prevalence of palatal abnormalities, and conversely those with nested deletions presented with a much lower rate of palatal defects. Overall, 26.9% of patients underwent palatal surgery, and the most common indication was velopharyngeal dysfunction. Palatal abnormalities are a hallmark feature of 22q11.2 Deletion Syndrome; understanding the incidence, presenting features, and treatment protocols are essential for practitioners counseling and treating families affected with this disorder.
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Affiliation(s)
- Oksana Jackson
- Division of Plastic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Sharkus
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Smith
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Jeong
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Solot
- Department of Speech Language Pathology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna McDonald-Mcginn
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Bohm LA, Miller JE, Morrell N, Sidman JD, Roby BB. Surgical Outcomes for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome. Otolaryngol Head Neck Surg 2019; 161:348-351. [DOI: 10.1177/0194599819839958] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to compare outcomes of concomitant palatoplasty and sphincter pharyngoplasty with pharyngeal flap and sphincter pharyngoplasty alone for the treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome. Thirty-one cases were identified for inclusion in the study. Patients were separated into 3 surgical groups: combined palatoplasty and sphincter pharyngoplasty (n = 11), pharyngeal flap (n = 7), and sphincter pharyngoplasty (n = 13). Outcome measures included perceptual speech analyses, surgical complications, and revision rates. There were no differences in preoperative speech analysis scores ( P = .31). The combined palatoplasty and sphincter pharyngoplasty procedure had similar speech outcomes compared to pharyngeal flap, and both were significantly better than sphincter pharyngoplasty alone. Complication rates ( P = .61) and the need for revision surgery ( P = .25) were similar among all 3 groups. Concomitant palatoplasty and sphincter pharyngoplasty may be an alternative treatment for velopharyngeal insufficiency in children with 22q11.2 deletion syndrome.
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Affiliation(s)
- Lauren A. Bohm
- Michigan Medicine, Ann Arbor, Michigan, USA
- Children’s Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | | | | | - James D. Sidman
- Children’s Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Brianne B. Roby
- Children’s Minnesota, Minneapolis, Minnesota, USA
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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22q11.2 Deletion: Surgical and Speech Outcomes of Patients With Velopharyngeal Insufficiency Treated With a Superiorly Based Pharyngeal Flap as the Primary Surgery. J Craniofac Surg 2018; 29:1480-1485. [PMID: 30052607 DOI: 10.1097/scs.0000000000004859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The most frequent palate diagnoses in patients with chromosome 22q11.2 deletion syndrome are a classic submucous cleft, occult, and velopharyngeal insufficiency without cleft, which generates alterations in speech that require surgery. Surgical protocols are controversial owing to syndrome characteristics that make their handling more complex. Pharyngeal flap pharyngoplasty is effective for this type of patient. The objective of this study is to examine the surgical management of velopharyngeal insufficiency in patients with chromosome 22 deletion, using a pharyngeal flap as the primary surgery. The clinical records of patients with chromosome 22 deletion and velopharyngeal insufficiency between 2015 and 2017 were analyzed retrospectively. Eight patients underwent pharyngeal flap pharyngoplasty as a primary surgery, including 1 with velopharyngeal insufficiency without a cleft, 1 with a classic submucous cleft, and 6 with occult submucous cleft. The pre- and postoperative protocol performed by speech therapists and surgeons included clinical evaluation of the oral cavity; perceptual, video recording, and nasometry speech evaluation; and videonasopharyngoscopy. All perceptual parameters and nasometry results significantly changed. Of the cases, 88% achieved a flap with the expected width and height and complete closure of the velopharyngeal sphincter. One patient required flap revision. Four of the 8 patients achieved normal resonance, and 2 of 8 showed mild hypernasality. Using the pharyngeal flap pharyngoplasty as a primary technique to correct velopharyngeal insufficiency in patients with chromosome 22 deletion provides satisfactory outcomes and decreases the number of surgeries. Preoperative planning must be conducted carefully and needs to be individualized to be successful.
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