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.

Development of a minimum protocol for assessment in the paediatric voice clinic. Part 1: evaluating vocal function

The European Laryngological Society (ELS) recommend that functional assessment of voice disorder in adults requires evaluation of a number of different parameters. The current paper presents a discussion of four of the five parameters highlighted in the ELS protocol: perceptual evaluation of voice, videostroboscopic examination, evaluation of aerodynamic performance in voice, and acoustic analysis. Subjective rating of voice in children is explored in a companion paper. These parameters have been extensively evaluated in adults, and a review of the literature pertaining to the paediatric population is presented.

Pain perception of children undergoing nasendoscopy for investigation of voice and resonance disorders

The primary objective of this descriptive and correlational study was to determine the level of pain and discomfort perceived by children undergoing nasendoscopy for investigation of voice and resonance disorders. The secondary objective was to explore whether gender, age, previous experience of painful or distressing medical procedures, and previous experience of nasendoscopy influenced the perception of pain during nasendoscopy. Twenty-three children self-reported the degree of pain perceived during nasendoscopy using the Wong-Baker Faces Pain Rating Scale. Parents also used this scale to rate their child's perceived pain. Otolaryngologists and speech pathologists rated the intensity and frequency of observed pain-related behaviors using the Child-Adult Medical Procedure Interaction Scale-Revised and the Procedure Behavior Checklist. Children perceived the procedure, on average, to be moderately painful, as did their parents. Only two children reported perceiving no pain during the procedure. The most frequently observed pain-related behaviors were muscle tension (86.96%), physical resistance (69.57%), requiring physical restraint (60.87%), crying (43.48%), and expressions of verbal pain (39.13%). No significant correlations were found between self-reported pain or observed pain and the variables of age, gender, previous experience of nasendoscopy, and previous experience of painful or distressing medical procedures, although children aged 4-7 years reported significantly more pain than children aged 8-18 years. Most children perceive nasendoscopy to be painful to some degree. This perceived pain occurred in conjunction with several observable pain-related behaviors that have the potential to interfere with the success of the procedure.

Evaluation of pharyngeal and laryngeal structure and function in patients with oculo-auriculo-vertebral spectrum

OBJECTIVE

This study described the occurrence and expression of pharyngeal and laryngeal anomalies in a population of patients with oculo-auriculo-vertebral spectrum (OAVS).

DESIGN

Cross-sectional study using chart review, physical examination, and endoscopic evaluation of the pharynx and larynx, and perceptual and aerodynamic evaluation of speech for assessment of vocal tract function.

SETTING

Academic tertiary referral center.

PATIENTS

Chart review of 41 patients with a diagnosis of OAVS and clinical evaluation of 23 of the patients identified in the initial chart review, ranging in age from 9 months to 17 years.

MAIN OUTCOME MEASURES

Data from chart review pertaining to airway and speech symptoms. Physical examination and endoscopic studies of pharyngeal and laryngeal structure and function and perceptual and aerodynamic evaluation of speech, resonance, and voice.

RESULTS

Chart review showed a high occurrence of indicators of pharyngeal and laryngeal abnormalities such as velopharyngeal inadequacy and airway obstruction. Clinical evaluations documented a variety of abnormalities in pharyngeal and laryngeal structure and function as well as impairment in speech articulation, resonance, and voice. Presence and severity of pharyngeal and laryngeal abnormalities were not correlated with the severity of expression of the spectrum based on mandibular morphology.

CONCLUSIONS

Oculo-auriculo-vertebral spectrum appears to be associated with a high occurrence of structural and functional abnormalities of the pharynx and larynx that may contribute to increased risk of airway obstruction, communication impairment, and morbidity.

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.

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.

Management of the hypodynamic velopharynx

Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.

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.

Survey of speech-language pathologists' training, experience, and opinions on nasopharyngoscopy

A questionnaire on nasopharyngoscopy was completed by 93 speech-language pathologists randomly selected from the Directory of the American Cleft Palate-Craniofacial Association. Although the majority rated nasopharyngoscopy as important in the assessment of velopharyngeal function, and believed that it should be performed by speech-language pathologists, the majority do not perform nasopharyngoscopic examinations. Moreover, 40% had no academic preparation and 20% had no clinical experience in nasopharyngoscopy. Implications of these findings concerning exposure to nasopharyngoscopy in speech-language pathology graduate training programs and in continuing education programs for practicing speech-language pathologists are discussed.

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.

Supraglottic contributions to pitch raising. Videoendoscopic study with spectroanalysis

Several questions pertaining to pitch raising recur frequently. Does the larynx rise with the production of higher frequencies? What happens to the pharyngeal walls between the soft palate and the larynx when the fundamental frequency is raised? How does the soft palate participate in pitch raising? To answer these questions, the present study was undertaken with the recently described simultaneous velolaryngeal endoscopy technique. Nine professional singers were asked to find the limits of their vocal range in any of six voice qualities: speech, falsetto, cry/sob, twang, belting, and opera. Simultaneous activities of the larynx, the pharyngeal walls, and the soft palate were submitted to videoendoscopy with synchronous voice recording and studied with spectroanalysis of discrete segments of the total phonation range. Our dual endoscopic study showed that 1) the larynx rose in all subjects with the production of higher frequencies, 2) with the highest fundamental frequency, the lateral pharyngeal walls significantly contracted toward the midline in an "upside-down V shape," creating a very narrow pharyngeal tube, and 3) the soft palate lifted and the velopharyngeal port narrowed considerably with higher frequencies.

Perceptual-physiologic approach to evaluation and treatment of dysphonia

The value of a perceptual-physiologic approach to both the evaluation and treatment of voice disorders is described and illustrated with an example of a patient with ventricular fold phonation. Objective measures are obtained to facilitate the understanding of the underlying pathophysiology and to document change over time. Evaluation data are recorded and interpreted collectively by a speech-otolaryngology team and may be valuable for medicolegal cases. Finally, the evaluation methods, particularly videolaryngoscopy, may be used for biofeedback purposes to facilitate voice therapy.