Obstructive Sleep Apnea following Pharyngeal Flap Surgery for Velopharyngeal Insufficiency: A Prospective Polysomnographic and Aerodynamic Study in Middle-Aged Adults

Three-Dimensional Comparative Changes in the Pharyngeal Airway of Patients with Cleft after Two-Jaw Orthognathic Surgery

BACKGROUND

The present study evaluated the three-dimensional changes of the pharyngeal airway after orthognathic surgery (OGS) in patients with unilateral and bilateral clefts, and in unilateral cleft patients with and without pharyngeal flap (PF).

METHODS

Forty-five patients with unilateral or bilateral clefts undergoing OGS were enrolled. Cone-beam computed tomographic images were obtained before and after OGS. We measured the pharyngeal airway volumes, minimal cross-sectional area, and the horizontal displacement of facial landmarks.

RESULTS

The patients with bilateral cleft exhibited smaller initial velopharyngeal volume (unilateral, 8623 mm 3 ; bilateral, 7781 mm 3 ; P = 0.211), whereas the velopharyngeal volume increased significantly with a median of 744 mm 3 after OGS ( P = 0.031). The median horizontal displacement of A point was 2.9 and 2.6 mm among the patients with unilateral and bilateral clefts, respectively ( P = 0.276), and the median horizontal displacement of B point was -2.9 and -3.3 mm among patients with unilateral and bilateral clefts, respectively ( P = 0.618). The unilateral cleft patients with PF exhibited lower initial velopharyngeal volume (patients with a history of PF surgery, 7582 mm 3 ; patients without a history of PF surgery, 8756 mm 3 ; P = 0.129) and a lower increase in velopharyngeal volume (patients with a history of PF surgery, 437 mm 3 ; patients without a history of PF surgery, 627 mm 3 ; P = 0.739) after OGS.

CONCLUSIONS

Midface hypoplasia and the decrease in the velopharyngeal volume were more prominent among the bilateral cleft patients and the unilateral cleft patients with PF. After OGS, the velopharyngeal volume increased considerably among the bilateral cleft patients, but no considerable differences were noted among the unilateral cleft patients with PF.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Effects of 3D Airway Geometry on the Airflow of Adults with Cleft Lip and Palate and Obstructive Sleep Apnea: A Functional Imaging Study

Objective  Individuals with cleft lip and palate (CLP) are at a high risk of developing obstructive sleep apnea (OSA). Hypothetically, the severity of OSA might be associated with the morphology of the upper airway (UAW) and the characteristics of the airflow. Thus, the present study aimed to assess and compare, in adults with CLP and skeletal class-III discrepancy, with or without OSA, simulations of airflow resistance and pressure according to the geometrical characteristics of the UAW and cephalometric parameters. Materials and Methods  According to the results of type-I polysomnography tests, the sample ( n  = 21) was allocated in 2 groups: 1) without OSA (N-OSA; n  = 6); and 2) with OSA (OSA; n  = 15). Cephalometric measurements were performed on the cone-beam computed tomography (CBCT) scans of the groups. After three-dimensional (3D) reconstructions, the volume (V) and minimal cross-sectional area (mCSA) of the UAW were generated. Computational fluid dynamics (CFD) simulations were used to assess key airflow characteristics. The results were presented at a significance level of 5%. Results  The UAW pressure values and airway resistance did not differ between the groups, but there was a tendency for more negative pressures (26%) and greater resistance (19%) in the OSA group. Volume and mCSA showed a moderate negative correlation with resistance and pressure. The more inferior the hyoid bone, the more negative the pressures generated on the pharyngeal walls. Conclusion  The position of the hyoid bone and the geometry of the UAW (V and mCSA) exerted effects on the airway-airflow resistance and pressure. However, key airflow characteristics did not differ among subjects with CLP, were they affected or not by OSA.

Obstructive Sleep Apnea in Adults with Treacher Collins Syndrome is Related with Altered Anthropometric Measurements, Increased Blood Pressure and Impaired Quality of Life

Objectives  This study aimed at evaluating the risk for obstructive sleep apnea (OSA) and its frequency in adults with Treacher Collins syndrome (TCS). The association of OSA with excessive daytime sleepiness (EDS), respiratory symptoms, and clinical variables was also assessed. Material and Methods  The subjects were prospectively screened for OSA through the Berlin Questionnaire and type I polysomnography. The Epworth Sleepiness Scale and the Respiratory Symptoms Questionnaire were used for assessing OSA-related symptoms. Quality of life was assessed by means of the Short Form 36 Health Survey. Results  The sample comprised 20 adults with TCS (55.0% female), aged 22.6 ± 5.8 years. Mean values of systemic blood pressure (113.0 ± 12.6/68.0 ± 9.5mmHg), body mass index (22.9 ± 5.9kg/m ² ), neck (34.1 ± 4.3cm), and waist circumference (80.4 ± 13.6cm) characterized the sample. A high risk for OSA was detected in 35% of the sample. Polysomnography results indicated an OSA frequency of 44.4%, with a median apnea-hypopnea index (AHI) value of 3.8 events/hour (minimum = 0.2; maximum = 77.5). Snoring (75.0%), nasal obstruction (70.0%) and EDS (20.0%) were the reported OSA-related symptoms. Quality of life median scores were 72.3 points (minimum = 45.0; maximum = 91.1). Strong positive correlations between AHI versus waist circumference and AHI versus systolic blood pressure were found. Moderate positive correlations between AHI versus body mass index and AHI versus neck circumference were detected. Negative correlation between AHI versus vitality were also observed. Conclusion  Adults with TCS are at high risk for OSA, which is associated with respiratory symptoms, altered anthropometric measurements, increased systolic pressure and impairment of quality of life.

Adult-onset obstructive sleep apnea and pediatric pharyngoplasty in 22q11.2 deletion syndrome

OBJECTIVE/BACKGROUND

We aimed to evaluate adult-onset obstructive sleep apnea (OSA) and related risk factors, including history of pediatric palatal/pharyngeal surgery to remediate velopharyngeal dysfunction, in 22q11.2 deletion syndrome (22q11.2DS).

PATIENTS/METHODS

Using a retrospective cohort design and standard sleep study-based criteria, we determined presence of adult-onset OSA (age ≥16 years) and relevant variables through comprehensive chart review in a well-characterized cohort of 387 adults with typical 22q11.2 microdeletions (51.4% female, median age 32.3, interquartile range 25.0-42.5, years). We used multivariate logistic regression to identify independent risk factors for OSA.

RESULTS

Of the 73 adults with sleep study data, 39 (53.4%) met criteria for OSA at median age 33.6 (interquartile range 24.0-40.7) years, indicating a minimum OSA prevalence of 10.1% in this 22q11.2DS cohort. History of pediatric pharyngoplasty (odds ratio 2.56, 95% confidence interval 1.15-5.70) was a significant independent predictor of adult-onset OSA, while accounting for other significant independent predictors (asthma, higher body mass index, older age), and for male sex. An estimated 65.5% of those prescribed continuous positive airway pressure therapy were reported as adherent.

CONCLUSIONS

In addition to factors of known importance in the general population, delayed effects of pediatric pharyngoplasty may contribute to risk of adult-onset OSA in individuals with 22q11.2DS. The results support increased index of suspicion for OSA in adults with a 22q11.2 microdeletion. Future research with this and other homogeneous genetic models may help to improve outcomes and to better understand genetic and modifiable risk factors for OSA.

Incidence of New-Onset Obstructive Sleep Apnea After Posterior Flap Pharyngoplasty in Children

INTRODUCTION

Obstructive sleep apnea (OSA) is a well-recognized complication of velopharyngeal insufficiency (VPI) surgery, but studies assessing OSA by means of a respiratory polygraphy (PG) are scarce. The aim of the study was to evaluate the incidence of new-onset OSA after posterior flap pharyngoplasty (PFP).

MATERIALS

The postoperative PG of children with VPI who had a normal preoperative PG were analyzed.

RESULTS

Eighteen patients (mean age, 9.8 ± 4.8 years; Pierre Robin sequence [n = 5], isolated cleft palate [n = 7], 22q11 deletion [n = 3], and 3 other diagnoses) were included in the study. Mean delay between surgery and the postoperative PG was 11.5 ± 13.5 months. Two patients (11%) developed severe OSA after PFP. One patient with 22q11 deletion developed overt OSA symptoms immediately after surgery with an apnea-hypopnea index (AHI) of 39 events per hour, requiring continuous positive airway pressure (CPAP) therapy. Obstructive sleep apnea improved spontaneously after 10 months, with an AHI of 2 events/h after CPAP weaning. The second patient had a cleft palate associated with a fetal alcohol syndrome and developed OSA symptoms after surgery with an AHI of 18 events/h requiring CPAP therapy. He could be weaned from CPAP 6 months later after a complete section of the pharyngeal flap with an AHI of 6 events/h during spontaneous breathing.

CONCLUSIONS

New-onset OSA after PFP in children with VPI who had a normal preoperative PG was uncommon (11%) in the present cohort.

Clinical study on obstructive sleep apnea following pharyngeal flap surgery

OBJECTIVES

This study aims to investigate the incidence and severity of obstructive sleep apnea (OSA) in cleft patients with velopharyngeal insufficiency (VPI) after pharyngeal flap surgery (PFS) and explore the influence of operation age.

METHODS

A retrospective study was conducted in 82 cleft patients after PFS. The patients were divided into two groups according to their age at the time of surgery. The incidence and severity of OSA were assessed at least 1.2 years (mean 6.0 years) postoperatively by polysomnography (PSG).

RESULTS

The incidence rates of OSA were 20% in the adult group and 31% in the child group. No significant difference was found between the two groups (P=0.289). Patients with OSA in the adult and child groups were classified into different levels of severity (mild, moderate, severe) according to the apnea hypoventilation index (AHI). No statistically significant difference in the severity of OSA was found between the two groups (P=0.079).

CONCLUSIONS

Some patients still have OSA average of 6.0 years after PFS, and operation ageis unrelated to the incidence and severity of OSA.

Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations

BACKGROUND

The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States.

METHODS

A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision.

RESULTS

A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type.

CONCLUSIONS

In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency

BACKGROUND

Velopharyngeal insufficiency (VPI) can cause resonance, speech and feeding problems. While reconstructive palatoplasty and surgical pharyngoplasty techniques are the mainstay of treatment for severe VPI, injection augmentation pharyngoplasty offers a minimally invasive approach in patients with mild-to-moderate VPI.

METHODS

We conducted a systematic review of the literature available on PubMed and Embase from 1990 to 2019 including studies that addressed VPI, incompetence, or dysfunction managed with injection augmentation. Patient demographics, etiology of VPI, injection material, volume of injection, number of injections, complications and both subjective and objective outcomes were recorded.

RESULTS

Twenty-nine studies met our inclusion criteria encompassing 587 patients, ages 3-75 years (mean = 16) who underwent injection pharyngoplasty. Injection materials included glutaraldehyde cross-linked (GAX) collagen (n = 5), calcium hydroxyapatite (n = 36), dextranomer and hyaluronic acid (n = 72) and autologous fat (n = 471). Follow-up averaged 15.4 months (range = 2-60 months). Functional improvements in nasality were recorded in a large proportion of patients (0.79, 95% CI 0.75 to 0.82). However, a greater proportion of patients in the synthetic materials group demonstrated either reduced or resolved hypernasality compared with those receiving autologous fat injections (χ2 = 7.035, n = 91/103 vs. 255/338, p = 0.008). Complete velopharyngeal gap closure post-injection was achieved at a higher frequency with injection of synthetic materials compared with autologous fat (χ2 = 11.270, n = 61/69 vs. 58/91 p = 0.001).r CONCLUSION: Injection pharyngoplasty offers a minimally invasive alternative intervention for treatment of VPI secondary to small velopharyngeal gaps. Patients treated with synthetic materials experienced a greater improvement in velopharyngeal closure and a corresponding improvement in resonance balance.

Three-dimensional tomographic assessment of the upper airway using 2 different imaging software programs: A comparison study

INTRODUCTION

Several imaging software programs with different tools are available for upper airway (UAW) analysis by means of cone beam computed tomography. Because of this wide variability, this study aimed to compare the reproducibility of two of the most used software programs on UAW segmentation, that is, Dolphin Imaging (Dolphin Imaging and Management Solutions, Chatsworth, Calif) and Mimics Research (Materialise, Leuven, Belgium).

METHODS

The sample consisted of 50 scans of adult subjects with Class III malocclusion; pharyngeal volume and minimal cross-sectional area (mCSA) were assessed twice by 2 experienced evaluators using both software programs. Intra- and intersoftware and/or evaluator agreement were calculated using the intraclass correlation coefficient (ICC). Bland-Altman analysis was used to visualize the intersoftware and interevaluator agreement.

RESULTS

Using Mimics Research and Dolphin Imaging, the respective mean values of volume (cm³) were 27.1 ± 8.4 and 24.7 ± 8.1 (P < 0.05) and of mCSA (mm²) were 167.8 ± 95.5 and 176.5 ± 102.3 (P < 0.05). Although differences between software packages were observed on both the analyzed variables, the results showed a high intersoftware agreement, with ICC of 0.87 (volume) and 0.97 (mCSA) and mean bias of 24.6 (volume) and -8.8 (mCSA). A high intrasoftware agreement was also observed, with values varying from 0.83 to 0.99. Excellent intra- and interevaluator agreement was also obtained, with ICC values from 0.93 to 0.99.

CONCLUSIONS

Dolphin Imaging and Mimics Research individually provide highly reproducible results, with clinically acceptable agreement between them for UAW segmentation, providing consistent values for volume and mCSA.

Endoscopic soft palate augmentation using injectable materials in dogs to ameliorate velopharyngeal insufficiency

Background

Velopharyngeal structure augmentation methods are used as alternatives to pharyngeal flap operations. Recently, we investigated the sites of velopharyngeal structure augmentation in dogs and reported that the most effective injection location is the soft palate. However, there have been no reports regarding the optimal materials for implantation or injection. In this study, we aimed to investigate the injectable materials used in soft palate augmentation in dogs to ameliorate velopharyngeal insufficiency (VPI).

Methods

Endoscopic soft palate augmentation (ESPA) was performed in dogs using purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. ESPA is an original technique developed by our group, and this is the first report of its performance. Moreover, we assessed the amount of nasal air leakage during inspiration at rest and during expiration under the rebreathing system at 1, 2, 3, 4, 5, and 6 months after injection of these materials.

Results

The amount of nasal air leakage during expiration under the rebreathing system was significantly decreased in all dogs injected with the ESPA materials, but neither apnea nor hypopnea was observed.

Conclusions

We investigated the optimal materials for use in ESPA, such as purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. We found that all of them reduced nasal air leakage and only autogenic fat tissue showed significant histologic differences in dogs at 6 months. This technique may also be useful for the treatment of patients with VPI.

The Behaviors of the Levator Veli Palatine Muscle Between 2 Surgical Conditions in Dog: The Comparison of Furlow and Pushback Methods

OBJECTIVE

This study was conducted to compare the velopharyngeal function among the beagle dogs which the levator veli palatini (LVP) muscles construction has been experimentally changed.

METHODS

Four groups of LVP muscle reconstruction were made (normal LVP, cut LVP, end-to-end sutured LVP, and overlapped-sutured LVP at the midline). Levator veli palatini contraction was induced by electrical stimulation or a hypercapnia condition to analyze the strength of the velopharyngeal closure using balloon with a blood pressure meter, and the electromyogram in those operated beagle dogs.

RESULTS

Under a hypercapnia condition, the velopharyngeal function did not differ significantly among the 4 groups in the terms of velopharyngeal pressure. The strongest closure was shown at the overlapped sutured LVP group by electrical stimulation.

CONCLUSION

The reconstruction of overlapped sutured LVP showed the most effective closure. This study suggested that the palatoplasty should be conducted along the overlapped LVP (like Furlow method).

Defining Risk of Postoperative Obstructive Sleep Apnea in Patients With 22q11.2DS Undergoing Pharyngeal Flap Surgery for Velopharyngeal Dysfunction Using Polysomnographic Evaluation

OBJECTIVE

To determine pre- and postoperative prevalence of obstructive sleep apnea (OSA) in patients with 22q11.2 deletion syndrome (DS) undergoing wide posterior pharyngeal flap (PPF) surgery for velopharyngeal dysfunction (VPD).

DESIGN

Retrospective study using pre- and postoperative polysomnography (PSG) to determine prevalence of OSA. Medical records were reviewed for patients' medical comorbidities. Parents were surveyed about snoring.

SETTING

Academic tertiary care pediatric hospital.

PATIENTS

Forty patients with laboratory confirmed 22q11.2DS followed over a 6-year period.

INTERVENTIONS

Pre- and postoperative PSG, speech evaluation, and parent surveys.

MAIN OUTCOME MEASURE

Severity and prevalence of OSA, defined by obstructive apnea hypopnea index (OAHI), before and after PPF surgery to determine whether PPF is associated with increased risk of OSA.

RESULTS

Mean OAHI did not change significantly after PPF surgery (1.1/h vs 2.1/h, P = .330). Prevalence of clinically significant OSA (OAHI ≥ 5) was identical pre- and postoperatively (2 of 40), with both cases having severe-range OSA requiring positive airway pressure therapy. All other patients had mild-range OSA. Nasal resonance was graded as severe preoperatively in 85% of patients. None were graded as severe postoperatively. No single patient factor or parent-reported concern predicted risk of OSA (OAHI ≥ 1.5).

CONCLUSIONS

Patients with 22q11.2DS are medically complex and are at increased risk of OSA at baseline. Wide PPF surgery for severe VPD does not significantly increase risk of OSA. Careful perioperative planning is essential to optimize both speech and sleep outcomes.

The Pushback Pharyngeal Flap: An 18-Year Experience

BACKGROUND

The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism.

METHODS

A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa.

RESULTS

There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001).

CONCLUSIONS

The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Adenoid hypertrophy causing obstructive sleep apnea in children after pharyngeal flap surgery

PURPOSE

Pharyngeal flap surgery used for treatment of velopharyngeal insufficiency (VPI) may be followed by obstructive sleep apnea (OSA) especially if the patient has developed adenoid hypertrophy. However, adenoidectomy may adversely affect speech in these patients. The aim of this study was to assess the effectiveness of transnasal endoscopic power-assisted adenoidectomy in relieving OSA in patients with adenoid hypertrophy who underwent pharyngeal flap surgery, and the impact of the procedure on their speech.

METHODS

Transnasal endoscopic power-assisted adenoidectomy for nine children presenting with adenoid hypertrophy was performed. The patients had previously undergone pharyngeal flap surgery for treatment of VPI. Flexible nasopharyngoscopy was used in the diagnosis of adenoid hypertrophy. Pre- and postoperative polysomnography with measurement of apnea-hypopnea index (AHI) was done. Additionally, auditory perceptual assessment of speech (APA) and nasalance scores was measured pre- and postoperatively.

RESULTS

All patients were shown to have OSA by polysomnography, and a larger adenoid size was significantly associated with a higher AHI. We achieved a significant improvement in AHI after adenoidectomy. However, six patients still demonstrated OSA, albeit with a reduced severity. Speech was not adversely affected postoperatively as the APA and nasalance scores showed non-significant changes.

CONCLUSION

Adenoid hypertrophy may be encountered in children who undergo pharyngeal flap surgery, which may cause OSA. Transnasal endoscopic power-assisted adenoidectomy is a safe and effective method for treatment of OSA in those patients without prejudicing the pharyngeal flap, and it has no adverse effect on speech.

Palatal evaluation and treatment in 22q11.2 deletion syndrome

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.

Evaluation of sites of velopharyngeal structure augmentation in dogs for improvement of velopharyngeal insufficiency

Background

Velopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI).

Methods

Velopharyngeal structure augmentation was performed on 10 beagles (age range: 20–24 months; weight range: 9–12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage.

Results

Pre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls.

Conclusions

During VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients.

Upper Airway 3D Changes of Patients With Cleft Lip and Palate After Orthognathic Surgery

Objectives:

The purpose of this study was to 3-dimensionally assess the airway characteristics of patients with unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) who underwent orthognathic surgery.

Design:

This was a retrospective study.

Setting:

The study took place at a national referral center for cleft lip and palate rehabilitation.

Patients and Participants:

The sample comprised cone-beam computed tomography (CBCT) scans obtained before and after orthognathic surgery of 15 individuals (30 CBCT scans), divided into 2 groups: UCLP group (n = 9 patients/18 CBCT scans) and BCLP group (n = 6/12 CBCT scans). All patients had a nonsyndromic UCLP or BCLP and a skeletal class III malocclusion at the preoperative period.

Interventions:

Airway volume, pharyngeal minimal cross-sectional area (mCSA), location of mCSA, sella-nasion-A point (SNA) and sella-nasion-B point (SNB) angles, and condylion-A point and condyloid-gnathion linear measurements were assessed in open-source software (ITK-SNAP and SlicerCMF).

Main Outcome Measure:

Airway dimensions of patients with UCLP and BCLP increase after orthognathic surgery.

Results:

After orthognathic surgery, UCLP group showed a significant 20% increase in nasopharynx volume. Although not significant, BCLP group also showed an increase of 18% in the same region. Minimal cross-sectional area remained dimensionally stable after surgery and was all located in the oropharynx region, on both groups. Additionally, a positive correlation was observed between volume and mCSA on both groups.

Conclusion:

Overall, individuals with UCLP and BCLP showed an increase in the upper airway after orthognathic surgery and this might explain the breathing and sleep improvements reported by the patients after the surgery.

The Impact of Velopharyngeal Surgery on the Polysomnographic Parameters After Cleft Palate Repair

Velopharyngeal surgical procedures may have adverse effect on the airway of the patients with velopharyngeal insufficiency (VPI). The aim of this study was to evaluate the polysomnographic parameters (PSG) in patients who underwent corrective surgery for treatment of VPI. The study included 39 patients who underwent 1 of 3 velopharyngeal surgical techniques; Furlow palatoplasty (12 patients), pharyngeal flap (18 patients), and sphincter pharyngoplasty (9 patients). The patients were subjected to PSG, and they were considered to have obstructive sleep apnea (OSA) with apnea-hypoapnea index (AHI) >1.Comparison of PSG parameters of patients showed insignificant difference regarding the total sleep time, sleep efficiency, arousal index, desaturation index, and minimum oxygen saturation. Significant difference was detected regarding peak end-tidal CO2 and AHI. Pharyngeal flap was detected as the most surgical technique that worsened the PSG parameters with OSA in 78% of patients, followed by sphincter pharyngoplasty with OSA in 56% of patients. Furlow palatoplasty was detected as the least impacting technique on the airway in 25% of patients who demonstrated OSA. In conclusion, velopharyngeal surgery has a variable impact on the PSG; pharyngeal flap has the most worsening effect followed by sphincter pharyngoplasty, while Furlow palatoplasty has the least adverse effect.

Buccinator myomucosal flap for the treatment of velopharyngeal insufficiency in patients with cleft palate and/or lip

Introduction

The interpretation of the speech results obtained with the buccinator myomucosal flap in the treatment of velopharyngeal insufficiency in patients with cleft palate has been limited by the restriction in the number of patients and the time of postoperative follow-up.

Objective

To evaluate the effect of the buccinator myomucosal flap on speech hypernasality in the treatment of patients with cleft palate and velopharyngeal insufficiency.

Methods

Patients with repaired cleft palate (± lip) who were submitted to surgical correction of velopharyngeal insufficiency using the bilateral buccinator myomucosal flap were assessed. Hypernasality (scores 0 [absent], 1 [mild], 2 [moderate], or 3 [severe]) was analyzed by three evaluators by measuring the audiovisual records collected in early and late preoperative and postoperative periods (3 and 12 months, respectively). The values were considered significant for a 95% Confidence Interval (p < 0.05).

Results

Thirty-seven patients with cleft palate (± lip) showing moderate (16.2%) or severe (83.8%) hypernasality in the preoperative period were included. Analyses of the late postoperative period showed that hypernasality (0.5 ± 0.7) was significantly (p < 0.05) lower than the hypernasality of the preoperative and recent postoperative periods (2.8 ± 0.4 and 1.7 ± 0.9, respectively).

Conclusion

The buccinator myomucosal flap is effective in reducing/eliminating hypernasality in patients with cleft palate (± lip) and velopharyngeal insufficiency.

Tomographic Pharyngeal Dimensions in Individuals with Unilateral Cleft Lip/Palate and Class III Malocclusion are Reduced When Compared with Controls

Objective

The objective of this study was to three-dimensionally evaluate the pharyngeal dimensions of individuals with complete nonsyndromic unilateral cleft lip and palate (UCLP) using cone beam computed tomography.

Design

This was a cross-sectional prospective study.

Setting

The study took place at the Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru-SP, Brazil.

Patients and Participants

The control group (CON) consisted of 23 noncleft adults with class III malocclusion, and the cleft group (UCLP) consisted of 22 individuals with UCLP and class III malocclusion. Two subgroups of individuals with class III malocclusion as a result of maxillary retrusion with (UCLP'; n = 19) and without (CON'; n = 8) clefts were also assessed.

Interventions

Pharyngeal volume, pharyngeal minimal cross-sectional area (CSA), location of CSA, pharyngeal length, sella-nasion-A point angle (SNA), sella-nasion-B point angle (SNB), and A point-nasion-B point angle (ANB), and body mass index were assessed using Dolphin software.

Main Outcome Measure

The pharyngeal dimensions of UCLP individuals are smaller when compared with controls.

Results

Mean pharyngeal volume (standard deviation) for the UCLP patients (20.8 [3.9] cm3) and the UCLP’ patients (20.3 [3.9] cm3) were significantly decreased when compared with the CON (28.2 [10.0] cm3) and CON’ patients (29.1 [10.2] cm3), respectively. No differences were found in the pharyngeal minimal CSA, ANB, or pharyngeal length values between groups (CON versus UCLP and CON’ versus UCLP'). CSAs were located mostly at the oropharynx, except in the UCLP’ patients, which were mainly at the hypopharynx. Mean SNA in the UCLP (76.4° [4.6°]) and UCLP’ groups (75.1 [3.1°]) were significantly smaller than those in the CON (82.8° [4.1°]) and CON’ groups (78.6° [1.2°]). SNB values were statistically smaller only for the comparison of CON versus UCLP patients.

Conclusion

The pharynx of individuals with UCLP and class III malocclusion is volumetrically smaller than that of individuals with class III malocclusion and no clefts.

A Treatment Protocol for Velopharyngeal Insufficiency and the Outcome

BACKGROUND

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications.

METHODS

The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed.

RESULTS

Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea.

CONCLUSION

The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.