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Perry JL, Snodgrass TD, Gilbert IR, Sutton BP, Baylis AL, Weidler EM, Tse RW, Ishman SL, Sitzman TJ. Establishing a Clinical Protocol for Velopharyngeal MRI and Interpreting Imaging Findings. Cleft Palate Craniofac J 2024; 61:748-758. [PMID: 36448363 PMCID: PMC10243551 DOI: 10.1177/10556656221141188] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Traditional imaging modalities used to assess velopharyngeal insufficiency (VPI) do not allow for direct visualization of underlying velopharyngeal (VP) structures and musculature which could impact surgical planning. This limitation can be overcome via structural magnetic resonance imaging (MRI), the only current imaging tool that provides direct visualization of salient VP structures. MRI has been used extensively in research; however, it has had limited clinical use. Factors that restrict clinical use of VP MRI include limited access to optimized VP MRI protocols and uncertainty regarding how to interpret VP MRI findings. The purpose of this paper is to outline a framework for establishing a novel VP MRI scan protocol and to detail the process of interpreting scans of the velopharynx at rest and during speech tasks. Additionally, this paper includes common scan parameters needed to allow for visualization of velopharynx and techniques for the elicitation of speech during scans.
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Affiliation(s)
- Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Taylor D Snodgrass
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Imani R Gilbert
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Bradley P Sutton
- Bioengineering Department, University of Illinois at Urbana Champaign, Urbana, IL, USA
| | - Adriane L Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Erica M Weidler
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Raymond W Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Stacey L Ishman
- Division of HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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Kollara L, Reiss SL, Singam S, Kellogg B. Velopharyngeal Characteristics in Aarskog-Scott Syndrome: A Case Report. Cleft Palate Craniofac J 2024; 61:892-896. [PMID: 36475306 DOI: 10.1177/10556656221141235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Aarskog-Scott syndrome (AAS), also known as facio-digito-genital syndrome, is a rare heterogenous syndrome characterized by facial dysmorphism, brachydactyly, and genetic abnormalities. Although severe craniofacial abnormalities have been reported in AAS, little is known about speech and resonance issues in AAS. Specifically, published data to date have only indicated reports of hypernasality associated with a cleft palate in AAS. This case report provides clinical and anatomic information surrounding hypernasal speech in the absence of an overt cleft palate in a patient with AAS.
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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
| | - Samantha L Reiss
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Sreekara Singam
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Brian Kellogg
- University of Central Florida College of Medicine, Orlando, FL, USA
- Division of Plastic & Craniofacial Surgery, Nemours Children's Hospital, Orlando, FL, USA
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Chin MG, Roca Y, Huang KX, Moghadam S, LaGuardia JS, Bedar M, Wilson LF, Lee JC. Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate. J Plast Reconstr Aesthet Surg 2024; 88:24-32. [PMID: 37950988 DOI: 10.1016/j.bjps.2023.10.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA). DESIGN Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n = 166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified. INTERVENTIONS The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty. MAIN OUTCOME MEASURES Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA. RESULTS Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p < 0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4 ± 2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p = 0.03). CONCLUSIONS Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.
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Affiliation(s)
- Madeline G Chin
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Yvonne Roca
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Shahrzad Moghadam
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Jonnby S LaGuardia
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Libby F Wilson
- Craniofacial/Cleft Palate Program, Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States.
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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] [What about the content of this article? (0)] [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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Asar A, Gaber R, Yehia M, El-Kassaby MAW. Treatment algorithm for velopharyngeal dysfunction in patients with cleft palate: a systematic review. Br J Oral Maxillofac Surg 2023; 61:259-266. [PMID: 37117086 DOI: 10.1016/j.bjoms.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/01/2023] [Indexed: 04/30/2023]
Abstract
The aim of this study was to review current literature regarding the speech outcome of different techniques of surgical treatment of VPD in cleft patients, in an attempt to reach a treatment algorithm. A systematic review was done, by searching Pubmed, Scopus, and Web of Science electronic databases, following the PRISMA guidelines. Articles reporting speech assessment results of secondary VPI surgeries on non-syndromic patients with CP. Surgical techniques were categorised into two groups; palatal and pharyngeal surgeries. Raw data were extracted to compare speech outcome and complication of each technique, with special emphasis on the factors affecting, the patients' selection for each technique. Our results showed comparable success and complication rates among these techniques. However, the factors governing selection of each technique were identified and taken into consideration to reach a preliminary algorithm. A preliminary treatment algorithm is described based on the results of our review; the most important factors affecting the technique choice are: VP gap size, LVP position, palatal mobility, palatal scarring, VP closure pattern and age of the patient.
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Affiliation(s)
- Aseel Asar
- Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Ain Shams University, Egypt.
| | - Ramy Gaber
- Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Ain Shams University, Egypt.
| | - Mahmoud Yehia
- Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Ain Shams University, Egypt.
| | - Marwa A W El-Kassaby
- Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Ain Shams University, Egypt.
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Mason KN, Riski JE, Williams JK, Jones RA, Perry JL. Utilization of 3D MRI for the Evaluation of Sphincter Pharyngoplasty Insertion Site in Patients With Velopharyngeal Dysfunction. Cleft Palate Craniofac J 2021; 59:1469-1476. [PMID: 34569298 DOI: 10.1177/10556656211044656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Sphincter pharyngoplasty is a surgical method to treat velopharyngeal dysfunction. However, surgical failure is often noted and postoperative assessment frequently reveals low-set pharyngoplasties. Past studies have not quantified pharyngoplasty tissue changes that occur postoperatively and gaps remain related to the patient-specific variables that influence postoperative change. The purpose of this study was to utilize advanced three-dimensional imaging and volumetric magnetic resonance imaging (MRI) data to visualize and quantify pharyngoplasty insertion site and postsurgical tissue changes over time. A prospective, repeated measures design was used for the assessment of craniometric and velopharyngeal variables postsurgically. Imaging was completed across two postoperative time points. Tissue migration, pharyngoplasty dimensions, and predictors of change were analyzed across imaging time points. Significant differences were present between the initial location of pharyngoplasty tissue and the pharyngoplasty location 2 to 4 months postoperatively. The average postoperative inferior movement of pharyngoplasty tissue was 6.82 mm, although notable variability was present across participants. The pharyngoplasty volume decreased by 30%, on average. Inferior migration of the pharyngoplasty tissue was present in all patients. Gravity, scar contracture, and patient-specific variables likely interact, impacting final postoperative pharyngoplasty location. The use of advanced imaging modalities, such as 3D MRI, allows for the quantification and visualization of tissue change. There is a need for continued identification of patient-specific factors that may impact the amount of inferior tissue migration and scar contracture postoperatively.
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Affiliation(s)
- Kazlin N Mason
- Human Services Department, School of Education, 2358University of Virginia, Charlottesville, VA, USA
| | - John E Riski
- Speech Pathology Lab, Center for Craniofacial Disorders, 160364Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joseph K Williams
- Speech Pathology Lab, Center for Craniofacial Disorders, 160364Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Richard A Jones
- Department of Radiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jamie L Perry
- Department of Communication Sciences & Disorders, 3627East Carolina University, Greenville, NC, USA
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Birch AL, Jordan ZV, Ferguson LM, Kelly CB, Boorman JG. Speech Outcomes Following Orticochea Pharyngoplasty in Patients With History of Cleft Palate and Noncleft Velopharyngeal Dysfunction. Cleft Palate Craniofac J 2021; 59:277-290. [PMID: 34085559 DOI: 10.1177/10556656211010623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report speech outcomes following Orticochea pharyngoplasty in 43 patients with cleft palate and noncleft velopharyngeal dysfunction. DESIGN A retrospective surgical audit of patients undergoing Orticochea pharyngoplasty between 2004 and 2012, with speech as a primary outcome measure. SETTING Patients known to a regional UK cleft center. METHODS Forty-three patients underwent Orticochea pharyngoplasty by a single surgeon in a UK regional cleft center. Twenty-one patients had undergone a prior procedure for velopharyngeal dysfunction. Pre- and postoperative speech samples were assessed blindly using the Cleft Audit Protocol for Speech-Augmented by a specialist cleft speech and language therapist, external to the team. Speech samples were rated on the following parameters: hypernasality, hyponasality, audible nasal emission, nasal, turbulence, and passive cleft speech characteristics. Statistical differences in pre- and postoperative speech scores were tested using the Wilcoxon matched-pairs signed-ranks test. Inter- and intrareliability scores were calculated using weighted Cohen κ. RESULTS Whole group: A statistically significant difference in pre- and postoperative scores for hypernasality (P < .001), hyponasality (P < .05), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported. Patients with cleft diagnoses: A statistically significant difference in scores for hypernasality (P < .001), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported for this group of patients. Patients with noncleft diagnoses: The only parameter to demonstrate a statistically significant difference was hypernasality (P < .01) in this group. CONCLUSIONS Orticochea pharyngoplasty is a successful surgical procedure in treating velopharyngeal dysfunction in both the cleft and noncleft populations.
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Affiliation(s)
- Alison L Birch
- South Thames Cleft Service, Evelina London, 8945Guys and St Thomas' NHS Foundation Trust, Northern Ireland, United Kingdom
| | - Zoe V Jordan
- South Thames Cleft Service, Evelina London, 8945Guys and St Thomas' NHS Foundation Trust, Northern Ireland, United Kingdom
| | - Louisa M Ferguson
- South Thames Cleft Service, Evelina London, 8945Guys and St Thomas' NHS Foundation Trust, Northern Ireland, United Kingdom
| | - Clare B Kelly
- Department of Women and Children's Health, 4616Kings College London, Northern Ireland, United Kingdom
| | - John G Boorman
- South Thames Cleft Service, Evelina London, 8945Guys and St Thomas' NHS Foundation Trust, Northern Ireland, United Kingdom
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Lam AS, Kirkham EM, Dahl JP, Kinter SL, Perkins JA, Sie KCY. Speech Outcomes After Sphincter Pharyngoplasty for Velopharyngeal Insufficiency. Laryngoscope 2020; 131:E2046-E2052. [PMID: 33103775 DOI: 10.1002/lary.29189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/26/2020] [Accepted: 10/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate perceptual speech outcomes following sphincter pharyngoplasty (SP) and to identify patient characteristics associated with velopharyngeal insufficiency (VPI) resolution or improvement. METHODS Retrospective review of prospectively collected data was performed of consecutive patients that underwent SP for management of VPI between 1994 and 2016 at a single tertiary care pediatric hospital. Demographic data, nasendoscopic findings, and speech characteristics were recorded using a standardized protocol. Pre- and post-operative VPI was graded on a five-point Likert scale. Frequency of post-operative VPI resolution and improvement was assessed and associations with patient characteristics were analyzed. The association between odds of VPI resolution or improvement and five patient characteristics identified a priori was performed controlling for confounding factors. RESULTS Two-hundred ninety-six subjects were included. All patients had at least minimal VPI pre-operatively; 72% were graded moderate or severe. Sixty-four percent experienced resolution and 83% improved at least one point on the VPI-severity scale. Of the five patient characteristics, only history of cleft palate repair was significantly associated with decreased odds of VPI improvement but not resolution when controlling for other variables. CONCLUSIONS Sphincter pharyngoplasty resulted in resolution of VPI in 64% and improvement in 83% of subjects. Children with a history of cleft palate had significantly decreased odds of VPI improvement compared to those without a history of cleft palate. Neither syndrome diagnosis nor 22q11 deletion had a significant association with speech outcomes after sphincter pharyngoplasty. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2046-E2052, 2021.
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Affiliation(s)
- Austin S Lam
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Erin M Kirkham
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - John P Dahl
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Sara L Kinter
- Speech and Language Services, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Kathleen C Y Sie
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
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Lee KC, Halepas S, Wu BW, Chuang SK. For Patients With Isolated Cleft Palate Does Revision Palatoplasty Have an Increased Risk of Inpatient Complication Compared to Primary Palatal Repair? Cleft Palate Craniofac J 2020; 58:72-77. [PMID: 32799652 DOI: 10.1177/1055665620949121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether revision palatoplasty was associated with increased rates of inpatient complication and wound dehiscence compared to primary palatal repair. MATERIALS AND METHODS This was a retrospective study of patients with isolated cleft palate treated with primary palatoplasty or revision surgery for fistula repair. The records were obtained from the Kids' Inpatient Database between 2000 and 2014. The primary predictor was the type of surgery, classified as either primary or revision palatoplasty. Secondary predictors included demographics and comorbidities. Primary study outcomes were the postoperative complication and dehiscence rates as noted during the hospitalization course. The secondary outcomes related to health care utilization as measured through length of stay (LOS) and hospital charges. RESULTS A total of 5357 total admissions (95.5% primary, 4.5% revision) were included in the final sample. Fistula repairs (odds ratio = 14.37, P < .01) had significantly greater odds of wound dehiscence. The rates of inpatient complication ranged from 3.5% to 3.7%, and there were no significant differences between primary and revision surgery (P = .82). Complications were independently associated with insurance status and congenital anomalies. Complications and wound dehiscence both significantly increased the LOS and the hospital charges. Fistula repairs had a shorter mean LOS (P = .02), however this did not translate into cost savings (P = .60). CONCLUSIONS Although the rates of inpatient complications were not significantly different, revision palatoplasty was associated with a greater odds of wound dehiscence. Failure of a primary repair may portend an increased risk of wound failure with subsequent surgeries.
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Affiliation(s)
- Kevin C Lee
- Division of Oral and Maxillofacial Surgery, 25065NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Steven Halepas
- Division of Oral and Maxillofacial Surgery, 25065NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Brendan W Wu
- Department of Oral and Maxillofacial Surgery, 12297New York University Langone Medical Center and Bellevue Hospital Center, New York, NY, USA
| | - Sung-Kiang Chuang
- Department of Oral and Maxillofacial Surgery, 6572University of Pennsylvania Health System, Philadelphia, PA, USA.,Brockton Oral and Maxillofacial Surgery Inc, Brockton, MA, USA.,Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA
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Prabhu SS, Kiell EP, David LR, Runyan CM. Obstructive Sleep Apnea Secondary to Pharyngeal Narrowing From Horizontal Donor Site Closure During Posterior Pharyngeal Flap Surgery. Cleft Palate Craniofac J 2020; 57:1140-1145. [PMID: 32292043 DOI: 10.1177/1055665620919326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The posterior pharyngeal flap is frequently the surgical intervention of choice for the correction of velopharyngeal insufficiency. Our patient initially presented for a superiorly based, posterior pharyngeal flap to correct for velopharyngeal insufficiency. However, the postoperative recovery was complicated by severe obstructive sleep apnea, which warranted division and subsequent takedown of the flap. Despite flap takedown, our patient's obstructive sleep apnea persisted. The patient's clinical course suggests that donor site closure, and not the actual pharyngeal flap, caused the persistent obstructive sleep apnea.
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Affiliation(s)
| | - Eleanor P Kiell
- Department of Otolaryngology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lisa R David
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher Michael Runyan
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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11
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Wong L, Lim E, Lu T, Chen P. Management of velopharyngeal insufficiency by modified Furlow palatoplasty with pharyngeal flap: a retrospective outcome review. Int J Oral Maxillofac Surg 2019; 48:703-7. [DOI: 10.1016/j.ijom.2019.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 11/25/2018] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
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Mason KN, Hauhuth K, Perry JL, Riski JE. Evaluating the Accuracy of Using at Rest Images to Determine the Height of Velopharyngeal Closure. J Craniofac Surg 2018; 29:1354-7. [PMID: 29905582 DOI: 10.1097/SCS.0000000000004444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Prior to performing secondary surgeries, lateral cephalograms have been used during phonation to evaluate the point of attempted velopharyngeal contact along the posterior pharyngeal wall relative to the palatal plane and the first cervical vertebra. The ability to quantify the height of velopharyngeal closure is an important aspect of planning corrective surgeries for velopharyngeal dysfunction. However, issues with patient compliance during the imaging process can present difficulties for obtaining adequate preoperative imaging data. The purpose of this study was to assess if the height of velopharyngeal closure can be accurately estimated and quantified from at rest images. Results demonstrate that the height of velopharyngeal closure above C1 can be accurately quantified using at rest images in children with cleft palate. No statistically significant difference was found between the measures obtained at rest or during sustained phonation images (P = 0.573). Thus, quantitative measures from at rest images can aid in the preoperative planning process by providing surgeons with a numeric distance for tissue insertion along the posterior pharyngeal wall above C1. This distance is correlated to the height of velopharyngeal closure and successfully placing tissue at this height is likely tied to improved postoperative speech outcomes.
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Abstract
Objective State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems. Method The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether. Conclusion Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.
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Affiliation(s)
- David P. Kuehn
- University of Illinois at Urbana-Champaign, Champaign, Illinois
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Liao YF, Noordhoff MS, Huang CS, Chen PKT, Chen NH, Yun C, Chuang ML. Comparison of Obstructive Sleep Apnea Syndrome in Children with Cleft Palate following Furlow Palatoplasty or Pharyngeal Flap for Velopharyngeal Insufficiency. Cleft Palate Craniofac J 2017; 41:152-6. [PMID: 14989690 DOI: 10.1597/02-162] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI). Patients A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI. Interventions An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively. Main Outcome Measures Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured. Results In the P group, the mean percentage of stage 2 sleep was lower than the F group (p < .05). The mean RDI and DI were larger in the P group, compared with the F group (p < .001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p < .001 and p = 0.05, respectively). Conclusions A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.
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Affiliation(s)
- Yu-Fang Liao
- Division of Orthodontics, the Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan
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15
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Abyholm F, D'Antonio L, Davidson Ward SL, Kjøll L, Saeed M, Shaw W, Sloan G, Whitby D, Worhington H, Wyatt R. Pharyngeal Flap and Sphincterplasty for Velopharyngeal Insufficiency Have Equal Outcome at 1 Year Postoperatively: Results of a Randomized Trial. Cleft Palate Craniofac J 2017; 42:501-11. [PMID: 16149831 DOI: 10.1597/03-148.1] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of this trial was to compare the relative effectiveness (efficacy and morbidity) of two surgical procedures for correcting velopharyngeal insufficiency (VPI). Design This was an international multicenter randomized trial to study the outcome of two surgical procedures (flap and sphincter pharyngoplasty) for speech, incidence of sleep apnea, and surgical complications. Method Ninety-seven patients 3 to 25 years old with repaired cleft palate and previously identified VPI were enrolled from five centers in the United States, Norway, and the U.K. Data were collected at presurgery, 3 months postsurgery, and 12 months postsurgery for subsequent analysis blind to the procedure. Main outcome measures included perceptual speech parameters, sleep apnea, nasalance measures, endoscopic features, and surgical complications. Results Groups for both surgical procedures achieved a high level of clinical improvement. At 3 months postsurgery, elimination of hypernasal resonance was achieved in twice as many patients after the flap procedure. This reached significance. However, at 12 months postsurgery, no statistically significant difference in outcomes remained between the two procedures for resonance, nasalance, endoscopic outcomes, or surgical complications. Flap and sphincter pharyngoplasty rarely resulted in clinically significant sleep apnea, and no difference was detected between the two procedures in the long-term incidence of sleep apnea. Conclusions Despite strongly held views in the literature concerning the relative effectiveness and safety of flap and sphincter pharyngoplasty, no significant differences were detected 1 year postoperatively.
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Rogers C, Konofaos P, Wallace RD. Superiorly Based Pharyngeal Flap for the Surgical Treatment of Velopharyngeal Insufficiency and Speech Outcomes. J Craniofac Surg 2017; 27:1746-1749. [PMID: 27763974 DOI: 10.1097/scs.0000000000003050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A retrospective chart review comparing pre and postoperative speech in 19 patients who underwent pharyngeal flap surgery for the diagnosis of velopharyngeal insufficiency. Eighteen of the patients had a history of cleft palate. Patients were assigned a speech grade between 1 and 5 based on the objective and subjective quality of their speech. Comparison of pre and postoperative speech showed significant improvement in speech quality from a mean grade of 3.37 to 2.00 (P < 0.001). This study demonstrates that a wide, superiorly based pharyngeal flap did lead to significant improvement in speech outcomes in this group of patients independent of gender or age.
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Affiliation(s)
- Cori Rogers
- Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, TN
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17
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Abstract
The primary focus of this study was to assess age-related changes in the vertical distance of the estimated level of velopharyngeal closure in relation to a prominent landmark of the cervical spine: the anterior tubercle of cervical vertebra 1 (C1). Midsagittal anatomic magnetic resonance images were examined across 51 participants with normal head and neck anatomy between 4 and 17 years of age. Results indicate that age is a strong predictor (P = 0.002) of the vertical distance between the level of velopharyngeal closure relative to C1. Specifically, as age increases, the vertical distance between the palatal plane and C1 becomes greater resulting in the level of velopharyngeal closure being located higher above C1 (range 4.88-10.55 mm). Results of this study provide insights into the clinical usefulness of using C1 as a surgical landmark for placement of pharyngoplasties in children with repaired cleft palate and persistent hypernasal speech. Clinical implications and future directions are discussed.
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Affiliation(s)
- Kazlin N Mason
- *East Carolina University, Greenville, NC; Children's Healthcare of Atlanta, Atlanta, GA †East Carolina University ‡Children's Healthcare of Atlanta, Atlanta, GA
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Spruijt N, Widdershoven J, Breugem C, Speleman L, Homveld I, Kon M, Van Der Molen AM. Velopharyngeal Dysfunction and 22q11.2 Deletion Syndrome: A Longitudinal Study of Functional Outcome and Preoperative Prognostic Factors. Cleft Palate Craniofac J 2012; 49:447-55. [DOI: 10.1597/10-049] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To describe the effect of time after velopharyngoplasty on outcome and to search for preoperative prognostic factors for residual hypernasality in patients with 22q11.2 deletion syndrome. Design Retrospective chart review. Setting Tertiary hospital. Patients Patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction who underwent a primary (modified) Honig velopharyngoplasty between 1989 and 2009. Main Outcome Measures Clinically obtained perceptual and instrumental measurements of resonance, nasalance, and understandability before and after velopharyngoplasty. Results Data were available for 44 of 54 patients (81% follow-up), with a mean follow-up time of 7.0 years (range, 1.0 to 19.4 years). During follow-up, 24 (55%) patients attained normal resonance and 20 (45%) had residual hypernasality or underwent revision surgery. Mean postoperative nasalance and understandability scores were closer to the norm than mean preoperative scores were (2.0 versus 5.5 standard deviations for the normal passage, 1.3 versus 8.1 standard deviations for the nonnasal passage, and score 2.3 versus 4.1 understandability). Serial measurements revealed that hypernasality only resolved an average of 5 years after surgery, and three patients whose resonance initially normalized later relapsed to hypernasality. Gender, age at surgery, lateral pharyngeal wall adduction, velar elevation, presence of a palatal defect, previous intravelar veloplasty, nasalance, understandability, adenoidectomy, hearing loss, and IQ were not able to predict poor outcome following primary velopharyngoplasty (all p > .05). Conclusions In this chart review of patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction, residual hypernasality persisted in many patients after velopharyngoplasty. None of the preoperative factors that were studied had prognostic value for the outcome.
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Affiliation(s)
- N.E. Spruijt
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J.C.C. Widdershoven
- Department of Otolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - C.C. Breugem
- Department of Plastic Surgery, University Medical Center Utrecht
| | - L. Speleman
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I.L.M. Homveld
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. Kon
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Kummer AW, Clark SL, Redle EE, Thomsen LL, Billmire DA. Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals. Cleft Palate Craniofac J 2012; 49:146-52. [DOI: 10.1597/10-285] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.
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Affiliation(s)
- Ann W. Kummer
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati, Cincinnati, Ohio
| | - Stacey L. Clark
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin E. Redle
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leisa L. Thomsen
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A. Billmire
- University of Cincinnati, Cincinnati, Ohio
- Division of Pediatric Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Searl J, Knollhoff S. Oral Pressure and Nasal Flow on /m/ and /p/ in 3- to 5-Year-Old Children Without Cleft Palate. Cleft Palate Craniofac J 2011; 50:40-50. [PMID: 23320855 DOI: 10.1597/11-149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives : (1) To compare oral pressure and nasal airflow in 3- to 5-year-olds versus older children and adults; (2) to describe stability of these measures in 3- to 5-year-olds at two recording times; and (3) to report participation rates of 3- to 5-year-olds for the aerodynamic protocol. Design : Prospective, nonrandomized, convenience samples in four age groups. Setting : University clinic. Participants : A total of 105 individuals without cleft palate and with normal speech for their age who were 3 to 5 (n = 45), 7 to 9 (n = 20), 11 to 13 (n = 20), or 20 to 30 years old (n = 20). All had normal nasal resonance and absence of nasally obstructive conditions on the testing day. Main Outcome Measures : Oral pressure and nasal airflow on /p/ and /m/ in syllable series and the word "hamper." Results : Oral pressure was significantly higher on /p/ for 3- to 5-year-olds versus the two oldest groups. Nasal airflow on /p/ occurred infrequently across groups. Oral pressure on /m/ was significantly higher for 3- to 5-year-olds versus adults. Nasal airflow on /m/ increased significantly with age. Oral pressure and nasal flow did not differ at two measurement times for the 3- to 5-year-olds. Of the 3- to 5-year-olds, 88% completed the protocol. Conclusions : Oral pressure decreased on /p/ and nasal airflow increased on /m/ from early childhood into adulthood. Nasal air escape on /p/ occurred rarely for speakers of any age; when it did occur, the magnitude was limited. Most preschool-aged children should be able to complete a velopharyngeal aerodynamic protocol, and measures are stable even for these young speakers.
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Sullivan SR, Vasudavan S, Marrinan EM, Mulliken JB. Submucous Cleft Palate and Velopharyngeal Insufficiency: Comparison of Speech Outcomes Using Three Operative Techniques by One Surgeon. Cleft Palate Craniofac J 2011; 48:561-70. [DOI: 10.1597/09-127] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Our purpose was to compare speech outcomes among three primary procedures for symptomatic submucous cleft palate (SMCP): two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. Design Retrospective review. Setting Tertiary hospital. Patients, Participants All children with SMCP treated by the senior author between 1984 and 2008. Interventions One of three primary procedures: two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. Main outcome Measures Speech outcome and need for a secondary operation were analyzed among procedures. Success was defined as normal or borderline competent velopharyngeal function. Failure was defined as persistent borderline insufficiency or velopharyngeal insufficiency with recommendation for a secondary operation. Results We identified 58 patients with SMCP who were treated for velopharyngeal insufficiency. We found significant differences in median age at operation among the procedures ( p < .001). Two-flap palatoplasty with muscular retropositioning (n = 24), double-opposing Z-palatoplasty (n = 19), and pharyngeal flap (n = 15) were performed at a median of 2.5, 3.6, and 9.5 years, respectively. There were significant differences in success among procedures (p = .018). Normal or borderline competent function was achieved in 6/20 (30%) patients who underwent two-flap palatoplasty, 10/15 (67%) following double-opposing Z-palatoplasty, and 11/12 (92%) following pharyngeal flap. Among patients treated with palatoplasty, success was independent of age at operation (p = .16). Conclusions Double-opposing Z-palatoplasty is more effective than two-flap palatoplasty with muscular retropositioning. For children older than 4 years, primary pharyngeal flap is also highly successful but equally so as a secondary operation and can be reserved, if necessary, following double-opposing Z-palatoplasty.
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Affiliation(s)
- Stephen R. Sullivan
- Pediatric and Craniomaxillofacial Surgery, Harvard Medical School, Department of Plastic and Oral Surgery, Children's Hospital, Boston, Massachusetts, Warren Alpert Medical School of Brown University and Rhode Island and Hasbro Children's Hospital, Providence, Rhode Island
| | - Sivabalan Vasudavan
- Craniofacial and Cleft Lip/Palate Orthodontics, Department of Dentistry, Children's Hospital Boston, Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Eileen M. Marrinan
- Central New York Cleft and Craniofacial Center, State University of New York, Upstate Medical University Hospital, Syracuse, New York
| | - John B. Mulliken
- Harvard Medical School, Department of Plastic and Oral Surgery, Children's Hospital, Boston, Massachusetts
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Abdel-Aziz M, El-Hoshy H, Ghandour H. Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern. J Craniofac Surg 2011; 22:813-7. [PMID: 21558943 DOI: 10.1097/SCS.0b013e31820f3691] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern.This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed.There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea.Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.
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Madrid JRP, Eduardo Nieto L, Gomez V, Echeverry P, Tavera MC, Oliveros H. Palatoplasty as the technique of choice for prevention of obstructive sleep apnea secondary to surgery for velopharyngeal insufficiency. Cleft Palate Craniofac J 2010; 48:145-9. [PMID: 20500068 DOI: 10.1597/09-178] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study is to compare patients treated with pharyngoplasty and those treated with palatoplasty for velopharyngeal insufficiency to establish what surgical procedure poses the highest risk for developing sleep apnea. The hypothesis tested in this study is that the incidence of obstructive sleep apnea syndrome associated with pharyngoplasty is greater than that associated with palatoplasty for velopharyngeal insufficiency. SUBJECTS Twenty patients were taken from the Institution FISULAB. DESIGN Observational cohort analytic study. MAIN OUTCOME MEASURES An overnight polysomnographic study was used to determine the incidence and severity of obstructive sleep apnea syndrome. RESULTS The incidence of obstructive sleep apnea syndrome following pharyngoplasty was shown to be significantly higher than after palatoplasty. The apnea-hypopnea index, also called the respiratory disturbance index, was 12.7 in the pharyngoplasty group and 1.35 in the palatoplasty group (p < .001). When obstructive sleep apnea syndrome was stratified into different levels of severity according to the values of respiratory disturbance index, there were noticeable differences between these two groups. In the palatoplasty group, one patient had mild obstructive sleep apnea syndrome. In the pharyngoplasty group, two patients had mild obstructive sleep apnea syndrome, one patient had moderate obstructive sleep apnea syndrome, and two patients had severe obstructive sleep apnea syndrome. CONCLUSIONS When comparing the apnea-hypopnea index (i.e., respiratory disturbance index) of patients treated for velopharyngeal insufficiency with palatoplasty versus pharyngoplasty, we observed an important difference between the groups, with the highest indices in the pharyngoplasty group.
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Sullivan SR, Marrinan EM, Mulliken JB. Pharyngeal Flap Outcomes in Nonsyndromic Children with Repaired Cleft Palate and Velopharyngeal Insufficiency: . Plast Reconstr Surg 2010; 125:290-8. [DOI: 10.1097/prs.0b013e3181c2a6c1] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Arneja JS, Hettinger P, Gosain AK. Through-and-Through Dissection of the Soft Palate for High Pharyngeal Flap Inset: A New Technique for the Treatment of Velopharyngeal Incompetence in Velocardiofacial Syndrome: . Plast Reconstr Surg 2008; 122:845-52. [DOI: 10.1097/prs.0b013e3181811a83] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To assess speech results and rate of obstructive sleep apnea using a modified, superiorly based pharyngeal flap performed after staged adenotonsillectomy in a group with velopharyngeal insufficiency. METHODS In this nonrandomized, retrospective case series (July 1, 1996, through June 30, 2003), patients were mainly children referred to a multispecialty craniofacial clinic. Patients underwent staged adenotonsillectomy 2 months before width-customized pharyngeal flap surgery. Short flaps were created high above the level of the palate, just long enough to reach the nasal surface. Donor sites were closed by superior advancement of the inferior posterior pharyngeal wall tissue. Cardiopulmonary and oximetry data were analyzed for immediate obstructive apnea. Speech results and airway symptoms were assessed at 6-month and yearly follow-up examinations. RESULTS In the 54 consecutive patients who underwent staged adenotonsillectomy, no apnea occurred immediately after surgery. Long-term clinical examination revealed 4 cases of loud snoring. Polysomnographic results were negative in all cases. Complications included 3 cases of bleeding, 1 requiring transfusion. Velopharyngeal insufficiency was eliminated in 94% of patients. CONCLUSION Complications related to obstructive sleep apnea have been significantly reduced while maintaining excellent speech results by a staged approach of removing tonsils and adenoids and by creating a short, high, wide, superiorly based pharyngeal flap with superior advancement of the inferior posterior wall to close the donor site.
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Affiliation(s)
- Burke E Chegar
- Center for Facial Plastics Head and Neck Surgery, Fayette Regional Health System, Connersville, Indiana, USA
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27
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Noorchashm N, Dudas JR, Ford M, Gastman B, Deleyiannis FWB, Vecchione L, Jiang S, Cooper GM, Haralam MA, Losee JE. Conversion Furlow palatoplasty: salvage of speech after straight-line palatoplasty and "incomplete intravelar veloplasty". Ann Plast Surg 2006; 56:505-10. [PMID: 16641625 DOI: 10.1097/01.sap.0000210154.72830.3d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The straight-line palatoplasty with intravelar veloplasty (IVVP) is one option for cleft palate repair. However, not all IVVPs are performed uniformly. Many IVVPs only address the medialmost portion of the levator muscle, an "incomplete IVVP," failing to completely dissect and adequately transpose the entire levator muscle, "complete IVVP." We believe that for optimal speech results, IVVPs should completely mobilize and posteriorly displace the levator. We propose that a conversion Furlow palatoplasty performed with a "complete IVVP" will correct postoperative velopharyngeal insufficiency (VPI) and alleviate the need for pharyngoplasty. METHODS Nineteen patients with postoperative VPI, having had prior straight-line palatoplasty and reported "IVVP," underwent conversion Furlow palatoplasty. Those with a pre- and postoperative Pittsburgh Weighted Speech Scale (PWSS) value and no other history of palatal surgeries were included in this study. Statistical analysis was performed by using the Wilcoxon signed ranks test. RESULTS Patients' median age was 5.5 years (range, 4-15 years), with 13 males and 7 females. The median preoperative PWSS score was 11.00 (range, 3-24.5), and the median postoperative was 1.00 (range, 0-5) (P < 0.001). All subcategories of the PWSS were also improved. Eight children had a preoperative fistula, and all were successfully corrected. At the time of conversion Furlow palatoplasty, all patients demonstrated no evidence of previous IVVP as the levator muscle was found to be scarred to the posterior edge of the hard palate. CONCLUSION The conversion Furlow palatoplasty can be used to significantly improve VPI and salvage speech after a straight-line palatoplasty with an "incomplete IVVP." Patients with postoperative VPI should first be considered for conversion Furlow palatoplasty performed with a "complete IVVP" prior to progressing to pharyngoplasty.
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Affiliation(s)
- Negin Noorchashm
- Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Abstract
OBJECTIVE The outcomes of 61 patients who underwent a pharyngoplasty for velopharyngeal insufficiency were reviewed to determine potential risk factors for reoperation. DESIGN This was a retrospective chart review of 61 consecutive patients over approximately 10 years (1993 to 2003). Variables analyzed included gender, cleft type, age at the time of pharyngoplasty, length of time between palate repair and pharyngoplasty, and associated syndromes. PARTICIPANTS Of the 61 patients, 20 (34%) had a unilateral cleft lip and palate, 5 (8%) had a bilateral cleft lip and palate, 13 (21%) had an isolated cleft palate, 7 (11%) had a submucous cleft palate, and 16 (26%) were diagnosed with noncleft velopharyngeal insufficiency. RESULTS Of the 61 patients, 10 (16%) required surgical revision. No statistically significant difference was found among gender, cleft type, age at the time of pharyngoplasty, the length of time between palate repair and pharyngoplasty, and associated congenital syndromes, with respect to the need for surgical revision (p > .05). Of the surgical revisions, 50% (5) were performed for a pharyngoplasty that was placed too low. CONCLUSIONS Because 50% of the pharyngoplasty revisions had evidence of poor velopharyngeal closure and associated hypernasality resulting from low placement of the sphincter, the pharyngoplasty needs to be placed at a high level to reduce the risk for revisional surgery. The pharyngoplasty is a good operation for velopharyngeal insufficiency with an overall success rate of 84% (51 of 61) after one operation and greater than 98% (60 of 61) after two operations.
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Affiliation(s)
- Landon S Pryor
- Northeastern Ohio Universities College of Medicine (NEOUCOM)/Summa Health System, Akron, Ohio, USA
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Deren O, Ayhan M, Tuncel A, Görgü M, Altuntaş A, Kutlay R, Erdoğan B. The Correction of Velopharyngeal Insufficiency by Furlow Palatoplasty in Patients Older than 3 Years Undergoing Veau-Wardill-Kilner Palatoplasty: A Prospective Clinical Study. Plast Reconstr Surg 2005; 116:85-93; discussion 94-6. [PMID: 15988251 DOI: 10.1097/01.prs.0000169714.38796.ad] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Velopharyngeal insufficiency may persist after primary repair of the palate. This insufficiency causes a speech deficit. Although there are many treatment alternatives, the most effective treatment of velopharyngeal insufficiency remains controversial. METHODS The authors performed Furlow palatoplasty in patients older than 3 years who had undergone primary palatoplasty with the Veau-Wardill-Kilner technique. Speech was assessed by a speech therapist before and after the operation. Velopharyngeal closure and velum motion were recorded using a video nasendoscope before and also 12 months after the operation. Any increase in velum length was measured. RESULTS After Furlow palatoplasty, 10 of 27 patients (37 percent) made complete recovery and 12 (44 percent) made substantial recovery from hypernasal resonance, but five (18.5 percent) showed no improvement. Regarding nasal emission, 16 of 27 patients (59.3 percent) made complete and eight (29.6 percent) made substantial recovery, but there was no change in three (11 percent). Five of 27 patients (18.5 percent) achieved complete intelligibility and 18 of 27 (66.7 percent) improved intelligibility, but four (14.8 percent) did not show any improvement in intelligibility. Articulation improved considerably in 17 of 27 (63 percent). The overall rate of surgical success and near misses who benefited from the surgery was 18 of 27 (67 percent), and a positive correlation between surgical success and articulation and intelligibility was noticed. Video nasendoscopy showed complete velopharyngeal closure in 15 of 27 patients (56 percent). The mean velar length increased by 44 percent. After secondary Furlow palatoplasty, patients with small gaps benefited more. CONCLUSIONS The results suggest that Furlow palatoplasty performed in later years improves not only speech but also velopharyngeal closure by reorienting the levator veli palatini muscle and augmenting the velum.
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Affiliation(s)
- Orgun Deren
- Department of Plastic and Reconstructive Surgery, Ankara Numune Research and Education Hospital, Ankara, Turkey.
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Armour A, Fischbach S, Klaiman P, Fisher DM. Does Velopharyngeal Closure Pattern Affect the Success of Pharyngeal Flap Pharyngoplasty? Plast Reconstr Surg 2005; 115:45-52. [DOI: 10.1097/01.prs.0000145635.87742.af] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Liao YF, Yun C, Huang CS, Chen PKT, Chen NH, Hung KF, Chuang ML. Longitudinal follow-up of obstructive sleep apnea following Furlow palatoplasty in children with cleft palate: a preliminary report. Cleft Palate Craniofac J 2003; 40:269-73. [PMID: 12733955 DOI: 10.1597/1545-1569_2003_040_0269_lfoosa_2.0.co_2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To longitudinally investigate the incidence and severity of obstructive sleep apnea (OSA) following Furlow palatoplasty for velopharyngeal insufficiency (VPI) in children with cleft palate. SUBJECTS Ten children, six boys and four girls, mean age 5.1 years, at Furlow palatoplasty. DESIGN Prospective analysis. MAIN OUTCOME MEASURES Overnight polysomnographic studies were used to determine the incidence and severity of sleep apneas 1 day prior to Furlow palatoplasty, 1 week postoperatively, and approximately 3 and 6 months postoperatively. RESULTS None of the patients suffered OSA prior to Furlow palatoplasty. A high incidence of mild OSA (100%) occurred during the early postoperative period (p <.001) but resolved within 3 months in all but two patients (20%). Only one OSA (10%) persisted 6 months postoperatively. CONCLUSIONS Furlow palatoplasty for VPI in children with cleft palate might induce temporary and mild OSA.
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Affiliation(s)
- Yu-Fang Liao
- Department of Dentistry, Craniofacial Center, Chang Gung Memorial Hospital, 199 Tung-Hwa North Road, Taipei 105, Taiwan
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Abstract
Surgical management of velopharyngeal insufficiency by attachment of posterior pharyngeal flap or construction of sphincter pharyngoplasty is reviewed. Posterior pharyngeal flap surgery is well established, with a long history dating back to the 19th century. Flaps have been based superiorly, inferiorly, or laterally. There have been reports of airway obstruction and obstructive sleep apnea associated with posterior pharyngeal flap surgery. The concept of surgical creation of a dynamic sphincter pharyngoplasty to provide velopharyngeal closure was first introduced by Hynes in 1950. Hynes and others have proposed several subsequent anatomic modifications. Airway dysfunction has also been reported following sphincter pharyngoplasty, but may not be as frequent or severe as with posterior pharyngeal flap. While several studies have compared posterior pharyngeal flap and sphincter pharyngoplasty in terms of speech outcome or complications, there is not, as yet, a consensus regarding the specific choice of one versus the other for surgical management of velopharyngeal insufficiency.
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Affiliation(s)
- G M Sloan
- Division of Plastic and Reconstructive Surgery and Surgery of the Hand, University of North Carolina, School of Medicine, Chapel Hill 27599-7195, USA
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Abstract
Velopharyngeal insufficiency (VPI) can be treated surgically with various operations. This article describes the use of a superiorly based folded pharyngeal flap for posterior wall augmentation to treat VPI. This is a retrospective study indicating that a folded flap to augment the posterior wall is likely to be as effective as other surgical techniques to treat small velopharyngeal gaps. Patients selected for this procedure had very good velar motion. Postoperative nasometric zoo passage scores improved by an average of 18 over preoperative scores. Additionally, a correlation was found between age and nasometry improvement after surgery. Younger patients did better. Patients in whom VPI was caused by adenoidectomy did well. The 2 syndromic patients did not do as well when treated with this type of operation.
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Affiliation(s)
- S D Gray
- Department of Surgery, Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City 84132, USA
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Abstract
OBJECTIVE This paper reports on the rates of failure of operations (pharyngeal flap and sphincter pharyngoplasty) performed for management of velopharyngeal dysfunction, and outcome following their revision. DESIGN Anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following pharyngeal flap and sphincter pharyngoplasty were critiqued. The results of primary pharyngeal flap were evaluated for 65 patients, and the results of primary sphincter pharyngoplasty were evaluated for 123 patients. All patients were treated for velopharyngeal dysfunction. The definition of surgical failure was based on persistent hypernasality and/or nasal turbulence on perceptual speech evaluation, and incomplete velopharyngeal closure on instrumental evaluation, at least 3 months postoperatively. SETTING All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, a tertiary cleft care center. PATIENTS, PARTICIPANTS All patients had failed surgical management initially, either with pharyngeal flap or sphincter pharyngoplasty, and all underwent repeat preoperative and postoperative perceptual speech evaluations; real-time lateral phonation fluoroscopy including still reference views; and flexible nasendoscopy of the velopharynx using standard speech protocols. INTERVENTIONS Revisional surgery for both procedures consisted of either tightening of the sphincter pharyngoplasty or pharyngeal flap port(s) or reinsertion of the sphincter pharyngoplasty or pharyngeal flaps following dehiscence. MAIN OUTCOME MEASURES The main outcome measure was normalcy of velopharyngeal function, i.e., elimination of perceptual hypernasality and instrumental evidence of complete velopharyngeal closure. The rates of pharyngeal flap failure and sphincter pharyngoplasty failure were determined for those patients requiring surgical revision. RESULTS Thirteen of 65 patients (20%) who underwent primary pharyngeal flap required revisional surgery. Of these 13 patients, eight were managed successfully with a single revisional operation. The remaining five patients (38%) continued to exhibit velopharyngeal dysfunction and underwent a second revision consisting of tightening or augmentation of the lateral ports. Speech results were satisfactory in all patients so treated; however, hyponasality with no other airway morbidity occurred in all five. Twenty of 123 patients (16%) who underwent primary sphincter pharyngoplasty required surgical revision. Of these 20 patients, 17 were managed successfully. For both procedures, the principal cause of failure was partial or complete flap dehiscence. CONCLUSIONS Rates of primary pharyngeal flap failure are roughly equivalent to rates of primary sphincter pharyngoplasty failure. Pharyngeal flap and sphincter pharyngoplasty failures can be salvaged with revisional surgery, which can provide a velopharyngeal mechanism capable of complete closure. Revisional surgery is usually associated with denasal speech.
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Affiliation(s)
- P D Witt
- Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, Washington University School of Medicine, Missouri 63110, USA.
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Abstract
OBJECTIVE We reviewed 24 children with Robin sequence who underwent cleft palate repair. METHOD All patients were 5 years of age or older at the time of review, allowing for accurate assessment of speech in relation to velopharyngeal function. All infants had palatal closure between 9 and 14 months of age, either V-Y repair (n = 16) or von Langenbeck repair (n = 8). RESULTS Only 1 of 16 children who had V-Y repair had borderline velopharyngeal dysfunction (VPD). For reasons that are unclear, in the von Langenbeck repair group, six of eight children had VPD, and four of six underwent pharyngeal flap. Three additional patients with nonsyndromic Robin sequence had palatoplasty and subsequent pharyngeal flap. Six of the combined total of seven children with nonsyndromic Robin sequence developed obstructive sleep apnea and require flap take-down. CONCLUSION Since conventional pharyngeal flap for VPD in nonsyndromic Robin sequence children resulted in a high incidence of obstructive sleep apnea, alternative management should be considered: modification of the standard pharyngeal flap, palatal lengthening (V-Y or double-opposing Z-plasty), or construction of a speech bulb.
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Affiliation(s)
- D L Abramson
- Department of Otolaryngology and Communication Disorders, Children's Hospital, Boston, Massachusetts, USA
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Abstract
OBJECTIVE When a patient presents with velopharyngeal incompetence (VPI) without an obvious structural or neurologic cause, the clinician is faced with a diagnostic challenge. We present an 11-year-old male with a long history of VPI who had been referred to our institution for evaluation and treatment. RESULTS Detailed clinical examination and work-up revealed a malignant brainstem tumor. The presenting symptoms of breathiness associated with VPI had been overlooked by several different clinicians in the past. The patient successfully underwent a sphincter pharyngoplasty. CONCLUSIONS A careful neurologic examination with special attention to the cranial nerves is necessary to identify subtle neurologic deficits and avoid delay in diagnosis. Differential diagnosis of neurogenic VPI is discussed.
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Affiliation(s)
- J F Lefaivre
- Speech Pathology Laboratory, Scottish Rite Children's Medical Center, Atlanta, Georgia 30342, USA
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Abstract
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.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
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.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, St. Louis Children's Hospital, Washington University School of Medicine, MO 63110, USA
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Abstract
The adolescent patient provides a unique opportunity for the clinician to be both retrospective and prospective. While adolescence is a period of selective and rapid oral facial growth and dental arch development, the period of rapid speech development is long past. The adolescent patient is entering a period of quiescence and is refining and adjusting existing speech skills. During the patient's adolescence, we have the opportunity to evaluate the outcome of earlier treatment and assess the results of our management strategies and techniques. We also have the opportunity to prospectively modify and improve our treatment strategies. This is a brief review of the experiences of one cleft palate center. Treatment goals and outcomes will be reviewed and areas that require continued refinement will be described.
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Affiliation(s)
- J E Riski
- Speech Pathology Laboratory, Scottish Rite Children's Medical Centre, Atlanta, GA 30342, USA
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