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Velopharyngeal insufficiency (VPI) refers to the mobility of the velopharyngeal sphincter to adequately separate the nasal cavity from the oral cavity during speech. The auditory result of this structural problem is hyperrhinophy, abnormal resonance and the production of distracting noises during speech created by turbulent airflow escaping from the nasal cavity.
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.
Velopharyngeal insufficiency (VPI) is a relatively uncommon diagnosis and requires an understanding not only by the otolaryngologist but also by primary care physicians who are often the first to recognize its presence. An appreciation of the speech pathology that occurs in VPI assists in the often challenging diagnosis. Although VPI is more commonly seen in the pediatric population, there are multiple causes for its presence in adults and children. We review the anatomy of the velopharynx and the etiology of VPI, as well as the evaluation and the management of these patients.
BACKGROUND: Velopharyngeal insufficiency is an uncommon complication of adenoidectomy. Persistent velopharyngeal insufficiency following adenoidectomy (VIA) may occur in association with an unrecognized syndrome, such as velocardiofacial syndrome (VCFS). Although the diagnosis of VCFS is primarily a clinical one, a test has been developed to identify the underlying chromosomal abnormality, ie, deletion of 22q11. OBJECTIVE: To describe characteristics and occurrence of the 22q11 deletion in a population with VIA. SETTING: Three tertiary referral centers. DESIGN: Retrospective case series of 23 patients with VIA who required intervention and had follow-up for more than 1 year. These patients' medical records were reviewed for indications for adenoidectomy, the presence of 22q11 deletion and whether a 22q11 deletion test was obtained, phenotypic evidence for VCFS, presence of a submucous cleft palate, velopharyngeal closure pattern, and type of speech intervention. RESULTS: Of the 23 patients, 9 underwent adenoidectomy for otitis media, 9 for obstructive sleep symptoms, and 5 for sinusitis therapy. Fourteen of the 23 patients were tested for a 22q11 deletion. Of these 14 patients, 9 had a 22q11 deletion with 5 having phenotypic evidence for VCFS. Six of the 23 patients had a submucous cleft palate, 2 of whom had a 22q11 deletion. CONCLUSIONS: Although VIA is uncommon, its occurrence should alert the otolaryngologist to the possibility of an underlying syndrome diagnosis. The 22q11 deletion test is beneficial in diagnosing patients with genotypic, but not phenotypic, VCFS in this population. In tested subjects of our patient population, 28% (4 patients) had the genotype for VCFS, without clinical evidence of VCFS.
The velopharyngeal sphincter is critical in enabling the functions of speaking and swallowing. Velopharyngeal insufficiency (VPI) results in hypernasal speech and nasal regurgitation. A frequent cause of VPI is congenital cleft palate, but otolaryngologists sometimes encounter iatrogenic VPI after surgery. Treatment of VPI with prostheses is often successful but not always well tolerated. Many surgical procedures have been proposed to correct palatal length or to enlarge the posterior pharyngeal wall. We report two cases in which autologous costochondral cartilage was used as implant augmentation. This approach is indicated and efficient when the velopharyngeal deficit is less than 5 mm. An autologous costochondral cartilage implant procedure is safe and reversible and can be expected to incite minimal host reaction.
PURPOSE OF REVIEW: Velopharyngeal insufficiency is a niche within our specialty, but patients with hypernasality present who have never been diagnosed previously. Otolaryngologists should be familiar with current trends in diagnosis and treatment of hypernasality. RECENT FINDINGS: Velopharyngeal insufficiency has been associated with genetic conditions and identifiable syndromes. Multiple surgical techniques are available for the treatment of this condition, the results of which vary widely in the literature. There is difficulty in interpreting the success of surgical outcomes on speech intelligibility and resonance because of the heterogeneity of the patient population and the subjective nature of assessing results. More studies are now available for the evaluation of associations of comorbid conditions and their impact on speech results. SUMMARY: Velopharyngeal insufficiency must be diagnosed properly. Syndromes and comorbid conditions must be identified. No single specialty can care appropriately for these patients. A team approach is the ideal method of evaluating and managing patients with velopharyngeal insufficiency. Specialists with a particular interest and training in the management of patients with clefts of the palate and velopharyngeal insufficiency must collaborate to obtain the maximal functional outcome for these patients.
Velopharyngeal insufficiency (VPI) is a well recognized but rare complication of adenoidectomy. Twenty children with this condition were seen and assessed at Great Ormond Street Hospital between 1993 and 2000. The commonest aetiology was occult submucous cleft palate (n = 5) but there was a wide range of other causes. Two children with severe behavioural disorders and normal palates developed mild symptoms, an aetiology not previously reported. Only two children had a classical submucous cleft palate. Nine children required surgical intervention and three revision procedures. Of the 15 treated children for whom follow-up data was available, 13 regained normal or near-normal speech. Many cases of postadenoidectomy VPI was not foreseeable. Following referral to a specialist cleft unit, normal or near-normal speech can be achieved in the majority with a combination of surgery and speech therapy.
Sphincter pharyngoplasty is frequently used for the management of children with velopharyngeal insufficiency. The purpose of this study was to evaluate outcome and revision rates of sphincter pharyngoplasty at the authors' institution. Two hundred fifty patients underwent sphincter pharyngoplasty for velopharyngeal insufficiency between January of 1987 and March of 2001. There were 117 female patients and 133 male patients, with a mean age at primary sphincter pharyngoplasty of 7.6 years (range, 1 to 45 years). Diagnoses included velopharyngeal insufficiency alone (n = 63), velopharyngeal insufficiency associated with cleft palate (n = 127), velocardiofacial syndrome (n = 32), submucous cleft (n = 15), and other (n = 13). Pharyngoplasty revision was defined as any secondary surgical revision of the sphincter as determined by clinical evaluation and objective speech assessment. The pharyngoplasty revision rate was found to be 12.8 percent (n = 32). A favorable outcome was demonstrated in 30 of these patients (93.8 percent) after pharyngoplasty revision. Two patients, one with a diagnosis of a submucous cleft and velocardiofacial syndrome and the other with a cleft palate, required a second revision because of persistent velopharyngeal insufficiency. The revision rate was highest in those patients with velocardiofacial syndrome (21.8 percent) and lowest in patients with velopharyngeal insufficiency alone (6.3 percent). Patients who required revision had significantly higher preoperative oral sentence nasometry (55.2 percent versus 46.1 percent; p < 0.01) and larger velopharyngeal areas (23.7 mm2 versus 18.9 mm2). There was no significant difference in age or sex for those patients who required a revision compared with those who did not require revision. Mean follow-up was 2.4 years (range, 4 months to 13.6 years). Sphincter pharyngoplasty is an effective procedure for the treatment of velopharyngeal insufficiency using revision rate as the standard of success. It had an 87 percent primary success rate that increased to 99 percent after a single revision. Patients with velocardiofacial syndrome, more severe preoperative hypernasal resonance, and larger velopharyngeal areas were more likely to require pharyngoplasty revision.
BACKGROUND: The surgical management of velopharyngeal insufficiency in children with velocardiofacial syndrome is inherently more difficult, with the need for revision being high. The purpose of this report was to evaluate and document the authors' experience with sphincter pharyngoplasty in the management of velopharyngeal insufficiency in children with velocardiofacial syndrome, and compare outcome. METHODS: In part I, 32 patients with velocardiofacial syndrome underwent sphincter pharyngoplasty for velopharyngeal insufficiency between January of 1987 and March of 2001. There were 18 girls and 14 boys, with a mean age at primary sphincter pharyngoplasty of 6.7 years. Pharyngoplasty revision was defined as any secondary surgical revision of the sphincter as determined by clinical evaluation and objective speech assessment. In part II, comparisons were made to 218 non-velocardiofacial syndrome patients with velopharyngeal insufficiency who underwent sphincter pharyngoplasty (cleft palate, n = 127; velopharyngeal insufficiency alone, n = 63; submucous cleft, n = 15; other, n = 13). There was no significant difference in the average age or gender in the two groups. All patients underwent screening of velopharyngeal function, which included perceptual speech evaluation, clinical screening of velopharyngeal closure, and oral examination. RESULTS: In part I, success of the primary sphincter pharyngoplasty was demonstrated in 78 percent of the velocardiofacial syndrome patients (n = 25), with a revision rate of 22 percent. Patients who required revision were slightly older, 8.6 versus 6.3 years (p = not significant). Preoperative nasometry scores were significantly higher in patients who required a pharyngoplasty revision (69 versus 54; p = 0.002). Patients who required revision of the pharyngoplasty were more likely to have larger velopharyngeal areas (30 mm versus 22 mm). In part II, the revision rate in patients with velocardiofacial syndrome was significantly higher than in those patients in the original cohort without velocardiofacial syndrome (22 percent versus 11 percent; p < 0.05). Preoperative objective speech data demonstrated significantly greater velopharyngeal incompetence in all categories (nasometry scores, pressure flow measurements, and radiographic measurements) for patients with velocardiofacial syndrome, and age at initial sphincter repair was slightly older (8.5 versus 7.7 years; p = not significant). CONCLUSIONS: The management of velopharyngeal insufficiency using sphincter pharyngoplasty in children with velocardiofacial syndrome is safe and effective. The higher need for surgical revision in velocardiofacial syndrome patients is most likely attributable to a greater degree of preoperative nasalance and a slightly later age of presentation. This should provide insight into various technique modifications in an attempt to minimize pharyngoplasty revision.
A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.
OBJECTIVE: Two-hundreds and nineteen velopharyngeal insufficiency cases treated with a modified pharyngoplasty were retrospectively analyzed, the effectiveness of the surgery was studied. METHODS: Two-hundreds and nineteen patients (111 males, 108 females, range from 4 to 33 years, mean age 14.2 years) with velopharyngeal insufficiency were studied. Among 219 patients, 44 with congenital velopharyngeal insufficiency, 21 with fistula after palatoplasty and 154 with velopharyngeal insufficiency after primary palatoplasty. All cases had special examination, Chinese speech intelligibility test and blowing test before and after modified pharyngoplasty. RESULTS: Hypernasality in all cases were reduced and blowing test increased with various degrees. The Chinese speech intelligibility rose from 41% to 63%. CONCLUSIONS: The modify pharyngoplasty is a safe and effective method for velopharyngeal insufficiency of patient.
OBJECTIVE: To study effective operation method of congenital velopharyngeal insufficiency by reviewing clinical data of 29 patients with pharyngoplasties. METHODS: 29 patients (9 male and 20 female, ranged from 4 to 25 years old, mean age was 13.5) with congenital velopharyngeal insufficiency were available for this study. All cases received Chinese speech intelligibility test and blowing test before and after the pharyngeal flap surgery. RESULTS: Chinese speech intelligibility of 29 cases who underwent pharyngoplasties was improved from 33.86% to 43.13%, and the blowing time was increased from 4.60 to 17.72 seconds, the degree of abnormal speech was reduced. CONCLUSION: The pharyngeal flap surgery is an effective method for congenital velopharyngeal insufficiency, which reduces hypernasality and increases oral pressure, improves the velopharyngeal function.
The purpose of this study was to appraise the value of preoperative speech assessments, nasopharyngoscopy, and surgical models as predictors of velopharyngeal deterioration after a Le Fort I maxillary advancement in cleft patients. This retrospective study involved a series of 26 cleft patients (16 unilateral complete and nine bilateral complete cleft lips and palates, and one isolated complete cleft palate) who had Le Fort I maxillary advancements between March 1, 1993, and February 7, 1996. The 13 male patients and 13 female patients ranged in age from 15.3 to 46 years (mean age, 19.5 years). Four of these patients had previously undergone pharyngeal flap surgery. Eleven patients had palatal fistulas and one had a bifid uvula that was repaired at the time of orthognathic surgery. Patients with perceived hypernasal speech preoperatively all had hypernasality after advancement (nine of nine). Velopharyngeal insufficiency was observed in two of the 16 whose resonance preoperatively was within normal limits. Speech assessment, therefore, predicted accurately the postoperative status in 23 of 26 patients. Twelve patients had preoperative nasopharyngoscopy that indicated a high risk for velopharyngeal insufficiency (borderline or inadequate closure). Nine of these patients had postoperative velopharyngeal insufficiency. Two of the 14 patients not judged at risk by nasopharyngoscopy developed velopharyngeal insufficiency. Therefore, 21 of the 26 patients were accurately predicted by nasopharyngoscopy. Scoping detected borderline velopharyngeal insufficiency in one patient who was not detected by speech alone. The combined predictive value of speech and scope identified all but one patient who would develop postoperative velopharyngeal insufficiency. The degree of anteroposterior movement determined from surgical models was not predictive of the outcome. Patients with hypernasal speech preoperatively continue to have hypernasal speech after Le Fort I advancement. Preoperative perceptual speech assessment by specially trained speech-language pathologists is an excellent test for predicting postoperative velopharyngeal insufficiency status. Nasopharyngoscopy is an invasive and resource-dependent test that should be assessed with respect to cost effectiveness. In this series, only one patient's risk was more accurately predicted using nasopharyngoscopy than by speech assessment alone.
The surgical therapy for velopharyngeal incompetence has always been a challenging problem. In spite of the surgical choices of palatal pushback, pharyngeal flap, pharyngoplasty, muscle transfers, and pharyngeal wall implants, the reported failure rate has varied from 10% to 50%. A group of ten patients with velopharyngeal insufficiency is presented, two posttonsillectomy and adenoidectomy, three secondary to congenital deficiencies, and five following palatal and pharyngeal paralysis secondary to severe closed head injuries. The technique and experience with the lateral port control pharyngeal flap is discussed.
BACKGROUND: The objectives of the study were to describe speech outcomes in a large series of patients undergoing Furlow palatoplasty for management of velopharyngeal insufficiency and to test whether preoperative velopharyngeal gap size and other patient characteristics significantly affect those outcomes. METHODS: Data collected included age at the time of surgery, surgeon, type of cleft, syndrome diagnosis, preoperative velopharyngeal gap size as determined by videonasendoscopy, and preoperative and postoperative perceptual speech assessments. Descriptive statistics were generated and ordinal logistic regression on the outcome variable, postoperative velopharyngeal insufficiency severity score, was performed. RESULTS: In this series of 154 patients, 148 had complete perceptual speech data. Of these 148 patients, 72 percent had improvement in velopharyngeal insufficiency severity after the procedure and 56 percent had complete resolution of velopharyngeal insufficiency. Postoperative insufficiency was scored as none or minimal (i.e., resolution) in 38 of 52 patients (73 percent) with a small preoperative velopharyngeal gap, 26 of 51 patients (51 percent) with a moderate preoperative gap, and four of 21 patients (19 percent) with a large preoperative gap. Preoperative velopharyngeal gap size was significantly associated (p < 0.0001) with postoperative insufficiency on ordinal multivariate logistic regression after controlling for preoperative insufficiency and other covariates. There was not a significant association between syndrome diagnosis, age at Furlow palatoplasty (younger than 5 years versus older), gender, surgeon, or presence of submucous cleft palate and postoperative speech outcome, in either the unadjusted or adjusted analyses. CONCLUSIONS: Preoperative velopharyngeal gap size, as determined with nasendoscopy, was significantly associated with postoperative velopharyngeal insufficiency severity after Furlow palatoplasty. Small gap size is associated with a greater likelihood of resolution.
One-third of a group of 18 patients with hemifacial microsomia demonstrated velopharyngeal insufficiency of a significant degree. The ones with velopharyngeal insufficiency tended to have more severe soft tissue and skeletal deformities of the maxillary-malar complex, associated with a total unilateral palatal paralysis. Cinefluoroscopy was not helpful in diagnosing the velopharyngeal insufficiency. Fiberoptic nasopharyngoscopy, in contrast, proved to be an excellent diagnostic tool. We suggest that patients with hemifacial microsomia have a careful, periodic speech evaluation as an essential part of their overall management.
To avoid the serious complications of pharyngeal flap surgery, a Furlow palatoplasty was used to correct velopharyngeal insufficiency after primary palatoplasty in 18 Chinese cleft palate patients (3 to 23 years old) from 1988 to 1992. The follow-up duration was 1 to 4 years. These patients were selected after a complete study for velopharyngeal insufficiency, including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, pattern of velopharyngeal closure, size of the velopharyngeal gap, extent of lateral pharyngeal wall movement, existence of a Passavant's ridge, and abnormal levator veli palatini muscle insertion. Complete velopharyngeal closure was achieved for 16 patients after surgery. The majority of these patients (15) had a velopharyngeal gap less than 5 mm. The 2 patients who still had velopharyngeal insufficiency after the surgery had a velopharyngeal gap larger than 10 mm before the surgery. The most important factor seemed to be the size of the velopharyngeal gap. Pattern of velopharyngeal closure or age of the patient also might play an important role. The results showed that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected patients. Although the criteria for the selection of this operation need further study, present results are encouraging.
The use of Gax collagen is proposed for correcting velopharyngeal insufficiency with posterior pharyngeal wall augmentation. The indications for this procedure are velopharyngeal insufficiency that remains after surgery and treatment by a speech pathologist. The procedure is also valuable after velum paralysis. Collagen (2.5-5cc) is injected through a device designed for vocal-fold and laryngeal rehabilitation. Several injection points are necessary to raise a good Passavant's ridge. The muscular activity of the posterior pharyngeal wall models the collagen pad for the first 3 weeks; afterwards, the collagen shape remains unchanged due to its integration in the host tissues. At this time, five patients have been injected with Gax collagen and have improved. The oldest case dates from 28 months ago; the most recent dates from 8 months ago. There were no adverse reactions, and the results remain stable at the present time.