MRI with synchronized audio to evaluate velopharyngeal insufficiency.

OBJECTIVE: To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure. DESIGN: Institutional Review Board-approved case series. SETTING: Tertiary care hospital. PATIENTS: Three healthy adult volunteers with a normal speech pattern. INTERVENTIONS: MRI with simultaneous recorded audio files evaluating velopharyngeal closure. MAIN OUTCOME MEASURE: Precise imaging and audio coordination of specific phonatory tasks. RESULTS: Synchronization of MRI and audio in all three adults. CONCLUSION: Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.

Injection pharyngoplasty with calcium hydroxyapatite for treatment of velopalatal insufficiency.

OBJECTIVE: To evaluate the efficacy of injectable calcium hydroxylapatite for treatment of velopalatal (VP) insufficiency (VPI). DESIGN: Observational case series of 7 patients treated with injectable calcium hydroxylapatite for VPI and followed for 10 to 24 months. SETTING: Academic pediatric otolaryngology practice. PATIENTS: Seven children aged 6 to 16 years with clinically significant VPI stemming from documented small VP gaps and who did not benefit from speech therapy were treated with calcium hydroxylapatite injection pharyngoplasty. INTERVENTION: Posterior pharyngeal wall augmentation with calcium hydroxylapatite. MAIN OUTCOME MEASURES: Treatment success was defined as (1) speech improvement to the degree that parents felt no additional treatment was needed and (2) meeting postoperative nasometric measures. Treatment failure was defined as parental report of insufficient improvement in speech. Complications and additional treatments for VPI were noted. RESULTS: There were no major complications in any of the 7 children injected with calcium hydroxylapatite. There was 1 minor complication: 1 patient was readmitted for postoperative pain and dehydration. Of the 7 patients, 4 experienced a satisfactory result for up to 17 months. Findings from postoperative nasometry were either within reference range, or less than 1 SD greater than the reference range, for all sounds. There were 3 treatment failures, each with preexisting craniofacial abnormality. Two patients in the group that failed treatment later underwent revision superior pharyngeal flap surgery without complication or hindrance from the calcium hydroxylapatite injection. Four children underwent subsequent magnetic resonance imaging evaluations up to 1 year after injection, which revealed no evidence of migration. CONCLUSIONS: The data from this small series suggest that posterior pharyngeal wall injection with calcium hydroxylapatite is safe and may be effective in treating select patients with VPI. Further longitudinal studies, with a larger series of patients, examining the safety, efficacy, and patient selection are warranted to better understand the possible use of posterior pharyngeal wall injection of calcium hydroxylapatite in children with symptomatic VPI.

The utility of the fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type I laryngeal clefts.

This case series of three young children with type I laryngeal clefts is presented to demonstrate the utility of fiberoptic endoscopic evaluation of swallowing (FEES) in managing these patients. FEES revealed laryngeal penetration in a posterior to anterior direction in two patients and penetration from lateral to medial in the third patient. The type of laryngeal penetration helped in making the diagnosis of a type I cleft in two children and helped establish a safe feeding regiment in the third child. Patients with type I laryngeal clefts are often misdiagnosed, most likely resulting from the complex presentation of signs/symptoms and the difficulty of detecting small clefts with currently available tests. The pattern of laryngeal aspiration seen with FEES can help in diagnosis and management in this patient population.

Type 1 laryngeal cleft: establishing a functional diagnostic and management algorithm.

OBJECTIVES: To report our experience with all patients diagnosed with type 1 laryngeal cleft over a period of 3 years in our referral practice and to describe a functional diagnostic and management algorithm for children with this disorder. METHODS: A prospective longitudinal study in a tertiary care referral center. Twenty pediatric patients diagnosed with type 1 laryngeal cleft in a 3-year period (5/1/2002-5/1/2005) were included in this study. The incidence, presenting symptoms, diagnostic procedures, medical and surgical interventions performed, and clinical outcomes were evaluated. RESULTS: The incidence of type 1 laryngeal cleft was 7.6%. Among the 20 patients in this study, aspiration with thin liquids was the most common presenting symptom (18 patients, 90%). Three patients underwent modified barium swallow (MBS) alone, 3 patients underwent functional endoscopic evaluation of swallow (FEES) alone, and 11 patients underwent both MBS and FEES prior to intraoperative endoscopic evaluation. Four patients (20%) were successfully treated with conservative therapy. Sixteen patients (80%) required endoscopic surgical repair after failing a course of conservative measures. The success rate of surgical repair was 94% (15 out of 16 patients). CONCLUSIONS: Type 1 laryngeal cleft can be challenging diagnostically. We propose a functional diagnostic and management algorithm that includes MBS, FEES, suspension laryngoscopy with bimanual interarytenoid palpation, and a trial of conservative therapy, as a way to diagnose and manage type 1 laryngeal cleft prior to consideration of surgical repair. If conservative therapy fails, then surgical intervention is indicated.

Type 1 laryngeal cleft: a multidimensional management algorithm.

IMPORTANCE: Early diagnosis and assessment in children with type 1 laryngeal cleft are essential in preventing aspiration and associated comorbidity. Appropriate use of conservative and surgical interventions in an evidence-based management strategy can improve overall outcome. OBJECTIVE: To evaluate the management of care for children with type 1 laryngeal cleft in our practice and develop an updated management algorithm. DESIGN, SETTING, AND PARTICIPANTS: We performed a review of medical records at a tertiary pediatric aerodigestive center. During a period of 7 years (July 18, 2005, to July 18, 2012), 1014 children younger than 18 years were evaluated for aspiration, choking, cough, or recurrent pneumonia. Of these, 44 children (4.3%) had a type 1 laryngeal cleft. Two were lost to follow-up; thus, 42 children were included in our final sample (28 males, 14 females). INTERVENTIONS: The care of 15 patients (36%) was managed conservatively, and 27 patients (64%) underwent endoscopic surgical repair of their laryngeal cleft. MAIN OUTCOME AND MEASURE: Assessment of our current management strategy. RESULTS: Success was defined as improving when a child was able to tolerate a feeding without aspirating or resolved when the child had transitioned to tolerating thin liquids. All patients received a trial of conservative therapy. Fifteen of the 42 patients (36%) had an anatomic cleft and were able to maintain the feeding regimen; thus, conservative treatment was successful in this group. The remaining 27 patients (64%) received surgical intervention. Overall operative success rate was 21 of the 27 patients (78%). The age of the child (P < .01) and comorbid conditions (P < .001) affected the outcomes of conservative measures and surgical repair. Only 6 patients did not demonstrate resolution, 5 of whom had significant comorbidities. CONCLUSIONS AND RELEVANCE: Age, comorbidity status, severity of aspiration, and the ability to tolerate a feeding regimen should be taken into account when deciding on conservative or surgical management for children with a type 1 laryngeal cleft. A clinical pathway for conservative and surgical management is presented.

Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children.

OBJECTIVE: To describe a modified rolled superior pharyngeal flap for treatment of velopharyngeal insufficiency (VPI) in children. METHODS: Prospective case series at a tertiary care multidisciplinary aerodigestive center. Four children, aged 5-12 years, with VPI refractory to speech therapy resulting after cleft palate (bilateral, submucous, or soft palate only) repair, failed traditional superior pharyngeal flap, fine motor incoordination, or adenoidectomy were studied. All 4 children underwent surgery with a modified superior pharyngeal flap, where aspects of the most commonly employed pharyngeal flap designs were combined to achieve the benefits of each technique and to allow for mucosal covering on either side of the flap, improved control of the lateral port size due to the horizontal-to-horizontal inset technique, and the ability to avoid a vertical or horizontal split in a previously repaired cleft palate. RESULTS: All 4 patients demonstrated resolution of their VPI as measured by subjective and/or objective criteria. Every patient required additional speech therapy postoperatively. CONCLUSIONS: Our modified superior pharyngeal flap technique may be a good option in patients with small velopharyngeal gaps undergoing revision velopharyngeal surgery. A larger, longitudinal study would better address the overall outcomes of this technique.

Cine magnetic resonance imaging with simultaneous audio to evaluate pediatric velopharyngeal insufficiency.

OBJECTIVE: To develop a protocol linking cine magnetic resonance (MR) imaging to simultaneously acquired audio recordings of specific phonatory tasks to evaluate velopharyngeal insufficiency (VPI) in children. DESIGN: Institutional review board-approved development and application of a novel dynamic cine MR imaging protocol linked to simultaneously recorded audio. SETTING: A tertiary care multidisciplinary pediatric airway center. PARTICIPANTS: Three healthy adult volunteers and 5 pediatric volunteers (age range, 9.3-18.9 years; mean age, 12.4 years) from the multidisciplinary pediatric airway center with VPI who previously had undergone nasopharyngoscopy, videofluoroscopy, or both. INTERVENTIONS: Cine MR imaging with simultaneously acquired audio files was performed in 3 adult volunteers to optimize the protocol and then in 5 pediatric volunteers meeting the inclusion criteria. MAIN OUTCOME MEASURES: High-resolution cine MR images with clear intelligible audio recordings of specific phonatory tasks. RESULTS: Using 3 healthy adult volunteers, a cine MR imaging VPI protocol was developed that links simultaneously acquired cine MR images to audio recordings of specific validated phonatory tasks. Five school-aged children with VPI from our multidisciplinary pediatric airway center were then enrolled and underwent cine MR imaging using this protocol. The cine MR images and audio recordings acquired were of sufficient diagnostic quality to evaluate VPI closure patterns in school-aged children with VPI. CONCLUSION: Cine MR imaging linked to audio is a quick, safe, and well-tolerated dynamic diagnostic imaging tool that may eventually have the potential to guide more precisely the selection and application of surgical techniques for VPI.

Injection pharyngoplasty with calcium hydroxylapatite for velopharyngeal insufficiency: patient selection and technique.

OBJECTIVE: To identify children who may benefit from calcium hydroxylapatite (CaHA) injection pharyngoplasty for symptomatic velopharyngeal insufficiency (VPI). DESIGN: Retrospective review of children with VPI who underwent injection pharyngoplasty with CaHA. SETTING: Multidisciplinary pediatric aerodigestive center. PATIENTS: Children with symptomatic VPI as defined by abnormal speech associated with subjective and objective measures of hypernasality. INTERVENTION: Posterior pharyngeal wall augmentation with injectable CaHA. MAIN OUTCOME MEASURE: Nasalence scores recorded as number of standard deviations (SDs) from normalized scores, and perceptual scoring recorded as standardized weighted score and caretaker satisfaction from direct report. RESULTS: Twelve children who had undergone injection pharyngoplasty with CaHA were identified. Of the 12 children, 8 demonstrated success at 3 months as defined by nasalence (<1 SD above normal nasalance scores), perceptual scoring (decrease in weighted score), and overall caretaker satisfaction. Four children were followed up for more than 24 months and continued to demonstrate stable success. The 4 children who failed the procedure all failed before the 3-month evaluation and demonstrated increased baseline severity of VPI as defined by increased preoperative nasalence scores (5.25 SD vs 2.4 SD above normalized scores), perceptual scores (weighted score, 4.25 vs 3.85), and characteristic nasendoscopy findings of a broad-based velopharyngeal gap or unilateral adynamism. Three of the 4 treatment failures occurred early in the senior author's (C.J.H.) experience with the technique. CONCLUSIONS: Injection pharyngoplasty with CaHA is a useful adjunct in the treatment of children with mild VPI. Efficacy and safety have been demonstrated more than 24 months after injection. Patient selection and operative technique are critical to the success of the procedure. Success is seen most often in children with mild VPI and small well-defined velopharyngeal gaps consistent with touch closure.