Treatment of Stress Velopharyngeal Incompetence With Injection of Hyaluronic Acid.

Stress velopharyngeal incompetence (VPI) is a challenging clinical entity that can be managed by a variety of surgical and nonsurgical approaches. We describe the case of a clarinetist who presented with nasal air escape while playing. She had successful improvement in her symptoms after targeted injection of a hyaluronic acid compound to her posterior pharyngeal wall. Our objective is to describe the safety and efficacy of this technique, to emphasize the multidisciplinary management of patients with stress VPI, and to review the importance of both nasopharyngoscopy and videofluoroscopy in their evaluation.

Velopharyngeal Dystonia: An Unusual Focal Task-specific Dystonia?

BACKGROUND: Velopharyngeal dysfunction produces a nasal speech pattern because of the inability to close the nasal airway during speech, most often associated with anatomical abnormalities of the palate. CASE REPORT: We describe two cases of possible velopharyngeal dystonia, a task-specific movement disorder causing a speech pattern similar to velopharyngeal dysfunction. Both patients experienced treatment response with anticholinergic medication. DISCUSSION: Dystonia affecting speech via involvement of the pharyngeal musculature may be an unrecognized etiology of voice disorders.

[Pediatric reversible acute velar palsy: A case report]. / Paralysie vélaire aiguë réversible de l'enfant : à propos d'un cas.

INTRODUCTION: Approximately 40 cases of acute idiopathic velopharyngeal reversible paralysis in the pediatric population have been reported in the literature. OBSERVATION: We present the case of a 12-year-old boy who had consulted in pediatric emergency departments for symptomatology including rhinolalia, nasal regurgitation, and deviation of the labial commissure. Paraclinical explorations helped diagnose rhombencephalitis with enterovirus. The introduction of oral corticosteroids was followed by rapid clinical improvement in 3 days. Monitoring 1 month later showed complete regression of symptoms. DISCUSSION: Similar cases in the literature describe the occurrence of nasal regurgitation and rhinolalia, sometimes associated with other cranial nerve impairment. The pathogenesis is rarely highlighted and the imaging results are always normal. Ad integrum recovery with or without corticosteroids is the rule. In light of this literature review, it is possible to conclude that the occurrence of such a suggestive clinical picture should limit the often costly and unnecessary additional tests.

An old flame reignites: vagal neuropathy secondary to neurosyphilis.

OBJECTIVE: This report describes neurosyphilis presenting as vocal fold paresis and velopharyngeal incompetence. This represents the first reported case of neurosyphilis presenting as a vagal neuropathy since 1963. STUDY DESIGN: Case report. METHODS: Review of medical records and literature search. RESULTS: The patient presented with voice changes and nasopharyngeal reflux of liquids. Examination showed a left vocal fold paresis and moderate velopharyngeal incompetence. Laryngeal electromyography revealed evidence of denervation, and neurologic evaluation showed bilateral Adie's pupils and a positive CSF VDRL. A remote history of syphilis treated with one intramuscular injection was obtained. The patient was treated with 6 weeks of penicillin and regained normal vocal function with minimal residual intermittent hypernasality. CONCLUSIONS: Given the recent increase in the incidence of syphilis in the United States, this case serves as a reminder of the importance of including syphilis in the differential diagnosis of cranial neuropathies and the increasing likelihood of syphilis presenting to otolaryngology and speech pathology practices. Syphilis, a disease whose incidence had declined progressively for 60 years in the United States, is now resurgent and must be considered in the evaluation of patients presenting with unexplained cranial neuropathies.

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.

Cross-linked hyaluronan for augmentation of the posterior pharyngeal wall: an experimental study in rats.

Velopharyngeal insufficiency can be treated in different ways. Augmentation injections of various space-filling materials have been tried, but a substance that has the ideal properties--easy to inject, non-toxic, and not immunogenic, and having a lasting effect--has not yet been found. Hylan b gel, a double cross-linked hyaluronan solution, is a new tissue augmentor that is not immunogenic and is easy to use. The purpose of this study was to evaluate the persistence of and the tissue reaction to hylan b gel injected into the posterior pharyngeal wall of 12 rats. Six rats acted as controls. A light immediate, and no late, inflammatory reaction developed in the pharyngeal mucosa after injection. Six months after injection, the gel was still present and the substance had been invaded by and surrounded by newly-formed, loose connective tissue. These results indicate that hylan b gel may be an appropriate substance in the augmentation of mild velopharyngeal insufficiency in man. However, further studies are needed to evaluate its long-term effects.

Sudden onset of velopharyngeal insufficiency in Klippel-Feil syndrome.

A 17-year-old girl with Klippel-Feil vertebral anomalies presented with sudden onset of VPI and hoarseness after a minor neck torsion injury. Her symptoms were felt to be due to compression of the brain stem by the odontoid process (through basilar invagination). The VPI and hoarseness responded to conservative management with oral steroids.

Palatopharyngeal incompetence in association with esophageal dysmotility, acquired glucocorticoid deficiency, and deficient tear production.

An 8 1/2-year-old male is described with the rare triad of acquired adrenal insufficiency, esophageal dysfunction, and alacrima. In addition, he had velopharyngeal insufficiency, which is a previously unreported feature of this syndrome. Although the pathophysiology of this disorder remains to be demonstrated, a defect may be present, linking hormone-receptor cyclic AMP-mediated processes with abnormalities in parasympathetic and voluntary neuronal innervation or transmission.