Three-dimensional finite element analysis on stress distribution after different palatoplasty and levator veli palatini muscle reconstruction.

OBJECTIVES: To establish a three-dimensional finite element model of the upper palate, pharyngeal cavity, and levator veli palatini muscle in patients with unilateral complete cleft palate, simulate two surgical procedures that the two-flap method and Furlow reverse double Z method, observe the stress distribution of the upper palate soft tissue and changes in pharyngeal cavity area after different surgical methods, and verify the accuracy of the model by reconstructing and measuring the levator veli palatini muscle. MATERIALS AND METHODS: Mimics, Geomagic, Ansys, and Hypermesh were applied to establish three-dimensional finite element models of the pharyngeal cavity, upper palate, and levator veli palatini muscle in patients with unilateral complete cleft palate. The parameters including length, angle, and cross-sectional area of the levator veli palatini muscle etc. were measured in Mimics, and two surgical procedures that two-flap method and Furlow reverse double Z method were simulated in Ansys, and the area of pharyngeal cavity was measured by hypermesh. RESULTS: A three-dimensional finite element model of the upper palate, pharyngeal cavity, and bilateral levator veli palatini muscle was established in patients with unilateral complete cleft palate ; The concept of horizontal projection characteristics of the palatal dome was applied to the finite element simulation of cleft palate surgery, vividly simulating the displacement and elastic stretching of the two flap method and Furlow reverse double Z method during the surgical process; The areas with the highest stress in the two-flap method and Furlow reverse double Z method both occur in the hard soft palate junction area; In resting state, as measured, the two flap method can narrow the pharyngeal cavity area by 50.9%, while the Furlow reverse double Z method can narrow the pharyngeal cavity area by 65.4%; The measurement results of the levator veli palatini muscle showed no significant difference compared to previous studies, confirming the accuracy of the model. CONCLUSIONS: The finite element method was used to establish a model to simulate the surgical procedure, which is effective and reliable. The area with the highest postoperative stress for both methods is the hard soft palate junction area, and the stress of the Furlow reverse double Z method is lower than that of the two-flap method. The anatomical conditions of pharyngeal cavity of Furlow reverse double Z method are better than that of two-flap method in the resting state. CLINICAL RELEVANCE: This article uses three-dimensional finite element method to simulate the commonly used two-flap method and Furlow reverse double Z method in clinical cleft palate surgery, and analyzes the stress distribution characteristics and changes in pharyngeal cavity area of the two surgical methods, in order to provide a theoretical basis for the surgeon to choose the surgical method and reduce the occurrence of complications.

Essential Palatal Myoclonus and Clicking Tinnitus in a Nine-Year-Old Boy-A Case Report.

The work describes a case of palatal myoclonus with distressing tinnitus in a 9-year-old boy and its successful treatment with injections of botulinum toxin. This case report discusses common questions about myoclonic-induced clicking tinnitus and provides answers. Laryngoscope, 134:397-399, 2024.

Single Oral Z-Plasty: A Clinical Validation of a Technique for Palatal Lengthening in Primary and Secondary Cleft Palate Repair.

BACKGROUND: In cleft palate repair, palate length is associated with improved speech outcomes. Although direct closure offers poor palatal lengthening, use of two opposing Z-plasties may reorient palatal musculature and lengthen the velum. The authors previously described a novel overlapping intravelar veloplasty to achieve longitudinal closure of the nasal mucosa with a single oral Z-plasty (1ZP), lengthening the palate in cadaver studies. This study aims to corroborate this finding in clinical cases. METHODS: A retrospective comparative study of patients with a cleft palate was conducted. Patients underwent cleft palate closure with 1ZP or intravelar veloplasty with straight-line closure. Preoperative and postoperative measurements of the palate along four dimensions were recorded. Analysis was conducted on preoperative and postoperative measurements within and between groups using the Mann-Whitney-Wilcoxon or chi-square test. RESULTS: Eighty-five patients were included (1ZP, n = 65; straight-line closure, n = 20). 1ZP increased soft palate length (SPL) by 33% ( P < 0.001) and total palate length (TPL) by 10% ( P < 0.001). Primary 1ZP increased SPL by 33% ( P < 0.001) and TPL by 10% ( P < 0.001). Secondary 1ZP increased SPL by 28% ( P < 0.001) and TPL by 8% ( P < 0.001). When comparing between primary and secondary 1ZP, 1ZP was equal with regard to percentage lengthening in SPL ( P > 0.9) and TPL ( P > 0.3). When compared with straight-line closure, 1ZP showed superior percentage lengthening in SPL ( P < 0.001) and TPL ( P = 0.038). CONCLUSIONS: 1ZP results in a statistically significant increase in palate length in both primary and secondary cleft palate repair. This technique provides an effective alternative in patients for whom 2ZP is not feasible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Predictors of surgical outcomes for limited palatal muscle resection in patients with obstructive sleep apnea.

OBJECTIVE: Limited palatal muscle resection (LPMR) is a modified palatal surgical technique to correct retropalatal obstruction without complications. This study aims to determine the associated factors affecting the success and cure rate of LPMR in patients with obstructive sleep apnea (OSA), thus guiding patient selection and improving surgical outcome. METHODS: Thirty-five OSA patients underwent LPMR were enrolled. All patients received routine physical examination, preoperative drug-induced sleep endoscopy (DISE), and polysomnography (PSG). Clinical, polysomnographic, cephalometric variables, and DISE findings were evaluated. These measurements were compared between the surgical success and failure group based on the results of preoperative and postoperative PSG. Furthermore, we compared the cured and non-cured groups in the surgical success group. RESULTS: Among 35 patients, the overall success rate was 57 % with a cure rate of 31.4 %. Patients with Friedman stage II had a significantly higher success rate (p = 0.032). According to DISE results, tongue base obstruction affected the surgical outcome (p < 0.001). The success rate was 100 % in the no tongue base obstruction during DISE, 72.2 % in the partial obstruction, and 9.1 % in the total obstruction. Tonsil size is also helpful in predicting surgical success rate (p = 0.041). Furthermore, patients with mild AHI were more likely to be surgical cures. when compared with patients with severe AHI (p = 0.044). CONCLUSION: Patients with larger tonsil size and no tongue base obstruction during DISE may have a higher chance of surgical success with LPMR. The lower AHI may be predictors of surgical cure after LPMR.

Limited Palatal Muscle Resection for the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis.

Background and Objectives: Limited palatal muscle resection (PMR) is a surgical technique employed to alleviate respiratory disturbances in obstructive sleep apnea (OSA) patients with retropalatal narrowing by reducing soft palate volume and tightening the muscles. Although some previous publications have demonstrated the effectiveness of limited PMR, the overall efficacy and therapeutic role of limited PMR for the treatment of OSA remain uncertain. This study utilized meta-analysis and a systematic literature review to estimate the overall effectiveness of limited PMR in treating OSA. Materials and Methods: Multiple databases, including PubMed, EMBASE, Cochrane Library, and Web of Science, were searched using specific keywords related to OSA and limited PMR. Original articles assessing respiratory disturbances before and after limited PMR in patients with OSA were included. Data from selected articles were collected using standardized forms, including clinicodemographic characteristics, apnea-hypopnea index (AHI), and lowest pulse oximetry values (minimum SpO2). Random effect models were used for analyzing significant heterogeneity. Egger's test and funnel plot were used to identify publication bias. Results: Four studies were included in this meta-analysis for AHI, and three studies were included for minimum SpO2 during sleep. A significant reduction in the AHI and an increase in the minimum SpO2 were shown following limited PMR as the standardized mean difference (95% confidence interval) was 2.591 (1.092-4.090) and 1.217 (0.248-2.186), respectively. No publication bias was found in either analysis. Conclusions: The results of the meta-analysis and systemic review add to the literature that limited PMR can result in a reduction in the AHI and an increase in min SaO2. In OSA patients with suspected retropalatal obstruction, limited PMR may be efficiently performed.

Cadaveric Study and Micro-Computed Tomography of the Anatomy of Palatine Aponeurosis and its Link to the Soft Palate Muscles and Pharyngeal Muscles.

OBJECTIVE: There have been few studies on the anatomy of palatine aponeurosis (PA). Herein, we elucidated the relationship between the PA and soft palate muscles and pharyngeal muscles. DESIGN: Two cadaveric specimens were dissected to observe the gross anatomy of the PA. Six cadaveric specimens were processed and scanned by micro-computed tomography to determine the elaborate anatomy. Images were exported to Mimics software to reconstruct a three-dimensional model. RESULTS: The PA covered the anterior (32.1%-38.8%) of the soft palate, extending from the tensor veli palatini (TVP) and connecting to 3 muscles: palatopharyngeus (PP), uvula muscle, and superior pharyngeal constrictor (SC). The SC and PP are attached to the PA on the medial side of the pterygoid hamulus. SC muscle fibers were attached to the hamulus, forming a distinct gap between the hamulus. Some muscle fibers of the PP and uvula originated from the PA. The PA extended from the TVP to the midline and the posterior edge of the hard palate. The PA was not uniformly distributed, which was complementary to the attached muscles in thickness. CONCLUSIONS: PA, as a flexible fibrous membrane, maintains the shape of the soft palate. It extends from the TVP and covers anteriorly about one-third of the soft palate. The PA provides a platform for the soft palate muscles and pharyngeal muscles, connecting to the PP, uvula muscle, and SC. These muscles are important for palatopharyngeal closure and middle-ear function. It is necessary to minimize the damage to the PA during surgical interventions.

An Exploratory Investigation of the Palatoglossus Muscle in Children Using Magnetic Resonance Imaging.

PURPOSE: There is currently little evidence reporting the typical morphology of the palatoglossus (PG) muscle. The primary purpose of this exploratory study is to determine whether magnetic resonance imaging (MRI) methods used to quantify the morphology of the levator veli palatini (LVP) muscle can be applied to the PG. The secondary purpose is to provide preliminary data regarding the relationship between the LVP and PG muscles in children. METHOD: Ten children between ages of 4 and 7 years participated in this study. Each participant was scanned using a nonsedated, child-friendly protocol with a T2-weighted, three-dimensional anatomical scan to obtain images of the oropharyngeal anatomy. Custom, oblique-coronal image planes were created to visualize and measure the LVP and PG muscles in their entirety from origin to insertion. Thermo Scientific Amira Software was used to obtain 2D measurements of PG muscle length, width, velar insertion distance, lingual insertion distance, and several angle measurements. RESULTS: The PG ranged from 17.95 to 26.96 mm in length across participants. Velar insertion distance ranged from 17.22 to 30.95 mm. Lingual insertion distance ranged from 26.91 to 36.02 mm. Width ranged from 2.32 to 3.08 mm. The angle formed by the PG and LVP muscle planes ranged from 7.3° to 52.7°. The LVP insertion angle ranged from 42.5° to 75.9°. The PG insertion angle ranged from 16.9° to 52.3°. CONCLUSIONS: MRI was successful in visualizing the PG muscle. The PG was consistent in size and shape within an individual participant but varied across the participant cohort.

Growth Effects on Velopharyngeal Anatomy Within the First 2 Years of Life.

PURPOSE: Limited quantitative data exist regarding growth of the velopharynx within the first 2 years of life. The purpose of this study was to (a) quantify changes in velopharyngeal structures due to growth during the first 2 years of life, (b) examine the impact of sex and race within this age range, and (c) provide normative measures for comparison to individuals with cleft palate. METHOD/DESCRIPTION: A retrospective chart review was completed of all patients up to 24 months of age that underwent magnetic resonance imaging of the head for medical necessity within the past 18 months using a three-dimensional fluid-attenuated inversion recovery sequence. Measurements of the velopharynx were obtained from 200 scans consistent with previous literature. Participants were divided into five groups based on corrected age for comparison. Variables of interest included adenoid depth, angle of origin, effective velopharyngeal ratio, effective velar length, levator veli palatini length, origin-origin distance, pharyngeal depth, sagittal angle, velopharyngeal ratio, velar insertion distance, velar length, and velar thickness. RESULTS: Velopharyngeal dimensions were significantly different among corrected age groups after controlling for sex and race. Regarding age, analyses revealed significant differences in all variables of interest except effective velopharyngeal ratio. Regarding sex, significant differences were observed for angle of origin, effective velopharyngeal ratio, effective velar length, levator veli palatini muscle length, and velar insertion distance. Regarding race, a significant difference was only observed for angle of origin. CONCLUSIONS: Results of this study demonstrate growth of velopharyngeal anatomy in normative infants with race and sex effects apparent in children up to 24 months of age. Variable growth trends were observed among different velopharyngeal measures.

Laryngeal, Pharyngeal and Respiratory Involvement in Palatal Tremor.

OBJECTIVE: To present cases of atypical palatal tremor (PT) and showcase the variable phenomenology of this condition. STUDY DESIGN: Retrospective case series. RESULTS: PT, or palatal myoclonus, is a movement disorder characterized by brief, involuntary rhythmic muscular contractions of the soft palate. Variants of PT have been described and include synchronous tremors in other branchial arch derivatives including the larynx, pharynx, neck, face, jaw, ocular and also respiratory and trunk muscles. We present 3 cases, including clinical videos, of atypical PT with extra-palatal manifestations, in addition to a brief discussion of the pathophysiology and management of this condition. CONCLUSION: Variations of PT are of interest to the practicing otolaryngologist as the clinical spectrum of this condition is wide and can present with laryngeal, pharyngeal, respiratory and other head and neck manifestations.

The cranial base and related internal anatomical features in Homo neanderthalensis and Homo sapiens.

The cranial anatomy of Homo neanderthalensis and Homo sapiens is well documented in the paleoanthropological and medical literature. However, there are few high-quality visual guides of their comparative morphology. We give here a detailed description of the anatomy of two important fossil specimens, La Chapelle-aux-Saints 1 and abri Pataud 1, based on high-resolution imaging data with each specimen representing the respective morphologies of H. neanderthalensis and H. sapiens. We describe the comparative morphology of external, endocranial, and internal characteristics of the cranium, with a focus on the petrous and tympanic portions of the temporal bone. This descriptive approach shows differences between our specimens, including in positions of cerebral components relative to cranial structures and patterns of dural sinus drainage. Numerous external and internal differences in the shape of the petrous temporal are also described, including its articulation with the tympanic bone and the orientation of the petrotympanic crest. The presence of a large protuberance between the osseous Eustachian tube orifice and carotid foramen in H. neanderthalensis suggests that the levator veli palatini muscle took origin more laterally than the dilator tubae arm of the tensor veli palatini muscle, a feature shared with H. sapiens. The overall pattern that emerges is one in which two species have undergone large-scale evolutionary changes in a functionally critical region. Such differences necessitate high-quality visualization and consideration of both internal and external morphology.

Vascular anatomy of the velopharyngeal muscles and its clinical implications: A fresh cadaveric study based on micro-computed tomography.

Poor speech improvement after levator veli palatini (LVP) reconstruction may be related to intraoperative vascular injury. We aimed to examine the vascular anatomy of the velopharyngeal muscles to provide a guide for arterial protection in cleft palate repair. Fresh adult cadaveric heads were injected with gelatin/lead oxide. The velopharyngeal specimens were stained with iodine and scanned using micro-computed tomography. Three-dimensional reconstruction models were obtained using a computer-aided design software. The ascending palatine artery (APaA), especially the posterior branch, is the main artery supplying the velopharyngeal muscles. The posterior branch of the APaA reaches the dorsal part of the musculus uvulae in the posterior one third of the soft palate (SP) and lies 1.75 mm (standard deviation, 0.06) under the nasal mucosa; the anterior branch penetrates the anterolateral side of the LVP to reach the anterior one third of the SP and lies 7.09 mm (0.03) under the oral mucosa. The posterior APaA, anterior ApaA, and ApaA trunk had mean diameters of 0.41 mm (0.04), 0.46 mm (0.06), and 0.65 mm (0.04) at 0.5, 1, and 1.5 cm distance from the palatal midline, respectively. To minimize vascular injury, mobilization of muscles during intravelar veloplasty should be performed within a distance of 1 cm from the palatal midline, and dissection of the oral submucosa should be reduced in the anterior one third of the SP, while wide dissection of the nasal submucosal should be avoided in the posterior one third of the SP.

Micro-Computed Tomography-Based Three-Dimensional Anatomical Structure of the Region Around the Pterygoid Hamulus.

OBJECTIVE: Palatoplasty would involve the structures around the pterygoid hamulus. However, clinicians hold different opinions on the optimal approach for the muscles and palatine aponeurosis around the pterygoid hamulus. The absence of a consensus regarding this point can be attributed to the lack of investigations on the exact anatomy of this region. Therefore, we used micro-computed tomography to examine the anatomical structure of the region surrounding the pterygoid hamulus. DESIGN: Cadaveric specimens were stained with iodine-potassium iodide and scanned by micro-computed tomography to study the structures of the tissues, particularly the muscle fibers. We imported Digital Imaging and Communications in Medicine images to Mimics to reconstruct a 3-dimensional model and simplified the model. RESULTS: Three muscles were present around the pterygoid hamulus, namely the palatopharyngeus (PP), superior constrictor (SC), and tensor veli palatini (TVP). The hamulus connects these muscles as a key pivot. The TVP extended to the palatine aponeurosis, which bypassed the pterygoid hamulus, and linked the PP and SC. Some muscle fibers of the SC originated from the hamulus, the aponeurosis of which was wrapped around the hamulus. There was a distinct gap between the pterygoid hamulus and the palatine aponeurosis. This formed a pulley-like structure around the pterygoid hamulus. CONCLUSIONS: Transection or fracture of the palatine aponeurosis or pterygoid hamulus, respectively, may have detrimental effects on the muscles around the pterygoid hamulus, which play essential roles in the velopharyngeal function and middle ear ventilation. Currently, cleft palate repair has limited treatment options with proven successful outcomes.

Morphometric and Immunohistochemical Characteristics of the Adult Human Soft Palate Muscles.

The soft palate is the only structure that reversibly separates the respiratory and gastrointestinal systems. Most species can eat and breathe at the same time. Humans cannot do this and malfunction of the soft palate may allow food to enter the lungs and cause fatal aspiration pneumonia. Speech is the most defining characteristic of humans and the soft palate, along with the larynx and tongue, plays the key roles. In addition, palatal muscles are involved in snoring and obstructive sleep apnea. Considering the significance of the soft palate, its function is insufficiently understood. The objectives of this study were to document morphometric and immunohistochemical characteristics of adult human soft palate muscles, including fiber size, the fiber type, and myosin heavy chain (MyHC) composition for better understanding muscle functions. In this study, 15 soft palates were obtained from human autopsies. The palatal muscles were separated, cryosectioned, and stained using histological and immunohistochemical techniques. The results showed that there was a fast type II predominance in the musculus uvulae and palatopharyngeus and a slow type I predominance in the levator veli palatine. Approximately equal proportions of type I and type II fibers existed in both the palatoglossus and tensor veli palatine. Soft palate muscles also contained hybrid fibers and some specialized myofibers expressing slow-tonic and embryonic MyHC isoforms. These findings would help better understand muscle functions.

A Preliminary Study of Anatomical Changes Following the Use of a Pedicled Buccal Fat Pad Flap During Primary Palatoplasty.

OBJECTIVE: The purpose of this study was to examine the surgical impact of the pedicled buccal fat pad (BFP) flap on the levator veli palatini (LVP) muscle and surrounding velopharyngeal (VP) anatomy following primary palatoplasty using magnetic resonance imaging (MRI). DESIGN: Observational, prospective. SETTING: MRI studies were completed at 3 different facilities. All participants with BFP flap were operated on by the same surgeon. PARTICIPANTS: Five pediatric participants with cleft palate with or without cleft lip (CP±L) who underwent primary palatoplasty with BFP flap placement. Comparison groups consisted of 10 participants: 5 with CP±L who did not receive the BFP flap and 5 healthy controls. INTERVENTIONS: All participants underwent nonsedated MRI 2 to 5 years postoperatively. MAIN OUTCOMES AND MEASURES: Anatomical measures of the velopharynx and LVP among the 3 participant groups. RESULTS: Median values were significantly different among groups for velar length (P = .042), effective velar length (P = .048), effective VP ratio (P = .046), LVP length (P = .021), extravelar LVP length (P = .009), and LVP origin-origin distance (P = .030). Post hoc analysis revealed a statistically significant difference between the BFP and traditional repair groups for effective VP ratio (P = .040), extravelar LVP length (P = .033), and LVP length (P = .022). CONCLUSIONS: This study provides preliminary support that the BFP flap creates a longer velum, with increased distance between the posterior hard palate and the LVP, and a larger effective VP ratio compared to traditional surgical techniques. Future research is needed to determine whether this procedure provides a more favorable mechanism for VP closure.

Quantitative Evaluation of Palatal Lengthening After Cleft Palate Repair When a Buccal Flap Is Routinely Combined With Furlow's Z-Plasty.

INTRODUCTION: The use of a buccinator myomucosal flap in combination with Furlow's Z-plasty during primary and secondary palatal repairs has been proposed by many authors to overcome some of the limitations of Furlow's technique. However, there have been no studies that quantitatively measured the effective palatal lengthening when the buccal flap is added. PATIENTS AND METHODS: The buccal flap is routinely used during primary palate repair in order to fill the gap between the hard palate and reoriented palatal muscle sling. The soft palatal length was measured in the midline from the posterior edge of the hard palate to the base of the uvula. All patients were measured before starting the surgery and just after palatal closure in the standard position for cleft palate repair. RESULTS: Seventy-three patients with cleft palate who were candidates for primary repair were included. The mean age at the time of operation was 11.4 ± 3.5 months. The mean preoperative palatal length was 21.36 ± 3.529 mm, whereas the mean postoperative palatal length was 29.64 ± 4.171) mm. The mean palatal length change was 8.29 ± 2.514 mm (P < 0.000). CONCLUSIONS: The Combined use of a buccinator myomucosal flap with modified Furlow's Z-plasty in primary cleft palate repair has proven effective for palatal lengthening and achieved tensionless closure without the need for relaxing incision. It also provided a pliable soft tissue attachment of the palatal muscles to the hard palate allowing for better muscle function and mobility.

Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers.

Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VParea), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VParea) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VParea, HN, and ModelKataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of ModelKataoka, A 3-P 0, and B F1 for the objective measurement of VPI or HN.