Sphincter Pharyngoplasty for Velopharyngeal Dysfunction: Impact of 22q11.2 Deletion Syndrome.

OBJECTIVE: Patients with 22q11.2 deletion syndrome (22q11DelS) often present with velopharyngeal dysfunction (VPD). VPD in patients with 22q11DelS is multifactorial beyond velopharyngeal insufficiency (VPI) alone, and differences in surgical outcomes are poorly understood. Our objective was to determine whether patients with 22q11DelS have an increased risk for persistent VPI after sphincter pharyngoplasty compared to patients without 22q11DelS. METHODS: We completed a retrospective cohort study of patients with 22q11DelS undergoing sphincter pharyngoplasty between 1995 and 2019 using a VPD clinic database. Patients with 22q11DelS were compared to a cohort of 2:1 frequency-matched (age, degree of velopharyngeal closure) patients without 22q11DelS. Variables included patient characteristics, surgical history, perceptual speech evaluation, and degree of closure on nasopharyngoscopic evaluations. Primary outcomes included postoperative VPI severity and hypernasality. Speech and nasopharyngoscopic characteristics were compared using Fisher's exact test. Postoperative VPI severity and hypernasality were compared between groups via relative risks (RR) from mixed effects Poisson regression models, with random effects of age and velopharyngeal closure. RESULTS: 134 patients (51 22q11DelS, 83 matched) were included, with mean age of 7.3 years (standard deviation 3.0) and 50% male. Cohorts had similar preoperative speech characteristics and nasopharyngoscopic findings. Patients with 22q11DelS had similar postoperative VP function as patients without 22q11DelS (RR 0.85, CI 0.46-1.57 for VPI severity, RR 0.83, CI 0.45-1.53 for hypernasality). Even after adjusting by preoperative variables, no differences were seen between both groups. CONCLUSION: Matched for age and pre-operative velopharyngeal closure, patients with and without 22q11DelS and VPI had similar benefits after sphincter pharyngoplasty. LEVEL OF EVIDENCE: Non-randomized controlled cohort study, 3 Laryngoscope, 133:2813-2820, 2023.

Valores de nasalancia para vocales, serie numérica y oraciones producidas por adultos hablantes de español chileno / Nasalance scores for vowels, number series and sentences produced by Chilean Spanish-speaking adults

Objetivo: El presente estudio tuvo como objetivo establecer y comparar valores de nasalancia en adultos de ambos sexos hablantes de español de Chile durante la producción de vocales sostenidas, una muestra de habla automática y la lectura de oraciones. Métodos: Participaron 46 adultos (25 mujeres y 21 hombres), con edad entre 18 y 29 años. Todos sin historia de tratamiento fonoaudiológico, patologías neurológicas, déficit intelectual, pérdida auditiva, síndromes u otras patologías que afectan la producción del habla. La adecuada función velofaríngea fue determinada en vivo a través de una evaluación perceptual de la resonancia. La nasalancia fue determinada con el Nasometer, modelo 6450, durante la producción sostenida de las vocales /a/, /i/, /u/, una repetición automática de la serie numérica 1-10 y la lectura de seis oraciones, cinco con consonantes orales de alta presión y una con consonantes nasales. La comparación entre ambos sexos fue realizada con el test de la U de Mann-Whitney. Resultados: La oración con sonidos nasales («Mi mamá me mima») presentó el porcentaje mayor de nasalancia, con un 66.36%, seguido de la serie numérica, con un 24.61%, y la vocal /i/, con un 23.57%. En tanto, las oraciones con sonidos orales y las vocales /a/ y /u/ sostenidas presentaron una nasalancia promedio que fluctuó entre un 10.5% (vocal /u/) y un 16.52% (oración: «Fifí fue feliz»). Por último, fue observado un promedio significativamente mayor en mujeres para tres oraciones orales: «Pipo patea la pelota» (p=.044), «Tito tapa tarros» (p=.041), y «Fifi fue feliz» (p=.027). Conclusión: Los valores de nasalancia obtenidos en adultos chilenos demostraron variaciones de acuerdo al estímulo de habla y el sexo de los hablantes.(AU)

Objective: The present study aimed to establish and compare nasalance scores in Spanish-speaking adults of both genders from Chile during the production of sustained vowels, an automatic speech sample and the reading of sentences. Methods: 46 adults participated, 25 women and 21 men, aged between 18 and 29 years. All without a history of speech therapy, neurological pathologies, intellectual deficit, hearing loss, syndromes or other pathologies that affect speech production. Adequate velopharyngeal function was determined in vivo through a perceptual evaluation of resonance. Nasalance was determined with the Nasometer, model 6450, during the sustained production of the vowels /a/, /i/ and /u/, an automatic repetition of the number series 1-10 and the reading of six sentences, five with consonants high pressure orals and one with nasal consonants. The comparison between both genders was made with the Mann-Whitney U test. Results: The sentence with nasal sounds («Mi mamá me mima») presented the highest percentage of nasalance with 66.36%, followed by the numerical series with 24.61% and the vowel /i/ with 23.57%. Meanwhile, sentences with oral sounds and sustained vowels /a/ and /u/ presented an average nasalance that fluctuated between 10.5% (vowel /u/) and 16.52% (sentence: «Fifi fue feliz»). Finally, a significantly higher average was observed in women for three oral sentences: «Pipo patea la pelota» (P=.044), «Tito tapa tarros» (P=.041), and «Fifi fue feliz» (P=.027). Conclusion: The nasalance values obtained in Chilean adults showed variations according to the speech stimulus and the gender of the speakers.(AU)

The case for the pharyngeal flap pharyngoplasty in the management of velopharyngeal dysfunction.

Velopharyngeal dysfunction (VPD) occurs when there is inadequate closure of the velopharyngeal sphincter during speech. An incompetent velopharyngeal sphincter may require surgical intervention to create a functional seal between the oropharynx and the nasopharynx during speech. To date, no single pharyngoplasty procedure has emerged as superior to another, and the comparison of results between studies has been limited by variation in outcomes reporting. Here, we use the newly defined Core Outcome Set for VPD (COS-VPD) to report a consecutive series of 109 patients managed with a midline pharyngeal flap and simultaneous dissection and repositioning of the velar muscles. The overall 30-day postoperative complication rate was 3.6% (4 out of 109 patients). At 12-month follow-up, 79.3% of patients experienced a statistically significant improvement in hypernasality. Seven patients (6.4%) developed obstructive sleep apnoea (OSA) postoperatively, and this was confirmed with polysomnography, with four (3.6%) patients requiring takedown of the pharyngeal flap. Seven patients in total (7.3%) required takedown of the pharyngeal flap and sphincter pharyngoplasty because of insufficient improvement of their VPD following the initial procedure. Patient-reported outcomes were investigated using the Velopharyngeal Effects on Life Outcome (VELO) instrument, and a mean total score of 74.5 out of 100 was recorded. We conclude that cleft surgeons should not be dissuaded by historical concerns about high rates of perioperative complications and OSA and should consider including the pharyngeal flap in their armamentarium when managing patients with VPD.

Growth in fetuses of the constrictor pharyngis superior with special reference to its meeting with the buccinator: an embryological basis of adult variations in palatopharyngeal anatomy.

PURPOSE: The constrictor pharyngis superior (CPS) initially develops along the posterior wall of the pharyngeal mucosal tube, whereas, during the early phase, the buccinators (BC) are far anterolateral to the CPS. The process and timing of their meeting during fetal growth have not been determined. METHODS: The topographical relationship between the growing BC and CPS was assessed in histological sections from 22 early- and mid-term fetuses of approximate gestational age (GA) 8-16 weeks, and eight late-term fetuses of approximate GA 31-39 weeks. RESULTS: At 8-9 weeks, the palatopharyngeus appeared to pull the CPS up and forward. Until 11 weeks, the CPS was attached to the hamulus of the pterygoid (pterygopharyngeal part). Until 13 weeks, the CPS extended anterolaterally beyond the hamulus to meet the BC. Some BC muscle fibers originated from the oral mucosa. Notably, by 30 weeks, the CPS-BC interface had become covered by or attached to the palatopharyngeus. Muscle fibers of the palatopharyngeus, however, were thinner than those of the CPS and BC. At and near the interface, BC muscle fibers tended to run along the left-right axis, whereas those of the CPS ran anteroposteriorly. A definite fascia (i.e., a future pterygomandibular raphe) was usually absent between these muscles in fetuses. CONCLUSIONS: The excess anterior growth of the CPS with its subsequent degeneration might cause individual anatomical variations in composite muscle bundles of the palatopharyngeus-CPS complex or palatopharyngeal sphincter. A tensile transduction from the BC to the CPS through the raphe seemed unnecessary for cooperative suckling and swallowing after birth.

Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function.

ABSTRACT: Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations.

BACKGROUND: The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States. METHODS: A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision. RESULTS: A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type. CONCLUSIONS: In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Upper airway stimulation: Fewer complications, ED presentations, readmissions, and increased surgical success.

OBJECTIVES: Evaluate the rate of complications, readmissions, emergency department presentations, and surgical success rates amongst three standard surgical treatment options for obstructive sleep apnea: upper airway stimulation, transoral robotic surgery, and expansion sphincter pharyngoplasty. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary care center. METHODS: Patients were included who were aged ≥18 years old and underwent upper airway stimulation, transoral robotic surgery, or expansion sphincter pharyngoplasty between January 2011 and May 2020. RESULTS: 345 patients were identified: 58% (n = 201) underwent upper airway stimulation, 10% (n = 35) underwent transoral robotic surgery, and 32% (n = 109) patients underwent expansion sphincter pharyngoplasty. There were 22 emergency department presentations and 19 readmissions, most of which were experienced by patients receiving transoral robotic surgery (six emergencies, seven readmissions) and expansion sphincter pharyngoplasty (12 emergencies, 11 readmissions). Patients with upper airway stimulation had four emergencies and one readmission. Only 2% of the upper airway stimulation cohort had a complication, whereas this was 20% and 12% for the transoral robotic surgery and expansion sphincter pharyngoplasty cohorts, respectively. Patients experienced the highest surgical success rate with upper airway stimulation (69%), whereas patients who received transoral robotic surgery and expansion sphincter pharyngoplasty had success rates of 50% and 51%, respectively. CONCLUSION: Treating obstructive sleep apnea with upper airway stimulation led to lower rates of complications, emergency department presentations, and readmissions in this series. In those for whom upper airway stimulation is appropriate, it may be more effective in successfully treating obstructive sleep apnea than transoral robotic surgery and expansion sphincter pharyngoplasty.

Evaluación perceptual de la insuficiencia velofaríngea en personas con fisura del paladar: una revisión integradora de literatura / Perceptual evaluation of velopharyngeal insufficiency in people with cleft palate: an integrative literature review

La insuficiencia velofaríngea (IVF) secundaria de fisura del paladar corresponde al cierre incompleto del mecanismo velofaríngeo durante el habla, debido a una falta de tejido en el paladar blando o las paredes de la faringe, lo cual genera una resonancia hipernasal y una emisión nasal de aire en los sonidos orales. Al respecto, en la literatura existen diversas propuestas para la evaluación perceptual de la IVF. Por esto, el objetivo del presente estudio es describir la evaluación perceptiva auditiva de la insuficiencia velofaríngea, mediante una revisión integradora de literatura. Para ello, en mayo de 2020 las bases de datos electrónicas PUBMED, LILACS, SciELO y Cochrane, fueron consultadas utilizando las palabras claves en inglés: "Velopharyngeal Sphincter", "Velopharyngeal Insufficiency", "Cleft Palate", "Speech Intelligibility", "Speech Production Measurement", "Speech Articulation Tests" y "Speech-Language Pathology" y sus respectivos equivalentes en portugués y español. Se seleccionaron artículos originales relacionados al tema, y se creó un protocolo específico para la extracción de los datos. En total se encontraron 2.385 artículos. De ellos, 2.354 fueron excluidos por el título, 13 por el resumen y 3 luego de la lectura del texto completo. Finalmente, a partir de la metodología desarrollada, en esta revisión fueron utilizados 33 artículos. A partir de la revisión realizada se concluye que los parámetros más utilizados en la evaluación son la hipernasalidad, la emisión nasal y la articulación compensatoria asociada a IVF. Estos parámetros son evaluados principalmente en oraciones, habla espontánea y palabras, por un fonoaudiólogo experto, en vivo y mediante grabaciones de audio.

Secondary Velopharyngeal insufficiency (VPI) to cleft palate corresponds to the incomplete closure of the velopharyngeal mechanism during speech, due to lack of tissue in the soft palate or the walls of the pharynx, which generates a hypernasal resonance and nasal air emission in oral sounds. In this regard, there are various proposals in the literature for the perceptual evaluation of VPI. For this reason, the objective of the present study is to describe the auditory perceptual evaluation of velopharyngeal insufficiency, through an integrative literature review. To this end, in May 2020 the electronic databases PUBMED, LILACS, SciELO and Cochrane were consulted using the key words in English: "Velopharyngeal Sphincter", "Velopharyngeal Insufficiency", "Cleft Palate", "Speech Intelligibility", "Speech Production Measurement", "Speech Articulation Tests" and "Speech-Language Pathology", and their equivalent properties in Portuguese and Spanish. Original articles related to the topic were selected, and a specific protocol for data extraction was created. In total, 2,385 articles were found. Of these, 2,354 were excluded due to the title, 13 due to the abstract and 3 after reading the full text. Finally, based on the methodology developed, 33 articles were used in this review. From the review carried out, it is concluded that the parameters most used in the evaluation are hypernasality, nasal emission and the compensatory joint associated with IVF. These parameters are evaluated mainly in sentences, spontaneous speech and words, by an expert speech therapist, live and through audio recordings.

Effects of velopharyngeal openings on flow characteristics of nasal emission.

Nasal emission is a speech disorder where undesired airflow enters the nasal cavity during speech due to inadequate closure of the velopharyngeal valve. Nasal emission is typically inaudible with large velopharyngeal openings and very distorting with small openings. This study aims to understand how flow characteristics in the nasal cavity change as a function of velopharyngeal opening using computational fluid dynamics. The model is based on a subject who was diagnosed with distorting nasal emission and a small velopharyngeal opening. The baseline geometry was delineated from CT scans that were taken, while the subject was sustaining a sibilant sound. Modifications to the model were done by systematically widening or narrowing the velopharyngeal opening while keeping the geometry constant elsewhere. Results show that if the flow resistance across the velopharyngeal valve is smaller than resistance across the oral constriction, flow characteristics such as velocity and turbulence are inversely proportional to the size of the opening. If flow resistance is higher across the velopharyngeal valve than the oral constriction, turbulence in the nasal cavity will be reduced at a higher rate. These findings can be used to generalize that the area ratio of the velopharyngeal opening to the oral constriction is a factor that determines airflow characteristics and subsequently its sound during production of sibilant sound. It implies that the highest level of turbulence in the nasal cavity, and subsequently the sound that will likely be perceived as the most severe nasal emission is produced when the size of openings is equal.

Spectrum Effects of a Velopharyngeal Opening in Singing.

The question whether or not a velopharyngeal opening is advantageous in singing has been discussed for a very long time among teachers of singing. The present investigation analyzes the acoustic consequences of a large, a narrow, and a nonexistent velopharyngeal opening (VPO). A divided flow mask (nasal and oral) connected to flow transducers recorded the nasal and oral DC flows in four female and four male classically trained singers while they sang vowel sequences at different pitches under these three experimental conditions. Acoustic effects were analyzed in three long-term average spectra parameters: (i) the sound level at the fundamental frequency, (ii) the level of the highest peak below 1 kHz, and (iii) the level of the highest peak in the 2-4 kHz region. For a narrow VPO, an increase in the level of the highest peak in the 2-4 kHz region was observed. As this peak is an essential voice component in the classical singing tradition, a narrow VPO seems beneficial in this type of singing.

The ancient practice of sutra neti leading to velopharyngeal stenosis: case report.

BACKGROUND: An ancient yoga technique called sutra neti, which is extensively used in India to keep the sinuses healthy, led to complete velopharyngeal stenosis in a 67-year-old male patient who presented with bilateral nasal obstruction, mouth breathing, anosmia and a change in voice. METHOD: The patient was diagnosed by nasal endoscopy using a zero-degree Hopkins rod endoscope, and adhesions were released using coblation. RESULTS: The patient had post-operative alleviation of symptoms and a patent velopharyngeal inlet on examination. CONCLUSION: Vigorous sutra neti can lead to velopharyngeal stenosis. Release of the stenosis is then required to cure the nasal blockade.

Voz hipernasal y regurgitación nasal aguda: reporte de un caso clínico y revisión de la literatura / Hypernasal speech and acute nasal regurgitation: a case report and a review of the literature

RESUMEN La voz hipernasal y la regurgitación nasal son síntomas de disfunción velofaríngea. Ésta puede tener múltiples causas: anatómicas, neurológicas o funcionales. Se describe el caso de una paciente de sexo femenino, de 13 años, que se presenta con voz hipernasal y regurgitación nasal aguda. Al examen físico se evidencia inmovilidad del velo del paladar derecho sin otros hallazgos neurológicos. El estudio con resonancia nuclear magnética de cerebro y punción lumbar fueron normales. Se diagnosticó una incompetencia velofaríngea aguda transitoria, de probable etiología viral. La paciente evolucionó de forma favorable con mejoría clínica progresiva. La incompetencia velofaríngea a causa de una paresia o parálisis del nervio vago y/o nervio glosofaríngeo es una causa poco frecuente de disfunción velofaríngea.

ABSTRACT Hypernasal speech and nasal regurgitation are symptoms of velopharyngeal dysfunction. This may have multiple causes, including velopharyngeal incompetence due to paresis or paralysis of the vagus nerve and/or glossopharyngeal nerve. We describe the case of a 13 year-old female patient, with hypernasal speech and acute nasal regurgitation, with a physical examination showing immobility of the right palate with no other neurological findings. Magnetic resonance imaging of the brain and lumbar puncture was normal. Transient acute velopharyngeal incompetence was diagnosed, probably of viral etiology. The patient evolved favorably with progressive clinical improvement. Velopharyngeal incompetence due to paresis or paralysis of the vagus and/or glossopharyngeal nerves is a rare cause of velopharyngeal dysfunction.

Analysis of Velopharyngeal Functions Using Computational Fluid Dynamics Simulations.

OBJECTIVES: Competent velopharyngeal (VP) function is the basis for normal speech. Understanding how VP structure influences the airflow during speech details is essential to the surgical improvement of pharyngoplasty. In this study, we aimed to illuminate the airflow features corresponding to various VP closure states using computed dynamic simulations. METHODS: Three-dimensional models of the upper airways were established based on computed tomography of 8 volunteers. The velopharyngeal port was simulated by a cylinder. Computational fluid dynamics simulations were applied to illustrate the correlation between the VP port size and the airflow parameters, including the flow velocity, pressure in the velopharyngeal port, as well as the pressure in oral and nasal cavity. RESULTS: The airflow dynamics at the velopharynx were maintained in the same velopharyngeal pattern as the area of the velopharyngeal port increased from 0 to 25 mm2. A total of 5 airflow patterns with distinct features were captured, corresponding to adequate closure, adequate/borderline closure (Class I and II), borderline/inadequate closure, and inadequate closure. The maximal orifice area that could be tolerated for adequate VP closure was determined to be 2.01 mm2. CONCLUSION: Different VP functions are of characteristic airflow dynamic features. Computational fluid dynamic simulation is of application potential in individualized VP surgery planning.

Retropharyngeal lipostructure in the treatment of velopharyngeal insufficiency: A prospective study and update.

INTRODUCTION: Retropharyngeal lipostructure is a recent procedure in velopharyngeal insufficiency (VPI), offering an effective alternative to heavier surgery. OBJECTIVES: To update and assess retropharyngeal lipostructure as a treatment for VPI in the University Hospital Center of Rouen (France). TYPE OF STUDY: Single-center prospective study, from May 2012 to May 2014. PATIENTS AND METHODS: Six patients (4 girls, 2 boys) presenting with VPI were treated by retropharyngeal lipostructure. Age at surgery ranged between 6 and 12 years. Four of the patients bore a 22q11 microdeletion. Treatment was indicated in case of Borel-Maisonny type 2b (n=2) or 2m (n=4) despite well-conducted speech therapy and of≥50% velopharyngeal sphincter closure on nasal endoscopy. Patients were assessed preoperatively and at 3 months, by a multidisciplinary team. Borel-Maisonny type was assessed by a speech therapist. Nasality was measured on assisted vocal evaluation (EVA®). Sphincter closure was assessed on dynamic MRI. RESULTS: Between 6 and 8cm3autologous fat was injected. At 3months, 4 children showed 1-grade improvement in Borel-Maisonny type. Nasality decreased systematically, from a mean 14.5% preoperatively to 10.5% postoperatively. MRI showed improvement in all cases, with complete closure in occlusive vowels in 3 children. CONCLUSION: EVA® and MRI provide precise objective assessment of VPI. Retropharyngeal lipostructure is a simple, relatively non-invasive, reproducible technique, providing good results in VPI.

Comparison of three different surgical techniques for designing pharyngeal flaps according to findings of videonasopharyngoscopy and multiplanar videofluoroscopy.

BACKGROUND: Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter (VPS) is unable to completely seal anatomical closure between the nasal and oral cavities during speech. Palatal repair can restore VPS function but the prevalence of VPI after repair has been reported ranging from 20% to 40%. The combination of flexible videonasopharyngoscopy (FVNP) and multiplanar videofluoroscopy (MPVF) has been reported as the best approach for assessing the VPS mechanism and planning effective surgical procedures aimed to correct VPI. OBJECTIVE: To study the outcome of three different techniques for performing pharyngeal flaps with the common denominator of individually designing the flap according to findings of VFNP and MPVF. MATERIAL AND METHODS: A total of 140 cases of pharyngeal flap surgery were reviewed. Three surgeons performed 3 different surgical techniques. All cases underwent nasometry, VNP and MPVF preoperatively. All surgical procedures were carefully planned and designed according to findings of VNP and MPVF. RESULTS: Nasal emission was completely eliminated in all cases. One-hundred-thirty-four patients (95%) demonstrated mean nasalance within normal limits after the surgical procedure whereas 6 patients persisted with mean nasalance scores above reference values postoperatively. There were no intraoperative or postoperative complications in any of the cases. No clinical data of sleep disordered breathing was detected in any of the cases after 2 months of postoperative follow-up. However, one case presented with clinical data of sleep disordered breathing 8 months postoperatively. CONCLUSIONS: The results of this study suggest that as long as pharyngeal flaps are being designed according to the findings of imaging procedures, different surgical techniques can provide similar successful outcomes with minimal complications.

Palatal Sphincter Pharyngoplasty With Cephalic Mucosa Preservation in Selected Cases of Velopharyngeal Insufficiency.

OBJECTIVES: Sphincter pharyngoplasty is a commonly performed procedure for the treatment of velopharyngeal insufficiency and is often indicated in patients with circular or coronal closure patterns of the velopharyngeal sphincter. The authors present a modified technique of sphincter pharyngoplasty (partially mucosalized palatal sphincter pharyngoplasty [PMPSP]) in which bilateral superiorly based myomucosal palatopharyngeal flaps were elevated (in a newly designed fashion) and inserted in the palate through preformed palatal tunnels. METHODS: This case series included 14 patients (5 male, 9 female) with persistent hypernasality who were subjected to treatment by PMPSP between May 2015 and August 2018. The palatopharyngeal flap was designed to be full thickness at its caudal segment, while its cephalic segment was denuded of its mucosa. The cephalic mucosa (of the flap) was elevated off the bed muscles as a medially based mucosa flap to be used at the end of the procedure to drape the upper part of the bed. RESULTS: Pain assessed using a visual analog scale had decreased significantly at day 10 after surgery, and normal oral feeding was regained within 7 to 10 days. No major complications were recorded. Postoperative nasoendoscopic and phoniatric assessments were reported. Statistically significant improvements were reported when comparing pre- versus postoperative auditory perceptual assessment following PMPSP. CONCLUSIONS: The newly reported PMPSP might be a useful technique for correction of velopharyngeal insufficiency in patients with weak palatal motion (coronal or circular pattern of velopharyngeal sphincter closure). PMPSP had good reported surgical and phoniatric outcomes.

22q11.2 Deletion: Surgical and Speech Outcomes of Patients With Velopharyngeal Insufficiency Treated With a Superiorly Based Pharyngeal Flap as the Primary Surgery.

The most frequent palate diagnoses in patients with chromosome 22q11.2 deletion syndrome are a classic submucous cleft, occult, and velopharyngeal insufficiency without cleft, which generates alterations in speech that require surgery. Surgical protocols are controversial owing to syndrome characteristics that make their handling more complex. Pharyngeal flap pharyngoplasty is effective for this type of patient. The objective of this study is to examine the surgical management of velopharyngeal insufficiency in patients with chromosome 22 deletion, using a pharyngeal flap as the primary surgery. The clinical records of patients with chromosome 22 deletion and velopharyngeal insufficiency between 2015 and 2017 were analyzed retrospectively. Eight patients underwent pharyngeal flap pharyngoplasty as a primary surgery, including 1 with velopharyngeal insufficiency without a cleft, 1 with a classic submucous cleft, and 6 with occult submucous cleft. The pre- and postoperative protocol performed by speech therapists and surgeons included clinical evaluation of the oral cavity; perceptual, video recording, and nasometry speech evaluation; and videonasopharyngoscopy. All perceptual parameters and nasometry results significantly changed. Of the cases, 88% achieved a flap with the expected width and height and complete closure of the velopharyngeal sphincter. One patient required flap revision. Four of the 8 patients achieved normal resonance, and 2 of 8 showed mild hypernasality. Using the pharyngeal flap pharyngoplasty as a primary technique to correct velopharyngeal insufficiency in patients with chromosome 22 deletion provides satisfactory outcomes and decreases the number of surgeries. Preoperative planning must be conducted carefully and needs to be individualized to be successful.

Evaluating the Accuracy of Using at Rest Images to Determine the Height of Velopharyngeal Closure.

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.

Structural Changes Following Velopharyngeal Resistance Training (Continuous Positive Airway Pressure Therapy): A Preliminary Report.

OBJECTIVE: To evaluate the feasibility/effectiveness of using magnetic resonance imaging (MRI) to document velopharyngeal (VP) structural changes induced by continuous positive airway pressure (CPAP) therapy. OUTCOME MEASURES: Changes in velar length and thickness, levator veli palatini (LVP) length and thickness, velar volume, and intravelar muscular proportion along the course of CPAP therapy participation (Pre-CPAP, Post-CPAP, and withdrawal). RESULTS: Velar and LVP lengths remained nearly the same, with the median changes (Δ) less than 0.6%, across repeated conditions. Although varying in magnitudes of change, median velar volume (Δ4%), velar thickness (Δ20%), LVP thickness (Δ17%), and intravelar muscular proportion (Δ10%) illustrated a consistent pattern of increases following the 8-week CPAP therapy. These VP structural measurements slightly decreased but remained above the pretraining condition after 8-week detraining. CONCLUSIONS: This report successfully demonstrated that MRI is a viable tool to document CPAP therapy-induced VP structural changes while providing preliminary empirical data.

Avaliação do efeito imediato de exercício de trato vocal semiocluído no mecanismo velofaríngeo em cinco portadores de fissura labiopalatina: estudo piloto / Assessment of the immediate effect of a semi-occluded vocal tract exercise on velopharyngeal mechanism in five patients with cleft lip and palate: pilot study

Introdução: As fissuras labiopalatinas não sindrômicas estão incluídas entre as malformações craniofaciais severas mais frequentes na população humana. O indivíduo acometido pode apresentar alterações no mecanismo velofaríngeo, comprometendo-se assim a inteligibilidade da fala. O objetivo deste estudo foi analisar o efeito imediato do exercício de trato vocal semiocluído no mecanismo velofaríngeo de pacientes com fissura labiopalatina. Métodos: A amostra foi composta por cinco sujeitos com fissura labiopalatina reparada cirurgicamente submetidos a avaliação multidimensional, de videonasofibroscopia, análise das imagens dinâmicas por meio de software especializado e análise de fala por meio da avaliação perceptivoauditiva e parecer autorreferido. Resultados: Todos os pacientes apresentaram melhora na fala encadeada após o exercício, melhora acentuada na impressão geral da emissão e projeção vocal, maior fechamento velofaríngeo e efeito positivo na autoavaliação. Conclusão: Observou-se efeito positivo do exercício de trato vocal semiocluído quando aplicado nessa amostra.