Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study

Ten patients with hard palate fistulas and velopharyngeal incompetence were examined cineradiographically with lateral and frontal projections during connected speech. The purpose was to study velopharyngeal function for open versus covered fistulas. Fistula length, width, and size were measured. With an open fistula, the degree of lateral pharyngeal wall activity was significantly correlated at the 0.05 level to fistula size. There was no statistically significant correlation between fistula size and the degree of velar activity. With the fistula covered, the velopharyngeal movements improved or even normalized in all patients regardless of fistula size. These findings indicate that patients with both velopharyngeal incompetence and an additional fistula will need covering of the fistula. If velopharyngeal incompetence persists after a temporary covering of the fistula, a combination of velopharyngeal flap surgery and fistula covering ought to be performed to normalize the velopharyngeal activity and speech and resonance.     

Levator repositioning and palatal lengthening for submucous clefts

Submucous clefts of the palate may present with velopharyngeal incompetence (VPI) or a history of recurrent otitis media. Many surgeons have favored a pharyngeal flap as primary treatment of the velopharyngeal incompetence associated with this disorder. The increasing number of case reports of sleep apnea and airway compromise associated with pharyngeal flaps prompted the use of levator muscle repositioning with palatal lengthening as initial therapy in 15 patients in an attempt to correct the pathologic anatomy while avoiding the postoperative sequelae. Patients were divided into two groups: group A (N = 8) had surgery before age 2 (11.8 +/- 5.7 months), and group B (N = 7) had surgery after 2 years of age (64.3 +/- 24.2 months). No patient in group A required a secondary operative procedure for velopharyngeal incompetence. Normal speech was obtained in 75 percent (N = 6), and slight velopharyngeal incompetence not requiring secondary correction was obtained in 25 percent (N = 2). Group B obtained less dramatic speech results: normal in 14 percent (N = 1), slight velopharyngeal incompetence in 58 percent (N = 4), and no improvement or severe velopharyngeal incompetence requiring a secondary procedure in 28 percent (N = 2). Patients with preoperative otologic disorders (N = 10) obtained significant improvement in 90 percent of cases (p = 0.002). Early surgical intervention in patients with abnormal speech prior to age 2 appears to result in normal speech in the majority of instances. Late repair with levator repositioning and palatal lengthening provided improved speech in 72 percent of patients.     

A single surgeon's experience with the Delaire palatoplasty

The purpose of this review was to evaluate the clinical outcomes regarding velopharyngeal insufficiency and fistulization in patients with cleft palate who underwent primary repair with the one-stage Delaire palatoplasty. All patients who had a primary Delaire-type palatoplasty performed by the senior surgeon over a 10-year period (1988 to 1998) were studied. During this period, each consecutive patient with an open palatal cleft underwent the same type of repair by the same surgeon. Speech quality and velopharyngeal competence as determined by a single speech pathologist were recorded. A total of 95 patients were included in this series. The average length of follow-up was 31 months (range, 1 to 118 months). Average age at time of surgery was 13.3 months (range, 6 to 180 months). Thirty-one patients (32.6 percent) had significant associated anomalies. The average length of hospital stay was 1.9 days (range, 1 to 8 days) with a trend in recent years toward discharge on postoperative day 1. There were no intraoperative complications, either surgical or anesthetic. Three patients (3.2 percent) developed palatal fistula; none of them required repair. Six patients (6.3 percent) had velopharyngeal incompetence. In patients with more than 1 year of follow-up, the incidence of velopharyngeal incompetence was 9.2 percent (6 of 65). The incidence of fistula after the Delaire palatoplasty was lower than usually reported. The incidence of velopharyngeal incompetence requiring pharyngoplasty was equal to or lower than that seen after other types of palatoplasty, suggesting superior soft-palate muscle function attributable to approximation of the musculus uvulae. The Delaire palatoplasty results in a functional palate with low risk for fistula formation and velopharyngeal incompetence.     

Implant-supported palatal lift prosthesis in a patient with velopharyngeal incompetence: a case report

doi: 10.1111/j.1741‐2358.2011.00561.x Implant‐supported palatal lift prosthesis in a patient with velopharyngeal incompetence: a case report Objective: To describe the use of dental implants in the treatment of velopharyngeal incompetence. Background: Velopharyngeal incompetence is characterized by the inability to contract the tissues of the soft palate. The most common causes are neuromuscular problems resulting from concussion and degenerative conditions of the central nervous system. Materials and methods: The treatment using palatal lift prosthesis is well established in the literature; however, reports on the use of osseointegrated implants are scarce. Rehabilitation using only this type of fibromucosal support is difficult in edentulous patients, since the prosthesis has a palatal lift extension. Results: The implants provided retention and stability to the prosthesis, improving swallowing and speech and contributing to improve the patient’s quality of life. Conclusion: This article reports the rehabilitation of a patient with a totally edentulous maxilla with velopharyngeal incompetence using an implant‐retained palatal lift prosthesis.     

Velopharyngeal incompetence without overt cleft palate. A collective review and experience with 98 patients.

Our experience in patients with velopharyngeal incompetence but without overt cleft palate is described, and the literature is reviewed.     

Velopharyngeal incompetence: a guide for clinical evaluation

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.     

Readaptation of the velopharyngeal valve following the uvulopalatopharyngoplasty operation

We have studied the mechanism of velopharyngeal valving in 27 patients undergoing uvulopalatopharyngoplasty for obstructive sleep apnea before and after surgery. The patients were assessed by peroral examination and nasendoscopy. Our observations and findings of the readaptation process of the velopharyngeal valve following the operation show us that its different closure patterns are due to a variable anatomy. A certain compensatory mechanism is possible mainly in the circular pattern and the circular pattern with Passavant's ridge and sagittal patterns. Passavant's ridge is an anatomic variant rather than a compensatory mechanism. The muscularis uvulae is important mainly in nonphonetic activities of the velopharyngeal valve. This information is important for clinical purposes in order to better correct problems associated with velopharyngeal incompetence.     

Collaboration of a dentist and speech-language pathologist in the rehabilitation of a stroke patient with dysarthria: a case study

Objective: To elucidate the effectiveness of the collaboration of a dentist and speech‐language pathologist (SLP) in the rehabilitation of a stroke patient with dysarthria. Design: A clinical case report treated in the rehabilitation hospital and dental surgery. Subject: A 71‐year‐old Japanese man who was admitted to the rehabilitation hospital for speech rehabilitation 2 years and 5 months after a stroke. Methods: Provision of prosthesis (palatal lift prosthesis + palatal augmentation prosthesis) for improving velopharyngeal incompetence (VPI) and articulation by dentist, and speech behavioural management by SLP including self‐monitoring and bio‐feedback training using the See‐Scape. Results: Speech behavioural management proved useful for promoting improvement in speech intelligibility to a functionally sufficient level after improving VPI by prosthesis. Conclusion: The collaborative efforts of the dentist and SLP in the rehabilitation of post‐stroke patients with velopharyngeal incompetence should be encouraged.     

Velopharyngeal function following maxillary advancement.

In a series of 40 patients who had maxillary advancements, none developed velopharyngeal incompetence. Unlike the cleft palate patient who is more at risk, there are distinct anatomical characteristics in craniofacial dysostosis which favor maintenance of the integrity of the velopharyngeal mechanism. Hyponasality was eliminated in 5 patients with Crouzon's disease. On cephalometric study, it was observed that after maxillary advancement the nasopharyngeal volume was expanded and the angle formed by the hard and soft palates was increased. On phonating cephalograms, the velopharyngeal contact became more physiological after maxillary advancement in the craniofacial dysostosis patient. The only postoperative articulatory changes after maxillary advancement were in the production of the /s/ sound, which is particularly sensitive to changes in dentoalveolar relationships.     

Hynes pharyngoplasty revisited

The treatment of velopharyngeal incompetence remains unsatisfactory because the causes are many, as are the variations in anatomic and physiologic defects. Therefore, full assessment and investigation are essential in tailoring the surgery to the defect. A modified Hynes pharyngoplasty has been used in 40 patients, aged 4 to 52, over a 4-year period for velopharyngeal incompetence of varying etiologic causes. Speech was assessed before and at least 6 months after pharyngoplasty. At the same time, radiologic and, when possible, nasendoscopic investigations were undertaken. Thirty-eight patients had no or variable nasal escape (variable defined as achieving intermittent closure), whereas 33 had normal or slight hyponasal resonance. There was only one complication, an asymptomatic dehiscence of the "bucket handle" flap from the posterior wall. Thirteen patients had an assortment of side effects, none requiring surgical treatment. We believe that patients who are suitable for the described sphincter pharyngoplasty are those with slight or moderate nasal escape having a mobile palate with an anteroposterior gap of 5 mm or less.     

Pharyngeal flap surgery: long-term outcomes at the University of Iowa

The pharyngeal flap is the most often used surgical approach to treat the problem of velopharyngeal insufficiency, a common challenge encountered in cleft palate and craniofacial clinics. The authors retrospectively reviewed short-term and long-term measures of children treated with the pharyngeal flap at the University of Iowa Cleft and Craniofacial Center. All patients who underwent pharyngeal flap surgery between January of 1970 and December of 2000, with at least one postoperative speech assessment between 2 and 5 years after the operation, were identified. Both hypernasality and hyponasality were evaluated on a scale from 1 to 6, with 1 indicating no involvement and 6 indicating severe effect on resonance. Velopharyngeal competence was also rated on a scale of 1 to 3, with 1 indicating competence and 3 indicating incompetence. These short-term data were then compared. The results showed that overall resonance performance continues to be adequate and may even improve as the patient continues to grow and mature. These findings support the use of the pharyngeal flap in the treatment of children with velopharyngeal insufficiency.     

Use of the pharyngeal flap in the treatment of congenital velopharyngeal incompetence

Seventy-four patients were referred to the senior author because of presumed velopharyngeal incompetence without cleft palate. As a result of an extensive preoperative evaluation that included assessment of articulation patterns, nasal emission, oronasal resonance, and general speech intelligibility, 57 of the 74 patients were selected for a pharyngeal flap procedure. In 54 of the 57 patients (95 percent), the operation corrected inappropriate nasal emission and hypernasality and improved intraoral air pressure to allow normal speech production.     

Levator muscle reconstruction: resulting velopharyngeal competence--a preliminary report

The purpose of this study was to evaluate a levator muscle reconstruction procedure on the basis of resulting velopharyngeal competence. Ages of the patients at time of surgery ranged from 5 months to 7 years. The patients were reevaluated postoperatively. If the patients were judged to have normal nasality and no nasal emission, the procedure was considered to have yielded a satisfactory result. If hypernasality and nasal emission resulted, the patients were examined utilizing nasoendoscopy and/or videofluoroscopy. If velopharyngeal incompetence was confirmed, the operative procedure was judged to be successful. Results showed that 60 percent success was achieved. The age range which yielded the best results (73 percent satisfactory) was 37 to 60 months. The data also revealed that the more severe the cleft, the less likely this operative procedure is to produce satisfactory results. The authors recommend continued evaluation of this procedure, preferably utilizing prospective studies.     

Late results of primary veloplasty: the Marburg Project

Forty-five randomly selected patients with unilateral cleft lip, alveolus, and palate, all operated upon by Dr. Wolfram Schweckendiek were evaluated by three American specialists to assess the validity of primary veloplasty. Examination revealed an unusually high incidence of short palate and poor mobility of the soft palate. Facial growth was found to be highly acceptable in the majority of the patients. Unusually high incidence of velopharyngeal incompetence was found in these patients.     

Augmentation of the failed pharyngeal flap.

Pharyngeal flaps are frequently used with good results to eliminate hypernasality and/or nasal escape. In a small percentage of patients, however, cicatricial contracture of the flap occurs to such a degree that velopharyngeal incompetence returns. The authors have devised a method of augmenting the scarred flap with small, superiorly based flaps lateral and adjacent to the original flap. Four cases are presented in which speech analysis was conducted prior to the procedure and then for 9 to 24 months postoperatively. The postoperative speech results are all within normal limits.     

Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties

Residual velopharyngeal insufficiency after palatal repair varies from 10 to 20 percent in most centers. Secondary velopharyngeal surgery to correct residual velopharyngeal insufficiency in patients with cleft palate is a topic frequently discussed in the medical literature. Several authors have reported that varying the operative approach according to the findings of videonasopharyngoscopy and multiview videofluoroscopy significantly improved the success of velopharyngeal surgery. This article compares two surgical techniques for correcting residual velopharyngeal insufficiency, namely pharyngeal flap and sphincter pharyngoplasty. Both techniques were carefully planned according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. Fifty patients with cleft palate and residual velopharyngeal insufficiency were randomly divided into two groups: 25 in group 1 and 25 in group 2. Patients in group 1 were operated on by using a customized pharyngeal flap according to the findings of videonasopharyngoscopy and multiview videofluoroscopy in each case. Those in group 2 received a sphincter pharyngoplasty also customized according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients in both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after the individualized velopharyngeal surgery was not significantly different between the patient groups (12 percent versus 16 percent; p > 0.05). It seems that customized pharyngeal flaps and sphincter pharyngoplasties performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy are safe and reliable procedures for treating residual velopharyngeal insufficiency in cleft palate patients.     

Does velopharyngeal closure pattern affect the success of pharyngeal flap pharyngoplasty?

Historically at The Hospital for Sick Children in Toronto, pharyngeal flap pharyngoplasty has been the treatment of choice for treatment of velopharyngeal insufficiency, regardless of velopharyngeal closure pattern. The authors hypothesize that pharyngeal flap pharyngoplasty is more effective in treating velopharyngeal insufficiency in patients with circular or sagittal velopharyngeal closure and less effective in treating the coronal closure pattern. Ninety-three patients who underwent superiorly based pharyngeal flap surgery for velopharyngeal insufficiency were evaluated in a retrospective chart review. Closure pattern was determined preoperatively by nasopharyngoscopy or multiview videofluoroscopy. Nasalance was assessed preoperatively and at 6 weeks and 1 year postoperatively. Nasalance during nonnasal speech was decreased on average, for all closure patterns, postoperatively. However, a significantly higher percentage of patients were corrected to normal nasalance scores in thenoncoronal group than in the coronal group (57 percent versus 35 percent, respectively) at 1 year postoperatively (p < 0.05). Surgical overcorrection, as determined by postoperative hyponasality, occurred at a rate of 13 percent in the coronal group versus 7 percent in the noncoronal group (not statistically significant). The results demonstrate that hypernasality in patients with a coronal velopharyngeal closure pattern can be improved by pharyngeal flap pharyngoplasty. This procedure, however, is more frequently effective in correcting noncoronal closure pattern velopharyngeal insufficiency than coronal pattern velopharyngeal insufficiency. The authors are now more selective in their approach to the management of velopharyngeal insufficiency and are more inclined to treat coronal pattern velopharyngeal insufficiency with sphincter pharyngoplasty.     

Surgical treatment of submucous cleft palate: a comparative trial of two modalities for palatal closure

Submucous cleft palate is a congenital malformation with specific clinical and anatomical features. It can be present with or without velopharyngeal insufficiency. Surgical treatment of this malformation is indicated only when velopharyngeal insufficiency has been demonstrated. This article compares two modalities of surgical treatment for submucous cleft palate. The first includes a minimal incision palatopharyngoplasty, as described in a previous report. The second combines the first technique with additional individualized velopharyngeal surgery (individualized pharyngeal flap or sphincter pharyngoplasty) performed simultaneously. The individualized part of the procedure was selected and performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy, as reported previously. Two hundred and three patients with submucous cleft palate were studied from 1990 to 1999. Videonasopharyngoscopy and multiview videofluoroscopy demonstrated velopharyngeal insufficiency in 72 patients, who were randomly divided into two groups. Those in group 1 (n = 37) underwent a minimal incision palatopharyngoplasty. Patients in group 2 (n = 35) also underwent that procedure but simultaneously received individualized pharyngeal flap or sphincter pharyngoplasty, according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients from both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after palatal closure was not significantly different in both groups of patients (14 percent versus 11 percent; p > 0.5). The mean size of the gap at the velopharyngeal sphincter during speech was not significantly different in both groups of patients before surgery (23 percent versus 22 percent; p > 0.5). After the surgical procedures, there was a nonsignificant difference between both groups of patients in mean residual size of the gap in cases of velopharyngeal insufficiency (7 percent versus 8 percent; p > 0.5). It seems that minimal incision palatopharyngoplasty is a safe and reliable procedure for palatal closure in patients with submucous cleft palate. The use of additional individualized velopharyngeal surgery performed simultaneously did not seem to decrease the frequency of residual velopharyngeal insufficiency. Moreover, the residual size of the gap at the velopharyngeal sphincter was not significantly reduced when an additional surgical procedure was performed simultaneously with palatal closure.     

The modified buccal musculomucosal flap method for cleft palate surgery

We have reported previously on a palatoplasty method, called the T-shaped musculomucosal buccal flap method, for the primary repair of a cleft palate. This method has been used on more than 90 patients, and satisfactory outcomes have resulted in terms of maxillar development, the prevention of fistulation, and verbal functions. However, 14.3 percent of these patients exhibited a velopharyngeal incompetence that showed no potential improvement through training. In the majority of these patients, the entire raw surface of the oral cavity side could not be covered with a buccal musculomucosal flap, and as a result, postoperative contraction of the soft palate occurred. Thus a new surgical method has proven effective in which both buccal musculomucosal flaps are used as an oral lining, the nasal mucosa having been extended by Z-plasty. We have performed 25 operations using this new method and have observed no postoperative contractions of the soft palate, notwithstanding two cases (8.0 percent) of postoperative fistulation.     

Cleft-palate repair by modified Furlow double-opposing Z-plasty: the Children's Hospital of Philadelphia experience

Although the optimal technique of cleft-palate repair remains controversial, several small series have suggested that superior speech results may be obtained with the Furlow double-opposing Z-plasty. To examine speech outcome in a large series of Furlow palatoplasties performed at a single center, we retrospectively reviewed the records of 390 cleft-palate patients who underwent Furlow palatoplasty at The Children's Hospital of Philadelphia from 1979 to 1992. Speech outcome at 5 years of age or greater was available for 181 nonsyndromic patients and was scored using the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence. No or mild hypernasality was noted in 93.4 percent of patients, with 88.4 percent demonstrating no or inaudible nasal escape and 97.2 percent demonstrating no errors in articulation associated with velopharyngeal incompetence. Secondary pharyngeal flap surgery was required in just 7.2 percent of patients. Age at palatoplasty, cleft type, and experience of the operating surgeon had no significant effect on speech results, although there was a trend toward better outcome in those undergoing palatal repair before 6 months of age and toward poorer outcome in those with Veau class I and II clefts. Overall, Furlow palatoplasty yielded outstanding speech results, with rates of velopharyngeal dysfunction that seem to improve upon those reported for other techniques.