Surgical Considerations and Choices in the Management of Velopharyngeal Dysfunction

2015 ◽  
Vol 25 (2) ◽  
pp. 54-65 ◽  
Author(s):  
John Jensen ◽  
Michael VanLue
Keyword(s):  
Surgical Technique ◽  
Cleft Palate ◽  
Comprehensive Evaluation ◽  
Surgical Techniques ◽  
Speech Language Pathologist ◽  
Imaging Results ◽  
History Of ◽  
Pharyngeal Flap ◽  
Sphincter Pharyngoplasty ◽  
Velopharyngeal Function

Determining the type of secondary surgical management to treat velopharyngeal dysfunction requires the incorporation of surgical indications and principles to the perceptual, acoustic/airflow, and imaging results of a comprehensive evaluation by a speech-language pathologist. In addition, how the specific type of surgical technique (primary and/or secondary) may affect velopharyngeal function also should be considered. The purpose of this paper is to consider three standard techniques commonly employed in speech surgery—Pharyngeal Flap; Sphincter Pharyngoplasty; and Furlow Double Opposing Z-Plasty—and provide examples of the specific imaging parameters that support the choice of surgical technique. In addition, information is provided regarding the characteristics of different primary surgical techniques for cleft palate which can influence velopharyngeal closure, given that the most common cause of velopharyngeal dysfunction seen in the clinic is a patient with a history of repaired cleft palate.

Velopharyngeal Function in Nonsyndromic Cleft Palate: Relevance of Surgical Technique, Age at Repair, and Cleft Type

1998 ◽  
Vol 35 (2) ◽  
pp. 95-100 ◽  
Author(s):  
Eileen M. Marrinan ◽  
Richard A. Labrie ◽  
John B. Mulliken
Keyword(s):  
Surgical Technique ◽  
Cleft Palate ◽  
Cleft Lip ◽  
Velopharyngeal Insufficiency ◽  
Significant Variable ◽  
Muscle Complex ◽  
Cleft Lip Palate ◽  
Pharyngeal Flap ◽  
Velopharyngeal Function ◽  
Repair Group

Objective The goal of this study was to determine the relative importance of surgical technique, age at repair, and cleft type for velopharyngeal function. Design This was a retrospective study of patients operated on by two surgeons using different techniques (von Langenbeck and Veau-Wardill-Kilner [VY]) at Children's Hospital, Boston, MA. Patients We included 228 patients who were at least 4 years of age at the time of review. Patients with identifiable syndromes, nonsyndromic Robin sequence, central nervous system disorders, communicatively significant hearing loss, and inadequate speech data were excluded. Main Outcome Measure Need for a pharyngeal flap was the measure of outcome. Results Pharyngeal flap was necessary in 14% of von Langenbeck and 15% of VY repaired patients. There was a significant linear association (p = .025) between age at repair and velopharyngeal insufficiency (VPI). Patients with an attached vomer, soft cleft palate (SCP), and unilateral cleft lip/palate (UCLP) had a 10% flap rate, whereas those with an unattached vomer, hard/soft cleft palate (HSCP), and bilateral cleft lip/palate (BCLP) had a 23% flap rate (p = .03). Age at repair was critical for the unattached-vomer group (p = .03) but was not statistically significant for the attached-vomer group (p = .52). Conclusions Surgical technique was not a significant variable either in aggregate or for the Veau types. Patients in the earliest repair group (8-10 months) were the least likely to require a pharyngeal flap. Early repair was more critical for HSCP and BCLP patients. There was no correlation between velopharyngeal insufficiency and Veau hierarchy. The attached vomer/levator muscle complex may be a more important predictor of surgical success than the anatomic extent of cleft.

Instrumental Assessment in Cleft Palate Care

2013 ◽  
Vol 23 (2) ◽  
pp. 49-61 ◽  
Author(s):  
Jamie Perry ◽  
Graham Schenck
Keyword(s):  
Cleft Palate ◽  
New Developments ◽  
Perceptual Evaluation ◽  
Advantages And Disadvantages ◽  
Instrumental Assessment ◽  
Speech Language Pathologist ◽  
Hypernasal Speech ◽  
Perceptual Assessment ◽  
Velopharyngeal Function ◽  
And Function

Despite advances in surgical management, it is estimated that 20–30% of children with repaired cleft palate will continue to have hypernasal speech and require a second surgery to create normal velopharyngeal function (Bricknell, McFadden, & Curran, 2002; Härtel, Karsten, & Gundlach, 1994; McWilliams, 1990). A qualitative perceptual assessment by a speech-language pathologist is considered the most important step of the evaluation for children with resonance disorders (Peterson-Falzone, Hardin-Jones, & Karnell, 2010). Direct and indirect instrumental analyses should be used to confirm or validate the perceptual evaluation of an experienced speech-language pathologist (Paal, Reulbach, Strobel-Schwarthoff, Nkenke, & Schuster, 2005). The purpose of this article is to provide an overview of current instrumental assessment methods used in cleft palate care. Both direct and indirect instrumental procedures will be reviewed with descriptions of the advantages and disadvantages of each. Lastly, new developments for evaluating velopharyngeal structures and function will be provided.

Management of Speech and Swallowing Disorders in Children with Oral Clefts

2019 ◽  
Author(s):  
Ravi K. Garg ◽  
Delora L Mount
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Speech Therapy ◽  
Cleft Lip And Palate ◽  
Treatment Options ◽  
Posterior Pharyngeal Wall ◽  
Diagnostic Tools ◽  
Pharyngeal Wall ◽  
Pharyngeal Flap ◽  
Sphincter Pharyngoplasty

Cleft lip and palate are common congenital anomalies with significant implications for feeding, swallowing, and speech. If a cleft palate goes unrepaired, a child will have difficulty distinguishing nasal and oral sounds. Even following cleft palate repair, approximately 20 to 30% of nonsyndromic children have persistent hypernasal speech. This often occurs due to velopharyngeal dysfunction (VPD), a term describing failure of the soft palate and pharyngeal walls to seal the nasopharynx from the oropharynx during oral consonant production. The gold standard for diagnosis is perceptual examination by a trained speech pathologist, although additional diagnostic tools such as nasendoscopy are often used. Treatment options for VPD range from speech therapy to revision palatoplasty, sphincter pharyngoplasty, pharyngeal flap, and pharyngeal wall augmentation. Palatal prosthetics may also be considered for children who are not surgical candidates. Further research is needed to improve selection of diagnostic and treatment interventions and optimize speech outcomes for children with a history of oral cleft. This review contains 1 figure, 3 videos, and 58 references.  Key words: Cleft lip and palate, hypernasal resonance, levator veli palatine, nasal emission, nasendoscopy, palatoplasty, pharyngeal flap, posterior pharyngeal wall augmentation, sphincter pharyngoplasty, velopharyngeal dysfunction

Objective, Noninvasive Evaluation of Velopharyngeal Function in Cleft and Noncleft Patients

1998 ◽  
Vol 35 (1) ◽  
pp. 35-39 ◽  
Author(s):  
Martin Kunkel ◽  
Ulrich Wahlmann ◽  
Wilfried Wagner
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Cleft Lip And Palate ◽  
Noninvasive Evaluation ◽  
Control Group ◽  
Pharyngeal Muscles ◽  
Pharyngeal Flap ◽  
The Difference ◽  
Acoustic Pharyngometry ◽  
Velopharyngeal Function

Objective The purpose of this study was to investigate a new diagnostic method that provides an approach to noninvasive, objective measurement of velopharyngeal movement by acoustic determination of epipharyngeal volume changes with velopharyngeal muscle function. Design This was a case control study, using consecutive samples. Setting This study took place at the Cleft Palate Rehabilitation Center of the University of Mainz, Germany. Patients Subjects were 29 consecutive cleft lip and palate (CLP) patients and 31 controls (21 patients with dysgnathia and 10 healthy volunteers). Intervention A series of transnasal acoustic measurements (pressure wave: 55 dB for 2 milliseconds) of epipharyngeal volume were performed with the pharyngeal muscles relaxed in end-expiration and while the velopharyngeal orifice was closed, with the difference in volume representing maximal pharyngeal movement. Results Cleft palate patients yielded significantly lower values of velopharyngeal movement (6.5 cm3) than did the control group (8.0 cm3)(p < .05; Mann-Whitney U test). Overlapping ranges of values were measured for the C(L)P and control groups. The least mobility (4.75 cm3) was measured in patients who had undergone pharyngeal flap surgery. Different patterns of restriction were observed in patients with and without a pharyngeal flap. Conclusion Acoustic pharyngometry may provide access to noninvasive quantitative measurement of velopharyngeal movement and a better understanding of the pattern of movement in C(L)P-patients. We expect it to be a helpful tool in objectively monitoring the progress of logopedic therapy.

Salvaging the Failed Pharyngoplasty: Intervention Outcome

1998 ◽  
Vol 35 (5) ◽  
pp. 447-453 ◽  
Author(s):  
Peter D. Witt ◽  
Terry Myckatyn ◽  
Jeffrey L. Marsh
Keyword(s):  
Revisional Surgery ◽  
Care Center ◽  
Surgical Revision ◽  
Flap Failure ◽  
Velopharyngeal Closure ◽  
Cause Of Failure ◽  
Pharyngeal Flap ◽  
Sphincter Pharyngoplasty ◽  
Definition Of ◽  
Velopharyngeal Function

Objective This paper reports on the rates of failure of operations (pharyngeal flap and sphincter pharyngoplasty) performed for management of velopharyngeal dysfunction, and outcome following their revision. Design Anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following pharyngeal flap and sphincter pharyngoplasty were critiqued. The results of primary pharyngeal flap were evaluated for 65 patients, and the results of primary sphincter pharyngoplasty were evaluated for 123 patients. All patients were treated for velopharyngeal dysfunction. The definition of surgical failure was based on persistent hypernasality and/or nasal turbulence on perceptual speech evaluation, and incomplete velopharyngeal closure on instrumental evaluation, at least 3 months postoperatively. Setting All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, a tertiary cleft care center. Patients, Participants All patients had failed surgical management initially, either with pharyngeal flap or sphincter pharyngoplasty, and all underwent repeat preoperative and postoperative perceptual speech evaluations; real-time lateral phonation fluoroscopy including still reference views; and flexible nasendoscopy of the velopharynx using standard speech protocols. Interventions Revisional surgery for both procedures consisted of either tightening of the sphincter pharyngoplasty or pharyngeal flap port(s) or reinsertion of the sphincter pharyngoplasty or pharyngeal flaps following dehiscence. Main outcome Measures The main outcome measure was normalcy of velopharyngeal function, i.e., elimination of perceptual hypernasality and instrumental evidence of complete velopharyngeal closure. The rates of pharyngeal flap failure and sphincter pharyngoplasty failure were determined for those patients requiring surgical revision. Results Thirteen of 65 patients (20%) who underwent primary pharyngeal flap required revisional surgery. Of these 13 patients, eight were managed successfully with a single revisional operation. The remaining five patients (38%) continued to exhibit velopharyngeal dysfunction and underwent a second revision consisting of tightening or augmentation of the lateral ports. Speech results were satisfactory in all patients so treated; however, hyponasality with no other airway morbidity occurred in all five. Twenty of 123 patients (16%) who underwent primary sphincter pharyngoplasty required surgical revision. Of these 20 patients, 17 were managed successfully. For both procedures, the principal cause of failure was partial or complete flap dehiscence. Conclusions Rates of primary pharyngeal flap failure are roughly equivalent to rates of primary sphincter pharyngoplasty failure. Pharyngeal flap and sphincter pharyngoplasty failures can be salvaged with revisional surgery, which can provide a velopharyngeal mechanism capable of complete closure. Revisional surgery is usually associated with denasal speech.

Stress Velopharyngeal Incompetence: Prevalence, Treatment, and Management Practices

2007 ◽  
Vol 44 (4) ◽  
pp. 424-433 ◽  
Author(s):  
Deonne Malick ◽  
Jerry Moon ◽  
John Canady
Keyword(s):  
Management Practices ◽  
Demographic Data ◽  
Posterior Wall ◽  
Fat Injection ◽  
Speech Language Pathologist ◽  
Velopharyngeal Incompetence ◽  
Management Techniques ◽  
Pharyngeal Flap ◽  
Sphincter Pharyngoplasty ◽  
Typical Treatment

Objective: Stress velopharyngeal incompetence is the unwanted coupling of the oral and nasal cavities while brass and woodwind musicians play their instruments. This study investigated both (1) the prevalence of stress velopharyngeal incompetence in college musicians, delineating symptoms and situations possibly associated with the condition; and (2) physicians’ experiences with musicians exhibiting stress velopharyngeal incompetence, including typical treatment and management techniques. Methods: Questionnaires were distributed to 297 brass or woodwind student musicians at three public universities and to 998 plastic surgeons and otolaryngologists. The musician questionnaire focused on demographic data and identification of symptoms that might indicate the presence of stress velopharyngeal incompetence. The physician questionnaire addressed demographics of the physician and his or her practice, familiarity and experience with stress velopharyngeal incompetence, and treatment and management suggestions for individuals experiencing the condition. Results: Thirty-four percent of the responding musicians reported symptoms of stress velopharyngeal incompetence, most often after 30 minutes of playing. Forty-five percent of the responding physicians reported being familiar with the term stress velopharyngeal incompetence, although only 27% reported ever having seen a patient with the condition. The seven most frequently reported intervention strategies were referral to a speech language pathologist (47.50%), sphincter pharyngoplasty (30.00%), pharyngeal flap (26.88%), referral to a cleft palate team (24.38%), watch and wait (18.75%), posterior wall fat injection (12.50%), and palatal lift (10.00%). Conclusions: Stress velopharyngeal incompetence is a potentially career-ending (or career-preventing) problem that currently may be undertreated and that is in need of more systematic study both in terms of its physiologic underpinnings and its management.

Comparing Quality of Life and Perceptual Speech Ratings in Children With Cleft Palate

2020 ◽  
pp. 105566562094943
Author(s):  
Hailey M. Pedersen ◽  
Paige A. Goodie ◽  
Maia N. Braden ◽  
Susan L. Thibeault
Keyword(s):  
Quality Of Life ◽  
Cleft Palate ◽  
Population Based ◽  
Velopharyngeal Insufficiency ◽  
Average Score ◽  
Life Outcomes ◽  
Speech Language Pathologist ◽  
Perceptual Characteristics ◽  
Velopharyngeal Function

Objective: To delineate the relationship between patient and parent-reported quality of life (QOL) ratings and perceptual characteristics of speech assigned by a speech-language pathologist (SLP) in children with repaired cleft palate. Design: Prospective. Setting: Academic Children’s Hospital. Participants: This population-based sample included children, aged 3 to 18 with a history of repaired cleft palate, and their parents. Intervention: Participants completed the Velopharyngeal Insufficiency Effects on Life Outcomes Questionnaire (VELO). Children’s speech was judged perceptually by an expert SLP using the Pittsburgh Weighted Speech Scale (PWSS). Main Outcome Measure(s): Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire assessed participant and parent perceptions of impact of velopharyngeal function on QOL. Pittsburgh Weighted Speech Scale assessed nasal emissions, facial grimacing, nasality, quality of phonation, and articulation. Results: Enrollment included 48 participant parent dyads. Overall, participants reported high QOL scores within the 95% CI with children reporting slightly better yet not significantly different QOL (86.27 ± 8.96) compared to their parents (81.81 ± 15.2). Children received an average score of 1.38 ± 1.96 on the PWSS corresponding to borderline velopharyngeal competence. A significant moderate negative correlation was found between PWSS total score and parent VELO total score (r = −0.51103, P = .0002). Mild–moderate significant negative correlations were measured between PWSS total and the 5 subscales of the VELO. No significant correlations were measured between PWSS and child VELO total responses or between total scores and subscales. Conclusions: Results suggest that as perceptual analysis of speech improves, overall QOL improves moderately.

Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals

2012 ◽  
Vol 49 (2) ◽  
pp. 146-152 ◽  
Author(s):  
Ann W. Kummer ◽  
Stacey L. Clark ◽  
Erin E. Redle ◽  
Leisa L. Thomsen ◽  
David A. Billmire
Keyword(s):  
Cleft Palate ◽  
Rating Scales ◽  
Current Practice ◽  
Velopharyngeal Insufficiency ◽  
Surgical Success ◽  
Perceptual Evaluation ◽  
Speech Language Pathologist ◽  
Velopharyngeal Function ◽  
E Mail ◽  
Normal Speech

Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.

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