|Year : 2017 | Volume
| Issue : 3 | Page : 68-72
Evolution of a safe and effective management protocol for velopharyngeal incompetence: Seeking good speech without airway compromise
John H Grant1, Meghan Amerson2, Laura Sconyers2, Ahmed Elsherbiny3
1 Department of Surgery, Division of Plastic Surgery, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America
2 Department of Hearing and Speech, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America
3 Department of Surgery, Division of Plastic Surgery, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America; Department of Plastic Surgery, Sohag Cleft and Craniofacial Unit, Sohag University Hospital, Sohag, Egypt
|Date of Web Publication||21-Nov-2017|
John H Grant
UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama; Division of Plastic Surgery, University of Alabama, 1600 7th Avenue South, Lowder 322, Birmingham, AL 35233
United States of America
Source of Support: None, Conflict of Interest: None
Objective: To document an evidence based evolution of VPI management over an 18 year period with the goal of optimizing speech while minimizing complications and need for re-operation. Design: An institutional review board approved, retrospective 18-year single surgeon, single-center series of 370 patients undergoing surgery for velopharyngeal incompetence (VPI). Methods: A review of our database between the years of 1997 and 2015 identified 370 patients who underwent surgical procedures for VPI. Records were reviewed for types of procedures performed each year. Procedures were evaluated for safety and efficacy as regards to speech outcome. The study population was divided into an earlier period (1997–2009) and a later period (2010–2015). Results: We demonstrated a reduction in the use of airway obstructive procedures such as sphincter pharyngoplasty from 25.2% of VPI surgeries in the early period to 10.4% in the late period. There has been a progressive shift toward more physiologic procedures such as re-repair with intravelar veloplasty (IVVP). The extent of IVVP has become more aggressive over the time period of the study. In our re-repair population, 89.7% of patients had improvement of the speech scores with 64.5% of all the re-repair patients achieving normal speech postoperatively. Autologous fat augmentation of the palate was introduced in the second period and represents about half of the procedures in the later period. Focused autologous fat augmentation of the palate resulted in statistically significant improvement in speech in 75.7% of cases. Conclusion: This study demonstrates an evidence-based evolution in management, shifting away from potentially airway obstructive procedures and toward a more physiologic approach to velopharyngeal competence. We outline the steps taken to reach the author's current approach to VPI management based on periodic outcome audits, specific anatomic findings, and goal-directed surgical interventions. With correct diagnosis and patient selection, VPI can be safely eliminated in over 70% of patients with a single procedure. We believe that this anatomic and physiologic approach improves safety while minimizing risks of airway obstruction.
Keywords: Palate fat graft, re-repair, velopharyngeal incompetence protocol
|How to cite this article:|
Grant JH, Amerson M, Sconyers L, Elsherbiny A. Evolution of a safe and effective management protocol for velopharyngeal incompetence: Seeking good speech without airway compromise. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:68-72
|How to cite this URL:|
Grant JH, Amerson M, Sconyers L, Elsherbiny A. Evolution of a safe and effective management protocol for velopharyngeal incompetence: Seeking good speech without airway compromise. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:68-72. Available from: https://www.jclpca.org/text.asp?2017/4/3/68/218892
| Introduction|| |
The goals of palatoplasty have moved far beyond the early surgical outcome measure of simply closing the defect. While the avoidance of healing complications such as fistula remain important, modern surgical repairs endeavor to repair the palatal cleft, achieving normal speech without airway compromise. Recent published reviews of speech outcomes cite a need for secondary surgery aimed at resolving residual velopharyngeal incompetence (VPI) ranging from 7.3% to 30%., Despite progressive improvement in surgical safety and technique, however, VPI remains a complication of palatoplasty, even in the best of circumstances.
This paper documents an 18-year evolution in VPI management, culminating in a protocol that provides surgical intervention that is individualized to the specific patient in an effort to maximize speech outcome while minimizing both the number of anesthetics and the risk of iatrogenic airway compromise.
| Materials and Methods|| |
We conducted an institutional review board approved, retrospective chart review of a single surgeon's 18-year experience with patients requiring surgery for VPI at the UAB Cleft and Craniofacial Clinic at Children's of Alabama Hospital. Patients were identified by reviewing the surgeon's database for patients undergoing VPI procedures. The center protocol included the following procedures for VPI; Sommerlad type re-repair with intravelar veloplasty (IVVP), autologous fat augmentation of the palate, and sphincter pharyngoplasty.
The study population was divided into an earlier period (1997–2009) and a later period (2010–2015). We report the algorithm used for selection of the surgical procedures in the early period of the study and compare this with the late period. Furthermore, we report the speech outcome of each procedure and the complications such as airway compromise, healing problems, and the need for additional surgery (residual VPI).
Surgical interventions were all performed by the same surgeon (JHG) adhering to standard techniques published elsewhere.,,, Speech assessment was performed using the Pittsburgh Weighted Speech Score. Periodic audits of our speech outcomes, published, under submission, or unpublished were performed throughout the 18 years, and the management protocol has been adjusted based on the results of these audits.
| Results|| |
The review identified 370 consecutive patients who presented with VPI and were surgically managed. The reported number of procedures in each year throughout the study period is shown in [Figure 1], and the difference between the two study periods as regards to the percentage of each procedure is shown in [Figure 2].
|Figure 1: The reported number of procedures in each year throughout the study period|
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|Figure 2: The percent of each procedure utilized for treating VPI patients in the early and late period of the study|
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The surgical procedures
Palate re-repair with IVVP was used in 183 cases, representing 49.5% of all VPI procedures. In our recent review of our re-repair series, adequate pre- and post-operative records for speech outcome analysis were available in 111 cases. Postoperatively, 65.8% of these patients achieved normal or borderline normal speech, 25.2% of patients improved but did not achieve normal speech, and only 9% of patients did not show improvement. There were no reported cases of postoperative hemorrhage or fistula. Some patients presented with concomitant palatal fistulas (16.2%) which were all successfully corrected with the procedure. No patients developed obstructive sleep apnea (OSA) postoperatively. One patient had mild sleep apnea preoperatively that was unchanged postoperatively and managed conservatively. The extent of IVVP has become more aggressive over time.
Autologous fat augmentation of the palate
Fat grafting to the palate was used in 128 cases representing 55.4% of all VPI procedures done in the late period of the study. Our previously published series consisted of 46 patients who were treated with a total of 61 autologous fat augmentation procedures. A single fat augmentation was required in 69.6% of cases. Two fat augmentations were required in 28.2% and a single patient received three fat augmentations (2.2%). The average volume of fat injected was small at 2.4 ± 1.1 ml. The average operative time was 39 ± 12.55 min. The procedure is safely done as an outpatient procedure and requires no postoperative dietary restrictions. Analysis showed no complications in the palate or donor site. Speech analysis, which was available in 37 cases, showed that 21.6% resolved their VPI, 54.1% of the patients had a significant improvement, whereas 24.3% showed no changes or deterioration.
There were a total of 59 sphincter pharyngoplasties used representing 15.9% of all VPI procedures. We note that over the time of the study, the need for sphincter pharyngoplasty has decreased from 25.2% of VPI procedures in the earlier period to 10.4% in the later period of the study. Data of 54 cases were available, from which 72.2% achieved normal or borderline normal speech, 18.5% improved but did not achieve normal speech, and only 9.3% failed to improve. Fourteen cases (25.9%) needed revision surgery in the form of tightening of the sphincter.
The procedure selection protocols
Our early protocol shown in [Figure 3] was re-repair with IVVP for cases with an obliquely positioned levator muscle. Pharyngoplasty was used if the muscles were judged to be in an acceptable position. The surgical protocol was modified in the later period as shown in [Figure 4] with the introduction of the procedure of fat grafting to the palate. The fat graft procedure is used in smaller sized defects, reserving the sphincter pharyngoplasty for larger defects. Another change is a more stringent definition of good muscle position as an indication for pharyngoplasty, such that a truly transverse muscle orientation is required for the pharyngoplasty to be indicated. This is also a result of the fact that, over the course of the study period, the re-repair IVVP procedure has become more radical.
|Figure 3: The center protocol during the early period of the study (1997–2009)|
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|Figure 4: The center protocol during the late period of the study (2010–2015)|
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| Discussion|| |
Managing VPI patients is challenging due to the great variability in patient presentation. There are many anatomical and functional factors influencing the speech status. Many surgical procedures have been described, with each having its advantages and disadvantages. No conclusive evidence supporting one over another exists. VPI surgery has a long learning curve and outcomes are typically dependent on operator experience. Most surgeons utilize a small number of techniques according to training and experiential preferences. The development of a center protocol for VPI management requires continuous auditing of outcomes keeping open the possibility for adding new procedures.
During primary palate repair, the importance of radical “IVVP” is well documented. We have also demonstrated the importance of more extensive levator repositioning to improve speech with the different extents and degrees of muscle dissection during the primary repair of the palate. Through this study and the continuous recurring internal audits of our cleft palate speech outcomes, we have endeavored to optimize the initial palatoplasty procedure evolving to what is now a circumferential skeletonization and retropositioning of the levator veli palatini muscle with delamination of the posterior aspect of the palate to create a sufficient tissue cover for the muscle to move into a transverse orientation. Our results mirror those of Sommerlad et al. and revealed a 7% need for secondary speech surgery following primary palatoplasty at the time of our last audit. As our primary palatoplasty levator repair has become more extensive, we have seen a decrease in the need for secondary IVVP in our own patients. It is still used extensively in patients who underwent primary palatoplasty elsewhere.
As reflected in our protocol, surgical procedures addressing VPI can be classified into palatal procedures and pharyngeal procedures. Palatal procedures are those which aim to improve the function and/or the length of the palate. Examples included re-repair with IVVP and secondary Furlow palatoplasty. These procedures are physiological and should have less deleterious effect on the airway. Pharyngeal procedures, on the other hand, are designed to decrease the velopharyngeal port which decreases the port size during both speech and respiration. These procedures tend to carry a higher risk of obstructive airway complication. Examples are the different versions of pharyngoplasties and pharyngeal flaps., The literature indicates that the incidence of OSA after pharyngoplasty is higher than once thought. In a recent study using routine objective assessment for all cases, OSA was found in a very high percentage of patients, reaching >80% with 43.2% of patients rated as a moderate-to-severe degree of OSA. This high incidence of airway compromise is in contrast to the re-repair IVVP procedure, which is not expected to have a detrimental effect on the airway due to its dynamic physiologic nature. This has been confirmed by Sommerlad et al. in a study using lateral videofluoroscopy. In their evaluation, they did not find significant changes in the resting velopharyngeal gap size after re-repair.
Over the 18-year study period presented here, we have demonstrated a shift away from potentially airway obstructive procedures and toward the more physiologic and anatomically directed approaches to VPI. We found in a separate concurrent study of our palate re-repair IVVP population that re-repair IVVP normalizes nasality and eliminates nasal air emissions in 64.5% of patients.
With our increasing experience with re-repair IVVP over several years, the extent of dissection of the velar muscle has become more radical, allowing a greater retropositioning of the levator sling with a resulting improvement in function and palatal excursion. The goal developed over the years is that the levator sling position is to become strictly transverse before opting for pharyngoplasty. Early in the study, less aggressive levator dissection, may have led to less optimal levator position, and we sometimes may have accepted that the palate had been optimized and that the patients were ready for the next procedure in the algorithm (the pharyngoplasty). This explains why in the early period of the study, pharyngoplasty procedures were sometimes done as a primary procedure for VPI. This order of intervention was not seen in the late period of the study. This also explains the decreasing number of pharyngoplasties needed over the course of the study. We feel that the functional advantages of a completely transverse levator sling are such that a transverse muscle sling is a prerequisite before opting for pharyngoplasty.
The advantage of utilizing pharyngoplasty only after first insuring the best palatal function with re-repair IVVP is the lower incidence of OSA as compared to if pharyngoplasty is done as the primary VPI procedure. This was confirmed in a study conducted by Mehendale et al., who studied the incidence of OSA with re-repair versus pharyngoplasty procedures after the previous re-repair and reported a significantly lower incidence of OSA with pharyngoplasties done after first optimizing velar function with palate re-repair compared to that reported in the literature for pharyngoplasty without previous re-repair. Hence, optimizing palatal function first allows the surgeon to use a more conservative and less obstructive pharyngoplasty. In our series, the number of pharyngoplasties has decreased in frequency over time from a mean of 25.2% of VPI procedures in the earlier years to only 10.4% in the later years.
Through the use of awake nasoendoscopy in our evaluation of VPI, we have identified a group of patients in whom the levator sling was shown to be transversely oriented, and a tiny sometimes inconsistent velopharyngeal closure gap was documented but was thought too small and to have too little impact on speech to warrant a potential airway compromise (by sphincter or pharyngeal flap). The resurgence of autologous fat grafting in the field of plastic surgery led us to explore fat grafting as a method to address these small focal gaps. Reports of inconsistent outcomes and even tragic complications with fat augmentation of the posterior pharyngeal wall led us to design our procedure of nasoendoscopically guided, selective augmentation of the palate, using small aliquots of autologous fat and avoiding the possibility of inadvertent injection into a major vessel such as a medially malpositioned carotid artery in a child with 22q11 deletion syndrome. In addition, the Orticochea sphincter pharyngoplasty sits lower in the pharynx than the palatal contact point with the adenoid pad so would not be the ideal anatomic intervention for this particular focal closure gap in an otherwise functional palate. Hynes sphincter pharyngoplasty could be considered but would necessitate dividing a palate with good overall function, something we found hard to suggest for a gap of 1–2 mm estimated size. The addition of this fat augmentation procedure in 2010, together with the improvement in the re-repair IVVP, also shared in the reduction in the percent of pharyngoplasties required.
The major protocol change that has occurred throughout years is that sphincter pharyngoplasty is now reserved for salvage cases only. In these cases, the palate has either been optimized or abandoned (due to lack of movement). Sphincter pharyngoplasty is done by a modification of the Orticochea technique and may be unilateral or bilateral as dictated by nasoendoscopic findings. We favor the sphincter pharyngoplasty over the pharyngeal flap due to a published lower incidence of obstructive symptoms. We also feel that in contrast to the typical unlined pharyngeal flap, the lack of a raw surface afforded by the sphincter pharyngoplasty makes for healing that is more predictable. The need for sphincter pharyngoplasty at our center over the past 3 years is now approximately 5% of our VPI procedures and tends to be utilized in children who have minimally mobile or immobile palates such as those with severe syndromic conditions or whose initial palatoplasty may have resulted in severe damage to the levator veli paltini muscles. In these cases, the palate must sadly be abandoned, and airway obstructive options such as prosthetic speech bulbs, palatal lifts, pharyngeal flaps, or sphincter pharyngoplasties must be considered.
| Conclusion|| |
The design of a cleft center VPI protocol has been a dynamic process, and changes have occurred as a result of continuous audits and the introduction of new or modified procedures to improve the overall speech outcome and decrease the airways problems. By following the philosophy and protocol above, we have been able to achieve normal speech in 70% of VPI patients with a single procedure, while avoiding obstructive airway complications and their sequelae.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]