Pharyngoplasty

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A dynamically functional velopharyngeal sphincter is essential for normal eating, normal breathing, and proper speech. The sphincter is positioned between the oral and nasal cavities. It coordinates appropriate airflow through each chamber. Thereby allowing a voice with good quality and power. Closure of the velopharyngeal port prevents nasal regurgitation during eating. It also allows pronunciation of consonants. Opening of the port allows for normal respiration and specific nasal articulations.

Speech and swallowing depend upon adequate closure of the velopharyngeal port. Velopharyngeal movements during phonation are distinct from those involved in swallowing. Good closure is achieved during swallowing and phonation. However, some may be unable to get adequate closure when speaking.

Certain consonant need high oral pressure. Inadequate closure allows air to escape through the nose. Thus leading to inappropriate nasal resonance during speech production.

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Velopharyngeal Insufficiency

“Velo” refers to the velum, or soft palate. It is the part of the roof of the mouth that moves when you say “ah.”

“Pharyngeal” refers to the throat (pharynx). During normal speech for certain sounds, the palate rises to touch the back of the throat. Thereby sending the air out of the mouth.

When a child has VPD, their soft palate does not contact the throat during speech. This lets air escape through their nose during speech.

It is a muscular valve extending from the posterior bony palate to the posterior pharynx. Majority of the sounds are produced with a closed velopharyngeal port.

VPI is usually considered as a symptom to velo-cardio-facial syndrome (VCFS).

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Occurrence

The occurrence of  velopharyngeal dysfunction in India and other countries is due to

  • Repaired or unrepaired cleft palate
  • Inadequate lengthening of the velum during primary palatoplasty
  • Abnormal function of the laevator musculature and cicatricial contracture of the velum
  • Submucous clefts
  • Neurogenic VPI

Damage to the cranial nerves innervating the velopharyngeal mechanism

  • Genetic conditions.
  • Iatrogenic VPI

Adenoidectomy

Maxillary resection

Uvulopalatopharyngoplasty

  • Increased space between the palate and the throat.
  • Motor speech disorder.
  • Unknown causes.

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Methods of assessment

Speech language pathologist assesses the velopharyngeal dysfunction.

The Pittsburgh weighted speech score (PWSS) is a standardized scoring system. McWilliams and Phillips described the Pittsburgh weighted speech score (PWSS) in 1979. This tool serves to grade VPI on a quantitative scale. The patients are then classified into four categories of velopharyngeal function. They are

  • Competence
  • Borderline competence
  • Borderline incompetence
  • Incompetence

A PWSS score of 3 or greater indicates velopharyngeal incompetence.[/vc_column_text][vc_column_text]

Closure patterns

The closure patterns of the Velopharyngeal port are of 3 types. It is based on the movements of the velum and the pharyngeal walls (posterior pharyngeal wall).

  • Circular/Constricted: Combined movements of the velum and pharyngeal walls contribute equally to close the port in a “purse-string” fashion.
  • Coronal: Posterior and superior movement of the velum is primarily responsible for velopharyngeal closure, with little contribution from the lateral pharyngeal walls.
  • Sagittal: Medial displacement of the lateral pharyngeal walls which is primarily responsible for closure, with little posterior movement of the velum.

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Methods to assess closure patterns

The recommended age for surgical procedure depends on the clinical problem. The child’s speech is to be clearly observed. This is important in case of children with cleft. Surgical recommendations are only made after evaluation. The evaluation is usually done by a trained speech therapist.

For assessment the child has to be 3 and 1/2 to 4 years old. Children over 4 years co-operate better to speech evaluation. The hypernasality correction is to be done before kindergarten or first class. This is the age when children begin noticing differences. Pharyngoplasty must be done before the brain gets accustomed to the speech.

An alternative option is the use of a removable dental appliance. This fills the gap in the back of the throat. This also prevents excess air leakage from the throat during speech. This appliance is designed by a speech Prosthodontist.

The methods for studying the closure pattern of velopharyngeal port are:

  • Nasoendoscopy (NE) – A flexible endoscope is used to provide a bird’s eye view. The location, shape and size of the opening can be determined. It is also used to assess palatal scarring.
  • Multiview Video Fluoroscopy (MVF) – It is a non-invasive procedure. It refers to images that are obtained during speech. The contribution of the velum and lateral pharyngeal walls to velopharyngeal closure can be determined.
  • Magnetic Resonance Imaging (MRI)- MRI is non-invasive. It is commonly used in un-cooperative patients. It is also used where precise anatomical information is necessary.
  • Nasometry- It is a device used to measure the energy emitted during speech. It is a very sophisticated device and is attached to a computer. The results are noted as nasalance score. It is purely objective but still used as a adjunct to speech development.

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Pharyngoplasty in India – Surgical techniques

The surgical management varies from person to person

  • Sphincter pharyngoplasty
  • Furlow’s pharyngoplasty
  • Pharyngeal flap
  • Posterior pharyngeal wall implant

During surgery the VPI port is reduced to a small gap. Thereby preventing air from escaping through the nose. Thus creating a positive pressure.

Patients who require usually have nasal twang. Long term speech difficulties can be corrected by pharyngoplasty. Pharyngoplasty is considered to come under plastic surgery. As a result it is usually done by a plastic surgeon. It can also be done by a pharyngoplasty specialist. Pharyngoplasty does not lead to obstructive sleep disorders.[/vc_column_text][vc_column_text]

Furlow’s pharyngoplasty

It is also known as Z-plasty. Furlow’s pharyngoplasty is a plastic surgical technique. It involves lengthening and thickening the soft palate. Along with realignment of abnormally placed palatal muscles. This operation is usually performed for children with clefts. Hypernasality may occur even after cleft palate repair.

It can also occur in patients with a hidden cleft palate. The increase in thickness and length provides improved contact. Thus preventing air leakage from the nose during speech. This procedure is also known to be beneficial in cleft palate patients with ear infections.[/vc_column_text][vc_column_text]

Sphincter pharyngoplasty

Sphincter pharyngoplasty refers to raising layers of muscle from the throat. The muscle is dissected from behind the tonsil. It is later folded over each other. Then sewn together side to side. This ridge of muscle acts like a bump in the back of the throat. Thus enabling the palate to rise up during speech. The size of the muscle dissected is based on the child’s anatomy (i.e. the shape and size of the gap located in the throat). This muscle layer cannot be visualized after surgery.

This procedure is more preferable than other types of pharyngoplasty. There are less chances of post-operative airway obstruction. The in-hospital recovery time is also less. The recovery period is about one night only.

Sphincter pharyngoplasty is followed in the best VPI correction hospital in India. Balaji Dental and Craniofacial Hospital is one of the best center for cleft lip and palate surgery in India. Some of the best palate surgeries are done here. The cost is also less when compared to other hospitals.

Pharyngeal flap technique has a recovery period of about 3-5 nights.[/vc_column_text][vc_video link=”https://www.youtube.com/embed/wFneafecSVU”][vc_column_text]

Conclusion

VPI is a common complication following palatoplasty. The selection of operative procedures depends on the multimodal patient assessment. It includes speech evaluation and imaging studies of the pharyngeal mechanism. A thorough understanding of the velopharyngeal anatomy and its physiology is crucial. This helps in understanding the deficit in patients with VPI. The success rate varies from 85-98% depending on the age.

Pharyngoplasty can also be done in older patients. Depending on the age the success rates varies. The success rate is about 60%-85% in patients who are about 35-40 years of age.[/vc_column_text][/vc_column][/vc_row][/vc_section]

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