INSUFICIENCIA VELOFARINGEA Son alteraciones estructurales. Hiperrinolalia Alteración resonancial de la articulación de los fonemas. Veloplastia funcional secundaria: Una alternativa no obstructiva en el tratamiento de la insuficiencia velofaríngea. J. Cortés Araya1,2, A.Y. Niño Duarte3, H.H. English Translation, Synonyms, Definitions and Usage Examples of Spanish Word ‘insuficiencia velofaríngea’.
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Sung Hsieh 4B.
Efeito da veloplastia intravelar sobre a nasalidade em indivíduos com insuficiência velofaríngea
Velopharyngeal insufficiency could be produced by a partial or inappropriate veloplasty performed to correct palate clefts. Phonoaudiologic therapy is often limited, and generally only obtains partial results. In these cases, pharyngoplasty seems to be the procedure of choice, there being several techniques published.
Whatever they are, they have the common factor of the use of pharyngeal gelofaringea that determine a reduction of the upper airway diameter with the consequent risk of generating obstructive sleep disorder. In order to obviate this situation and simultaneously lengthen and provide velopalatine competence, a surgical technique, inspired by the DELAIRE principles, that aims to make the velar mophofunctional reconstruction or secondary functional veloplasty has been designed.
We present our experience based on a series of 15 cases treated in this new way: At this moment, the remaining muscular structures are identifyed, the palatal bone and nasal and buccal mucosa border are separated and are joined in a vflofaringea posterior position of the contralaterals of the midline. In our experience, we have achieved velar lengthening and hypernasal correction or improvement.
After the surgery, patients were evaluated with a phonetic test and aerophonoscopy. The outcome of this evaluation has shown the effectiveness of this surgical technique. Presentamos nuestra experiencia basada en una serie ibsuficiencia 15 casos tratados de esta nueva manera: Santiago de Chile, Chile.
It is common to observe the presence of sequels in patients born with velar or velomaxillary clefts, who have received veloplasties as primary treatment Fig. These sequels are expressed as velar dysfunctions, affecting the voice and audition of the patients suffering it. Clinically, they are known as open rhinolalia as the voice is affected, it becoming nasal, and on the other hand, we find hypoacusis, secondary to chronic otitis media, that affects middle ear ventilation.
The disorders caused by velar dysfunction are grouped under the term of “Velopharyngeal insufficiencies. In these cases, the velum is, to a greater insuficirncia lesser degree, shortened, atrophic and its muscular fibers are displaced from their insuficeincia insertion site, and are incapable of moving in order velpfaringea contact with the pharyngeal wall insuficirncia normally occurs.
Generally, in these cases, the phonoaudiological therapy is limited and its results are often unsatisfactory. The pharyngoplasty classically presents as the procedure of choice in these cases, many techniques having been described Fig. It is then sutured to insuficoencia flap that is cut in its posterior wall, either with the superior or inferior base.
The result is that, in fact, air escape toward the nasal pits can be prevented, improving the rhinolalia but with the biological cost of a reduction in the diameter of the upper airway with the consequent respiratory reduction.
Several studies show that this deterioration in respiratory capacity affects children more seriously than adults. Based on our preliminary experience of 15 cases, this article aims to present an original surgical treatment that corrects velopharyngeal insufficiency without affecting the upper airway diameter and achieving an appropriate velar morphology, that subsequently permits the emission of adequate voice and audition.
From January to Junewe treated a series of 15 cases of patients having velar cleft sequels, characterized by moderate or severe velopharyngeal insufficiency, residual bucconasal clefts or fistulas and adherences due to mucosa scaring.
iinsuficiencia At the time of surgery, the patients were between 8 and 22 years of age and all were evaluated, prior to the surgical treatment by the same phonoaudiologists, the surgical decision being made jointly by the phonoaudiologist and the surgeon.
For practical reasons, we have classified velopharyngeal insufficiencies into three types: In the decision to perform this surgical procedure or not, we have defined Inclusion Criteria, considering those patients who, in spite of velar shortening, have a morphologically adequate velar muscular tissue insuficienciq as Exclusion Criteria, those patients with previous marked asymmetric muscular reparations or in whom severe tissue loss is verified or in whom there is some neurological incapacity or alteration.
A surgical technique has been designed that aims to make the anatomical reconstruction of the soft palate based on the muscular elements available and that can be identified, dissected and functionally recovered. The procedure is based on the empiric verification that there is an anatomic substrate available in many velopharyngeal incompetences, whose functionality can be rescued and reestablished although it does not function adequately since the muscles are often displaced, atrophic and deformed.
Thus, this operation is a secondary functional reconstruction of the soft palete or secondary functional veloplasty, inspired by the functional principles of Delaire. The surgical objective is to identify, dissect and adequately reinsert the tissues.
With the help of a mouth opener that allows us to have an adequate operative field, we should first perform a total opening of the palate, sectioning it sagitally in the middle line. To completely expose the region, we incise from the retrouvular region at the height in which the posterior pillars should be found behind until the mucosa that lines the hard palate in front, searching for the bone reference of the posterior nasal spine.
In this way, we expose both hemivelums, the borders remaining reverted towards the middle line. Once this is done, we have sufficient access to dissect from the palate vault to the region of the posterior pillars Figs. At this time, we dissect the muscular plane, searching for the elevator muscle of the soft palate or elevator muscle of the velum that should be uninserted from the bone palate and carried backwards, to then be joined in the middle line.
We do the same with the posterior pillar or palatopharyngeal muscle of each side. We dissect it to join one with the contralateral side and thus establish an arrangement between them that is as similar as possible to normal anatomy.
We place special emphasis on the preservation of the pterygoid hooks and of their muscular insertions Figs. Then the mucosa of the nasal side of the hard palate is identified and sutured with its contralateral side, thus establishing a clear separation between the nasal and buccal cavities.
Suturing is continued, from front to back, thus moving the previously dissected soft palate musculature to a more posterior position than it previously had. The closure of this muscular plane is completed with the reconstruction of the posterior pillars, that are searched for behind the uvula region. Once this nasal and muscular functional plane is closed, the buccal plane is closed.
It is started by closing the inferior side of the posterior pillars, the uvula, the soft palate area itself until reaching the hard palate area. At this time, the possible fistulas are corrected or the adherences or folds existing are eliminated. A phonoaudiological examination was performed in each patient to evaluate the results. This examination was performed by the same specialist in all the cases. In order to make the study of the results objective, the examination included an instrumental evaluation using an aerophonoscope.
Both this evaluation and the phonoaudiological examination were performed in the preoperative as well as postoperative period of each patient. The aerophonoscopic studies were performed with an apparatus ” ” and the operation was done by the same phonoaudiologist in all the cases.
In the upper half of the figure, an improper air escape through the nose due to failure in the occlusion of the velar sphincter can be seen and the intensity of the phoneme emission can be seen in the lower half.
We can verify how, after the surgical correction, the air escape is almost imperceptible and the intensity of the voice increases considerably. Valopharyngeal insufficiency is a usual condition observed in those born with soft palate fissures and treated surgically, regardless of the technique used. Although there are clinical backgrounds that verify that an early velum reconstruction is associated to better long term results regarding the quality of voice and audition, velopharyngeal insufficiency may occur as a sequel of any technique.
Treatment dependent factors would thus not only be important among the factors to be considered in its appearance, but also constitutional factors, such as width and depth of the pharynx and quality of the tissues involved, among others. For the treatment of velopharyngeal insufficiency, several treatments have been tested, as, for example, phonoaudiological reeducation, which is really the base of any therapy, by itself, or as a complement to another procedure.
The use or orthesis or other prosthesic additions that help to improve the velopharyngeal competence and surgical techniques, as the reoperation of the velum or the pharyngoplasty techniques, have been tested. The latter may be the surgical technique used by the greatest number of surgeon who deal with the management and treatment of this condition. From a practical point of view, however, if we compare the pharyngoplasty surgical techniques versus the secondary functional reconstruction of the velum proposed, we see how the velar reoperation offers certain advantages regarding the former, especially because of its surgical simplicity.
In fact, performing a secondary functional veloplasty not only implies reduction of the operative time but also economy in the means necessary to obtain the objective: This antero-posterior lengthening is achieved on freeing the palatine aponeurosis with its tensor muscles and elevator of the soft palate from its insertions in the palate vault and once dissected, this is carried to a more posterior position, preserving the essential structures for its mobility, such as the pterygoid hooks.
If both surgical techniques are compared in regards to anatomic territory operated, we see that the operative site in the secondary reconstruction is the palate and the incisions are performed in the velar or maxillary area exclusively, without going into neighboring anatomic sectors. On the contrary, when other topographic territories such as the posterior or lateral wall of the pharynx, rich in vessels such as ascending and descending pharyngeal vessels are affected by the pharyngoplasties, there is a potential risk of excessive bleeding and even more so in the cases that present anatomic variations, as for example, the Shprintzen Syndrome or Velocardiofacial Syndrome, that does not occur in secondary functional veloplasty since it has a different anatomic substrate.
In the immediate postoperative period, the discomfort caused by the exposure and manipulation of the pharyngeal tissues determined by the pharyngoplasty techniques are obviated when a secondary functional veloplasty is performed for the same reason detailed in the previous point. This period is easier, there not only being less breathing difficulty, since there is no type of airway restriction, but also fewer eating and speaking restrictions, since there are no invasive zones exposed, as occurs, on the contrary, in the postoperative of the pharyngoplasties.
When the mechanisms by which one technique and another improve the velopharyngeal insufficiency are analyzed, we see that these are completely different. From the functional point of view, a pharyngoplasty produces different changes. On the one hand, it can treat the velopharyngeal insufficiency, improving the voice, an aspect that has some unanimity 9 since a flap shifted from the pharynx mechanically prevents air passage to the nasal pits. However, this beneficial characteristic is also the origin of its greatest disadvantage: Although there have been efforts to improve the ventilatory aspects associated to the pharyngoplasty techniques, 10 there is documented evidence of airway obstruction due to surgical treatments that use the pharynx lumen, as the Furlow technique itself, 2,11,12 appearance of cardiovascular disorders and even post-operative death in patients having syndromes such as the Velocardiofacial or Pierre Robin ones.
Until recently, snoring was not considered as a pathological clinical sign and Sleep Medicine had not appeared in the clinical discipline spectrum.
On the other hand, there are deformities in the facial skeleton in relationship to the frequent structural characteristics observed in cleft patients. In this situation, insuficieencia maxillary occupies a more posterior and higher anatomic site in the upper floor of the face, impacted in an area that normally should be available for air passage towards the bronchi. Thus, it is doubly serious to use operative techniques that restrict the air passage by the upper airway and thus facilitate the appearance of obstructive respiratory disorders to a population that presents intrinsic characteristics of obstructive risk.
The greatest advantage of the technique proposed is precisely that it returns the normal velar morphology and thus the capacity to the velopharyngeal structures to obtain competence, leaving this sector in conditions of being reeducated phonoaudiologically inzuficiencia thus achieving a correct voice free of nasalizations, preserving the caliber and functionality of the upper airway.
Perhaps the greatest disadvantage of this technique is its limited indication. In fact, it is not useful in all the cases of velopharyingeal insufficiency VFI. There is VFI having neurological etiology, as certain velar paralysis or others idiopathic ones, such as some malformations that are expressed with agenesis or hypoplasy of the velopalatine sectors.
Insuficiencia velofaríngea, disfagia neurogénica
They do not respond to surgical treatment as that proposed since the indispensable substrate is not available: The challenge of the prevention and treatment of velopharyngeal insufficiency continues to exist.
We believe that the search for solutions to this old problem should be oriented towards treatments in general and to the design of surgical techniques in particular that manage to correct velopharyngeal insufficiency without altering other structures, such as the pharynx, functions, such as respiratory or biological rhythms, velofaringe as circadian.
Along this reflexive line, imsuficiencia proposal is oriented to the recovery of the forms and function, searching for the recovery of normal anatomy and physiology of the zone with our technique. Posterior pharyngeal flap and sphincter pharyngoplasty: The state of the art.
Incidence and severity of velkfaringea sleep apnea following pharyngeal flap surgery in patients with cleft palate. Cleft Palate Craniofac J ; Secondary funtional repair of the velar cleft.
J Ann Chir Plast ; The assessment of middle ear function and hearing by tympanometry in children before and after early cleft palate repair. British Journal of Plastic Surgery ; Rev Stomatol Chir Maxillofac ; Evidence in infants with cleft palate that breast milk protects against otitis media.
An anatomic evaluation of the furlow double opposing Z-plasty technique of cleft palate repair. Ann Acad Med Singapore ; A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control l.
Cleft Palate J ; The Cleft Palate-Craniofacial Journal ; Insuficienxia pulmonale secondary to cleft palate repair.