Ariela Nachmani

Frontal and lateral cephalometry in patients with sleep-disordered breathing

Objectives/Hypothesis The traditional lateral‐view cephalometric analysis is limited because it provides only two‐dimensional analysis of the three‐dimensional craniofacial structure. The objectives were to analyze lateral and frontal cephalometric radiographs in a series of normal patients and those with varying degrees of sleep‐disordered breathing and to define the degrees of narrowing or other unfavorable anatomical changes that might differentiate the patients with sleep‐disordered breathing from normal subjects.

Levator veli palatini muscle and eustachian tube function.

Thirty previously unoperated patients with submucous cleft palate, occult submucous cleft palate, and unilateral congenital paralysis of the levator veli palatini muscle were examined. All patients were subjected to a comprehensive otoscopic, endoscopic, audiologic, and tympanometric evaluation. A correlation was made between levator veli palatini muscle anomalies, eustachian tube orifice anomalies, and middle ear ventilation and disorders. Normal middle ear ventilation was found in 23 patients. Negative middle ear pressure that consequently normalized following treatment of coexisting sinusitis was found in 3 patients. Only in 4 patients was chronic middle ear disease found. In one of them, middle ear effusion disappeared following successful treatment of sinusitis. Our conclusion is that the levator veli palatini muscle has no significant function in the opening mechanism of the eustachian tube and must be considered as a velopharyngeal valve muscle only.

Speech-aid prostheses for neurogenic velopharyngeal incompetence ☆ ☆☆

STATEMENT OF PROBLEM When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. PURPOSE This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. METHODS Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. RESULTS Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. CONCLUSION Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance.

Occult and overt submucous cleft palate: from peroral examination to nasendoscopy and back again

Peroral examination of the soft palate is of greater value than generally recognized. The nasendoscopic examination provides essential information on the velopharyngeal valve physiology and pathology. However, nasendoscopy cannot be performed in individuals who are uncooperative such as young children, patients with personality disturbances or those mentally retarded, or in the presence of severe deformity of the nose. In these patients the peroral examination is of particular practical clinical application. Forty cases of occult and overt submucous cleft palate were included in the present study. We describe the contribution of systematic assessment of the soft palate intraorally, based on a correlation with nasendoscopic examination of the velopharyngeal valve in speech. An accurate peroral examination can provide additional information on abnormality of the velar musculature as well as the existence of Passavants ridge. This information is particularly important in children who are too young for nasendoscopix examination, but because of their poor speech intelligibility, early diagnosis and treatment are imperative.

Endoscopic partial adenoidectomy for Children with submucous cleft palate

OBJECTIVE Children with submucous cleft palate who suffer from chronic nasal obstruction because of hypertrophic adenoids usually are not subjected to adenoidectomy because of the fear of postoperative velopharyngeal insufficiency. These patients present a therapeutic challenge because we are aware more than ever of the importance of normal nasal breathing and nocturnal respiration, especially during childhood. Our hypothesis was that transnasal endoscopic horizontal limited adenoidectomy may relieve nasal obstruction while preserving the function of the velopharyngeal valve. The objective of this study was to evaluate the efficacy of transnasal endoscopic horizontal partial adenoidectomy in patients with submucous cleft palate and adenoidal hypertrophy. SETTING Patients were either referred to the outpatient clinic of the Palate Surgery Unit (seven patients) or were patients referred to the senior authors (Y.F.) private clinic. All the patients had been operated on by this senior author (Y.F.). PATIENTS Ten children aged 3.5 to 13 years (six girls and four boys) with submucous cleft palate and hypertrophic adenoids were included in the study. All the patients were hyponasal and suffered nasal obstruction, loud snoring, and episodes of apnea. INTERVENTIONS Endoscopic partial adenoidectomy was accomplished to open the lower third of the choanae. Nasal breathing was achieved in all the patients, and only mild snoring remained in two patients. The hyponasality disappeared and speech intelligibility normalized. Mild hypernasality developed in two patients but was still perceived as an overall improvement in speech. CONCLUSIONS Transnasal endoscopic horizontal partial adenoidectomy may be an effective surgical method for relief of nasal obstruction while preserving velopharyngeal valve function in patients with submucous cleft palate who suffer from obstructive adenoids.

Nasopharyngeal profile and velopharyngeal valve mechanism

Proper management of velopharyngeal insufficiency requires an understanding of normal velopharyngeal anatomy and function. The present cephalometric study correlates the nasopharyngeal profile at rest with velopharyngeal function as observed by nasendoscopy and fluorographic and videofluoroscopic studies. Fifty-two normal individuals and 23 patients with insufficient velopharyngeal valves were examined. A correlation was found between nasopharyngeal profiles at rest and the closure patterns of the velopharyngeal valve. It was found that when existent, Passavants ridge is subsequently formed where thick soft tissue corresponding to the superior constrictor muscle is found beneath the mucosa of the posterior pharyngeal wall at rest. Our conclusion is that Passavants ridge is formed by the superior constrictor. The present study represents additional confirmation that differences in velopharyngeal closure patterns are the result of differences in anatomy. A biomechanical model of velopharyngeal valving is presented based on individual spatial muscular orientation and the hierarchical recruitment of the velopharyngeal muscles. This recruitment is progressive and is dependent on the effort required to achieve tighter velopharyngeal sealing. (Plast. Reconstr. Surg. 92: 603, 1993.)

Axial configuration of the velopharyngeal valve and its valving mechanism.

The variability of the normal velopharyngeal (VP) closure mechanism was studied by investigating VP anatomy in relation to its closure mechanism in 60 patients. The axial configuration of the VP isthmus, as observed in axial CT scans at rest, was found to be correlated with VP function in terms of its closure patterns in speech as observed by nasendoscopy. A flat VP isthmus was found to be closed mainly in the anteroposterior direction, forming the coronal closure pattern. A deep VP isthmus is closed by movement of the velum and medial movement of the lateral pharyngeal walls, forming the circular closure pattern. A flat VP isthmus occurs when the hamuli are posteriorly located and the muscular slings, therefore, open more posteriorly. We conclude that posterior insertion of the velar muscles on to the skull base results in a flatter, larger VP axial configuration, whereas an anterior insertion results in a VP axial configuration that is deeper and less flat. A flat VP isthmus contracts mainly in an anteroposterior direction, exhibiting a coronal closure pattern, while a deep or round VP isthmus contracts centripetally, exhibiting a circular closure pattern. Variability of the VP valving mechanism is of anatomic and not of functional origin.

Velopharyngeal Anatomy in Patients With Obstructive Sleep Apnea Versus Normal Subjects

PURPOSE Obesity can cause disturbed breathing and is one of the most significant risk factors for obstructive sleep apnea (OSA). However, the anatomic basis of OSA and, specifically, the anatomic mechanisms leading from obesity to OSA are still unclear. We examined the anatomic features of the velopharynx in patients with OSA versus those without in correlation with the body mass index (BMI), age, history of snoring, and OSA severity and re-evaluated the contribution of adding a frontal view to the cephalometric analysis of patients with OSA. MATERIALS AND METHODS Lateral and frontal cephalometric measurements were taken to assess the velopharyngeal anatomic features of 306 men with various degrees of OSA and 64 men without OSA and without a history of snoring. The demographic, polysomnographic, and cephalometric features were compared. RESULTS The patients with OSA had an increased pharyngeal length, thicker velum, a thicker posterior pharyngeal wall, a reduced pharyngeal width, and a consequent narrowing of the pharyngeal lumen. As the BMI increased, the OSA severity increased. Also, in parallel, the velum and posterior pharyngeal wall thickness increased and the pharyngeal width decreased. Three types of velopharyngeal narrowing, with an increased occurrence in severe degrees of OSA, were identified: bottle shape, hourglass shape, and tube shape. These aerodynamically unfavorable changes might cause increased upper airway resistance, explaining the development of both OSA and hypoventilation syndrome in obese patients. CONCLUSIONS Velopharyngeal thickening and lumen narrowing were shown to be features of obese men with OSA. However, these features developed only above a threshold BMI value. The combination of frontal and lateral cephalometry is important for comprehensive evaluation of patients with OSA.

Is Isolated Palatal Anomaly an Indication to Screen for 22q11 Region Deletion

OBJECTIVE Velocardiofacial syndrome (VCFS) is the most common multiple anomaly disorder associated with palatal clefting. Cytogenetic hemizygous deletion of 22q11 region is found in 80% of patients. The frequency of 22q11 deletion in patients presenting with isolated palatal anomalies has not been fully assessed. Our objective was to determine the frequency of the deletion in patients with isolated palatal anomalies. DESIGN Patients were referred because of velopharyngeal insufficiency because of isolated congenital palatal anomalies. Diagnosis of palatal anomalies was confirmed by videonasopharyngoscopy, multiview videofluoroscopy and cephalometry. Other clinical findings suggestive of VCFS were sought, and subjects with these characteristics were excluded from the study. Peripheral blood samples from all patients were analyzed cytogenetically utilizing fluorescent in situ hybridization for the 22q11 region. RESULTS Thirty-eight patients aged 3 to 31 years were included in the study. Nine had cleft palate, 7 cleft lip and palate, 10 overt and 11 occult submucous cleft palate, and 1 had a deep nasopharynx. No deletion of 22q11 region was detected in any of the evaluated patients. CONCLUSIONS A routine screening for the 22q11 deletion in older children and adults presenting with an isolated palatal anomaly may not be required. Because other signs related to VCFS such as facial dysmorphism and behavioral or psychiatric disorders may evolve at an older age, young patients should be followed up and reevaluated for additional relevant symptoms that may lead to deletion evaluation. In light of the fact that the current literature is inconsistent, the relative small size of this study and the significant consequences of missed 22q11.2 deletion, more information is needed before definitive recommendations can be made.

On the variability of velopharyngeal valve anatomy and function: a combined peroral and nasendoscopic study.

The oropharynx stripped of the tonsils and the excessive mucosal folds after the uvulopalatopharyngoplasty operation allows a closed observation of the outline of the pharyngeal muscles. Forty-two consecutive patients undergoing uvulopalatopharyngoplasty were subjected to peroral examination of the oropharynx combined with nasendoscopic examination of the velopharyngeal valve. At rest, the oropharynx of the patients with coronal closure patterns was found to be flat relative to the oropharynx of the patients with the other closure patterns. During closure of the velopharyngeal valve, an anteroposterior movement of the velum, forming the nasendoscopic coronal closure pattern, was observed in patients with a flat oropharynx. On the other hand, a medial movement of the pharyngeal walls was found, forming the circular or sagittal closure pattern seen in patients with a deep oropharynx. Our conclusion is therefore that a different muscular orientation is responsible for both the different pharyngeal configuration at rest and the different contribution of the lateral and posterior pharyngeal walls to velopharyngeal valve closure.