Peter D. Witt

the Effect of Surgeon Experience on Velopharyngeal Functional Outcome following Palatoplasty: Is There a Learning Curve?

&NA; There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of “total procedures” and “procedure per year” were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of “total procedures” was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeons improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high‐volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low‐volume surgeons. The influence of the surgeons cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty. (Plast. Reconstr. Surg. 102: 1375, 1998.)

Acute obstructive sleep apnea as a complication of sphincter pharyngoplasty

This report describes postoperative airway compromise following sphincter pharyngoplasty (SP) for treatment of post-palatoplasty velopharyngeal dysfunction. A retrospective review of 58 SPs performed for post-palatoplasty velopharyngeal dysfunction, on 30 male, and 28 female patients, over a 5-year study period was undertaken at a tertiary referral academic institution (Washington University School of Medicine), at the St. Louis Childrens Hospital, Cleft Palate and Craniofacial Deformities Institute. Eight patients were identified who had the following inclusion criteria: overt perioperative and/or postoperative airway dysfunction, identifiable syndromes, or microretrognathia. Items reviewed were patient demographic factors, associated medical problems, genetics evaluations, nasendoscopic characteristics of velopharyngeal closure, anesthetic evaluation of the patients, and the incidence and severity of perioperative complications. Particular attention was paid to factors contributing to the airway obstruction. Of the eight subjects with perioperative and/or postoperative upper airway dysfunction following SP, five patients had Pierre Robin sequence/micrognathia, while three patients had a history of perinatal respiratory and/or feeding difficulties without micrognathia or an identified genetic disorder. All but two episodes of airway dysfunction resolved within 3 days postoperatively. These patients were discharged home with apnea monitors; both were readmitted with recurrent airway dysfunction. Continuous positive airway pressure (CPAP) was utilized successfully in all instances, and no patients required take-down of the SP to relieve airway dysfunction. CPAP is an effective, noninvasive treatment strategy for management of iatrogenically induced apnea following SP, without sacrificing the surgical benefit of improved speech intelligibility.

Salvaging the failed pharyngoplasty : Intervention Outcome

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 Childrens 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.

Sphincter pharyngoplasty : a preoperative and postoperative analysis of perceptual speech characteristics and endoscopic studies of velopharyngeal function

Perceptual speech and endoscopic evaluations were videotaped preoperatively and postoperatively for 20 patients who underwent sphincter pharyngoplasty. Randomized videotapes of these evaluations were rated by clinicians experienced in assessment of patients with velopharyngeal dysfunction. Results of perceptual speech ratings showed that nasal resonance following sphincter phryngoplasty improved in 79 percent of patients (p = 0.006), frequency of nasal emission decreased in 74 percent (p = 0.018), and severity of emission decreased in 79 percent (p = 0.006). Rating of the overall change in speech quality was not statistically greater than chance (p = 0.41). Thirty percent of patients were judged to be hyponasal postoperatively, while none had been preoperatively. Results of endoscopic evaluations showed that 75 percent of patients had a quantitative decrease in orifice size (p = 0.013). Despite improved velopharyngeal function, 65 percent of patients were still considered candidates for additional surgical management postoperatively. While sphincter pharyngoplasty resulted in improved perceptual speech characteristics and velopharyngeal function, only 18 percent of patients showed complete resolution of hypernasality and nasal emission, and only 35 percent demonstrated complete velopharyngeal closure postoperatively. (Plast. Reconstr. Surg. 93: 1154, 1994.)

Management of the hypodynamic velopharynx.

Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.

Composite grafting and hyperbaric oxygen therapy in pediatric nasal tip reconstruction after avulsive dog-bite injury.

It is estimated that more than four million people are bitten by dogs in the United States each year. The majority of such injuries are minor, and their treatment does not usually require surgical consultation. However, the authors report a case in which a Rottweiler inflicted a mutilating nasal tip/alar rim avulsion on a 5-year-old boy. They report their experience with immediate reconstruction of the nasal defect using a large ipsilateral auricular cartilage composite graft (crus helix). Adjunctive hyperbaric oxygen therapy (without sedation or anesthesia) was used to maximize the stimulus for graft revascularization. Reconstructive goals were achieved while avoiding the need for a central facial donor site defect.

Quantification of dynamic velopharyngeal port excursion following sphincter pharyngoplasty.

&NA; The sphincter pharyngoplasty is a surgical procedure designed to correct velopharyngeal dysfunction. Its advocates cite the theoretical advantage of its induction of dynamic activity of the neovelopharyngeal port, but this dynamic activity has yet to be quantitatively demonstrated in the literature. The purpose of this study was to quantify postoperative velopharyngeal dynamism and to document the results of intervention outcome on sphincteric excursion measurements from minimal‐to‐maximal orifice closure. We conducted a 7‐year retrospective review of speech videofluoroscopy evaluations in patients who had undergone sphincter pharyngoplasty in our center. Between 1989 and 1994, there were 58 patients so treated for postpalatoplasty velopharyngeal dysfunction by two surgeons using the same operative technique. Patients for whom sphincter pharyngoplasty was recommended fulfilled both of the following criteria: (1) velopharyngeal dysfunction caused by an anatomic, myoneural, or combined deficiency of the velopharyngeal sphincter that would not be expected to be managed by speech therapy alone, and (2) preoperative videonasendoscopy and speech videofluoroscopic studies that demonstrated large‐gap coronal, circular, or bow‐tie closure patterns or velopharyngeal hypodynamism. Of the original 58 patients, 24 underwent postoperative speech videofluoroscopic evaluations with basal views. Of these, 20 of the evaluations (83 percent) were of adequate quality to be included in a research study. Still images showing maximum and minimum excursion of the sphincter in basal view were obtained. To test for observer reliability, the speech videofluoroscopic studies were randomized and presented for measurement to the same individual on two occasions, each session separated by a 1‐month time interval. Topographic imaging software was used to obtain maximum and minimum measurements to within 0.1 mm. Partitioning the variance of the data showed that measurement variability was a very small portion of the total, and that difference between the minimum and maximum values was the largest source of variability. Of the total variability in the data, 64.0 percent originated in the minimum/maximum difference, 34.3 percent came from patient variability, and only 1.7 percent resulted from original or repeat measurements. The patient variability may be exaggerated because of variability in the scale of measurement. Results of this study indicate a quantifiable and statistically significant difference in maximum‐to‐minimum excursion of sphincteric closure. Sphincter pharyngoplasty appears to be dynamic in the majority of cases. (Plast. Reconstr. Surg. 101: 1205, 1998.)

Speech outcome following palatoplasty in primary school children: do lay peer observers agree with speech pathologists?

&NA; The aim of this study was twofold: (1) to test the ability of normal children to discriminate the speech of children with repaired cleft palate from the speech of unaffected peers and (2) to compare these naive assessments of speech acceptability with the sophisticated assessments of speech pathologists. The study group (subjects) was composed of 21 children of school age (aged 8 to 12 years) who had undergone palatoplasty at a single cleft center and 16 matched controls. The listening team (student raters) was composed of 20 children who were matched to the subjects for age, sex, and other variables. Randomized master audiotape recordings of the children who had undergone palatoplasty were presented in blinded fashion and random order to student raters who were inexperienced in the evaluation of patients with speech dysfunction. The same sound recordings were evaluated by an experienced panel of extramural speech pathologists whose intrarater and interrater reliabilities were known; they were not direct care providers. Additionally, the master tape was presented in blinded fashion and random order to the velopharyngeal staff at the cleft center for intramural assessment. Comparison of these assessment methodologies forms the basis of this report. Naive raters were insensitive to speech differences in the control and cleft palate groups. Differences in the mean scores for the groups never approached statistical significance, and there was adequate power to discern a difference of 0.75 on a 7‐point scale. Expert raters were sensitive to differences in resonance and intelligibility in the control and cleft palate groups but not to other aspects of speech. The expert raters recommended further evaluation of cleft palate patients more often than control patients. Speech pathologists discern differences that the laity does not. Consideration should be given to the utilization of untrained listeners to add real‐life significance to clinical speech assessments. Peer group evaluations of speech acceptability may define the morbidity of cleft palate speech in terms that are most relevant to the patients themselves and may safeguard against the possibility of offering treatment that may be unnecessary.

Do palatal lift prostheses stimulate velopharyngeal neuromuscular activity

The purpose of this investigation was to evaluate the ability of palatal lift prostheses to stimulate the neuromuscular activity of the velopharynx. Nasendoscopic evaluations were audio-videotaped preprosthetic and postprosthetic management for 25 patients who underwent placement of a palatal lift prosthesis for velopharyngeal dysfunction (VPD). These audio-videotapes were presented in blinded fashion and random order to three speech pathologists experienced in assessment of patients with VPD. They rated the tapes on the following parameters: VP gap size, closure pattern, orifice estimate, direction and magnitude of change, and qualitative descriptions of the adequacy of VP closure during speech. VP closure for speech was unchanged in 69% of patients and the number of patients rated as improved or deteriorated was nearly identical at about 15%. Postintervention gap shape remained unchanged in 70% of patients. The extent of VP orifice closure during speech remained unchanged in 57% of patients. Articulations that could impair VP function improved in 30% of patients, deteriorating in only 4%. Results of this study neither support the concept that palatal lift prostheses alter the neuromuscular patterning of the velopharynx, nor provide objective documentation of the feasibility of prosthetic reduction for weaning.

The evolution of velopharyngeal imaging.

&NA; Currently, functional visualization of the velopharynx requires tests that are either invasive (endoscopy) or that impart ionizing radiation (speech videofluoroscopy). The overall intrusiveness of endoscopy may limit its clinical utility, especially in young children. As a resut of growing awareness of the long‐range effects of radiation exposure associated with X‐ray imaging, radiographic research on subjects and studies not judged to be clinically necessary have been all but abandoned. The static nature of lateral radiographs precludes temporal assessment, and the two dimensionally of images derived from both of these diagnostic modalities may limit understanding of spatial anatomic relationships and may preclude quantitative analysis. The need for a noninvasive, rapid, and easily repeatable method for examination of the velopharynx has fomented the innovative application of existing technologies, especially magnetic resonance imaging. We present an updated overview of techniques for imaging the velopharyngeal mechanism, with a focus on residual velopharyngeal dysfunction after initial palatoplasty. We provide a comprehensive perspective of the role of currently available instrumentation, summarize the work in our center regarding the technological developments of magnetic resonance imaging, and speculate about future applications of magnetic resonance imaging systems for evaluation of velopharyngeal dysfunction. The limitations of each of these measures discussed are emphasized. Witt PD, Marsh JL, McFarland EG, Riski JE. The evolution of velopharyngeal imaging. Ann Plast Surg 2000;45:665‐673