eMedicine Specialties > Plastic Surgery > Craniofacial

Craniofacial, Pharyngoplasty and Pharyngeal Flaps: Workup

Author: Pravin K Patel, MD, Associate Professor of Surgery, Division of Plastic Surgery, Northwestern University School of Medicine; Chief of Plastic and Craniofacial Surgery, Shriners Hospitals for Children; Head of Craniofacial Surgery, Children's Memorial Hospital
Coauthor(s): Erin K McGraw, MA, CCC-SLP/L, Speech-Language Pathologist, Cleft Palate and Craniofacial Team, Shriners Hospital for Children-Chicago; Raja Ramaswamy, MS, The Chicago Medical School; Mary M O'Gara, MA, Director, Cleft Lip and Palate Institute, Inc; Associate Professor, Northwestern University Medical School; Mitchell F Grasseschi, MD, Assistant Professor, Department of Plastic Surgery, Feinberg School of Medicine, Northwestern University; Private Practice, Plastic and Reconstructive Surgery
Contributor Information and Disclosures

Updated: Feb 23, 2009

Workup

Laboratory Studies

  • Patients with symptoms of velopharyngeal (VP) dysfunction (ie, hypernasality, nasal emission, facial grimacing, compensatory misarticulations) on perceptual speech screen are referred to a VP diagnostic center for video-recorded standard perceptual, nasoendoscopic, and fluoroscopic speech evaluations. The videos and patient records are reviewed by the interdisciplinary VP dysfunction team (ie, speech/language pathologist, otolaryngologist, prosthodontist, plastic surgeon), and a consensus is reached for recommended management.
  • Based initially on history and physical examination, appropriate tests and procedures should be performed to confirm or rule out concomitant abnormalities of syndromic etiology.

Imaging Studies

  • The videofluoroscopic technique involves the instillation of barium into the nasopharynx. Real-time imaging can be used for playback at normal speed or slow motion. The images can be obtained in 3 dimensions (lateral, frontal, and basal). A major advantage of videofluoroscopy is its ability to help evaluate patients who are uncooperative or noncompliant. The examination usually takes 2-3 minutes, with radiation exposure of less than 0.02 Gy.
  • Videoendoscopy or nasopharyngoscopy uses a fiberoptic nasopharyngoscope with a high-intensity light attached to an endoscopic video monitor. The procedure can be videotaped. The scope is highly flexible and well tolerated (tip size of 3 mm).
    • Topical anesthesia and phenylephrine are sprayed into the nasopharynx to establish mucosal decongestion and to induce superficial vessel vasoconstriction. The nasopharyngoscope is placed through the nasal cavity superior to the VP port, and the movements of the velum, the lateral pharyngeal walls, and the posterior pharyngeal wall are observed while the patient repeats oral speech targets that he or she can correctly articulate. In addition, the depth and width of the pharynx and abnormal morphology and distortions in movements of the palate and pharyngeal walls are evaluated.
    • The major advantage of videoendoscopy is the lack of ionizing radiation. This allows for a longer, more in-depth examination that can be repeated as often as necessary.
    • Further, the ability of videoendoscopy to help assess all structures at the same time in relation to each other is superior to the 2-dimensional view obtained from videofluoroscopy.

Other Tests

  • Pre-VP management tonsillectomy and/or adenoidectomy are advised if the initial airway evaluation findings indicate that the lymphoid mass will compromise the operation or patency of the ports.
    • These procedures are performed 3 months before VP surgery, as needed to facilitate technical execution of the subsequent procedure.
    • Clinical manifestations of VP insufficiency may worsen after tonsillectomy and adenoidectomy. Repeating the evaluation 3 months after these procedures is a wise plan because of potential changes in closure patterns that may alter the treatment plan as a result of such surgery.
  • Preoperative consultations from appropriate subspecialists are recommended as needed by the VPI team.
  • Pulsations of the posterior wall should alert the surgeon to possible anomalous internal carotid arteries that are placed too medial in location. Angiography should be performed to help with visualization and avoid injury to the vasculature.
  • To minimize the risk of surgically-induced obstructive sleep apnea, a careful assessment of the upper airway, which may include formal sleep studies, is done before performing surgery.

Diagnostic Procedures

  • A video-recorded standard perceptual speech screen should be performed by a trained speech/language therapist.
  • A nasoendoscopic speech evaluation should be performed.
  • A fluoroscopic speech evaluation should be performed.
  • The video-recorded evaluations and patient records are reviewed by the interdisciplinary VP dysfunction team (ie, speech/language pathologist, otolaryngologist, prosthodontist, plastic surgeon), and a consensus is reached for recommended management.

More on Craniofacial, Pharyngoplasty and Pharyngeal Flaps

Overview: Craniofacial, Pharyngoplasty and Pharyngeal Flaps
Workup: Craniofacial, Pharyngoplasty and Pharyngeal Flaps
Treatment: Craniofacial, Pharyngoplasty and Pharyngeal Flaps
Follow-up: Craniofacial, Pharyngoplasty and Pharyngeal Flaps
Multimedia: Craniofacial, Pharyngoplasty and Pharyngeal Flaps
References
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References

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Further Reading

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Keywords

velopharyngeal dysfunction, VPD, velopharyngeal insufficiency, velopharyngeal inadequacy, velopharyngeal incompetence, VPI, VP inadequacy, VP incompetence, VP insufficiency, VP augmentation, velopharyngeal augmentation, cranio-facial surgery, cranio-facial pharyngoplasty, craniofacial pharyngoplasty, pharyngeal flap, speech disorder, resonance disorder, hypernasality, misarticulation, escape of air through the nose, nasal emissions, aberrant facial movements, grimacing, cleft palate repair, cleft palate, structural palate deficiency, myasthenia gravis, cerebrovascular accident, upper motor neuron lesion, lower motor neuron lesion, head trauma, short palate, scarred palate, tightened palate, levator palatini dysfunction, levator palatini malposition, poor pharyngeal wall mobility, misarticulated speech, palatal prosthesis, velar lift, VP obturator, velopharyngeal obturator

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Contributor Information and Disclosures

Author

Pravin K Patel, MD, Associate Professor of Surgery, Division of Plastic Surgery, Northwestern University School of Medicine; Chief of Plastic and Craniofacial Surgery, Shriners Hospitals for Children; Head of Craniofacial Surgery, Children's Memorial Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Erin K McGraw, MA, CCC-SLP/L, Speech-Language Pathologist, Cleft Palate and Craniofacial Team, Shriners Hospital for Children-Chicago
Erin K McGraw, MA, CCC-SLP/L is a member of the following medical societies: American Cleft Palate/Craniofacial Association and American Speech-Language-Hearing Association
Disclosure: Nothing to disclose.

Raja Ramaswamy, MS, The Chicago Medical School
Raja Ramaswamy, MS is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Mary M O'Gara, MA, Director, Cleft Lip and Palate Institute, Inc; Associate Professor, Northwestern University Medical School
Disclosure: Nothing to disclose.

Mitchell F Grasseschi, MD, Assistant Professor, Department of Plastic Surgery, Feinberg School of Medicine, Northwestern University; Private Practice, Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Larry Hollier, Jr, MD, Assistant Professor, Department of Plastic Surgery, Baylor University College of Medicine
Larry Hollier, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, AO Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

S Anthony Wolfe, MD, Chief, Division of Plastic Surgery, Miami Children's Hospital; Voluntary Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami School of Medicine
S Anthony Wolfe, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic and Reconstructive Surgery, Florida Medical Association, and Southeastern Society of Plastic and Reconstructive Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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