| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Velpharyngeal Insufficiency I would like to talk a little bit about velopharyngeal insufficiency. I will start with some cases. These kids will come up again during the course of the talk. First we have a seven-year-old female with velocardiofacial syndrome. She has difficulty with articulation due to velopharyngeal insufficiency, and she also has a learning disability. She has not responded to speech therapy and is very difficult to understand. Next we have a four-year-old female without a history of cleft palate and who also has VPI. She has no known contributing medical conditions or syndrome. Then we have an 11-year-old male with a history of unilateral complete cleft lip and palate who underwent palatoplasty at a young age and then underwent a pharyngeal flap operation for VPI three years prior to the exam that you are going to see. He experienced a lot of improvement after that but came back because he had a few sounds that were still problematic for him. This is a combination of different definitions, really it is basically my definition of VPI. It is the inability to maintain the separation of the oro- and nasopharynges during speech and/or swallowing. We are going to talk mainly about speech today. It results from a deficiency or a dysfunction of tissues in the velum orpharyngeal walls which together make up what is called the velopharyngeal isthmus, valve, or sphincter. This concept was first described by Passavant in 1863. Just really briefly, there is some embryology reviewed which is not really depicted here, the primary palate which is anterior to the incisive foramen forms at about four to six weeks, and then the secondary palate fuses in an anterior posterior direction in the midline between weeks six and 12. A defect in the secondary palate development is commonly related to VPI later. On the color slide on the top, you can see some of the important muscles in this. You have the levator veli palatini right here and the palatopharyngeus which you can kind of tell are antagonistic in their forces. The musculus uvulae is here which is the only intrinsic muscle of this palate. The superior constrictor muscle is cut and then here you have the tensor veli palatini which really does not contribute much to palatal movement but is very important in eustachian tube problems related to cleft palate. The levator is the primary elevator of the palate, and the palatopharyngeus is the primary depressor of the palate. The musculus uvulae effectively forms a bulge or a hump when it contracts which is important for some people in velopharyngeal competence, and the constrictor is responsible for the lateral and posterior walls. In the bottom plate here we have an image that is not real clear but it has one side that is supposed to depict a normal palate with the muscles all sort of facing each other in a sling-like fashion in the soft palate, and this is a cleft side and the most important thing to note here is that the levator muscles insert into the back end of the hard palate. The movements that are important in velopharyngeal closure are those of the soft palate or velum, which is up and back and you also have the lateral walls which move medially and the posterior wall which moves anteriorly in some people. Related to this posterior wall movement is the concept of Passavant’s ridge which is a dynamic temporary posterior wall muscle mass that comes forward during speech. This may be important for velopharyngeal closure in some people but really it is often below the area of contact. A more important landmark really is higher up or approximately at the prominence of C1, sometimes the adenoid pad, and this is about the level of the hard palate. It is important to identify this prior to contemplating surgery. This will come into play later when we talk about those things. Velopharyngeal closure can occur in several patterns. The most common is the coronal pattern, which involves the posterior movement of the velum towards the posterior wall. The circular pattern is the next most common and involves basically a collapsing towards the middle of the pharynx by all of the involved walls including the soft palate, and then the sagittal pattern is the least common and this is where the lateral walls meet in the midline. And with this pattern there really can be quite minimal movement of the velum and/or the posterior wall. So VPI is basically when these closure patterns are incomplete. Some authors distinguish between velopharyngeal insufficiency and competence. You will see that sometimes. Most, however, use these words interchangeably and that is the way I will use them today. There are various reasons why velopharyngeal insufficiency can occur listed here. The structural reasons—among those cleft palate is the most common—and you will see incidences of post cleft palate repair, VPI between 5 and 70% but it is quite common. Submucous cleft palate is an incomplete cleft with muscular diastasis only. This is a picture of what it looks like. The mucosa is intact but the muscles are not, and there is a triad that distinguishes it with a notched hard palate. This is the back end of the hard palate here. This blue is called the zona pellucida which is where the mucosa is intact on the nasal and oral side but there is nothing between, and then the bifid uvula is also part of the triad. You can also get VPI after adenoidectomy or with some congenital anatomic irregularities like a short palate or deep pharynx. Tonsillar hypertrophy has been described as causing VPI by itself as it can inhibit movement of the palate against the posterior wall. You can get VPI after maxillary advancement surgery; and there is a concept of stress VPI, which is related to those who need to generate very high pressures such as those playing woodwind instruments. Neuromotor causes basically consist of various causes for hypotonia and there are several of these. You can also get dysarthrias and apraxias which can have VPI as a component. These are basically poor movement of the articulators or poor coordination of the articulators, respectively. The bottom category, mislearning, is basically not true VPI. It is a competent valve being used ineffectively. It responds to speech therapy and it really just mimics VPI. One syndrome of the 100 that are associated with cleft palate and/or VPI is velocardiofacial syndrome. This is caused by a deletion of the long arm of chromosome 22. It is associated with cleft palate as well as some distinguishing facial characteristics such as a broad nasal bridge, bulbous fleshy nasal tip, an elongated face, and small low set ears. These patients also have small or absent adenoids and pharyngeal hypotonia. You can see a lot of swallowing dysfunction in these kids. When contemplating surgery on them, you should be aware that the internal carotids are often in an abnormal location and generally medial and near the nasopharynx. You can sometimes see this pulsating when you do an endoscopic examination. These kids also have learning disabilities and there are cardiac anomalies. In all, there are really 30 or more anomalies that are associated with this syndrome. These are just the highlights. Evaluation of VPI is best done with a team approach. Players involved include the speech and language pathologist, the radiologist, the surgeon, and a geneticist to evaluate further syndrome manifestations; but the perceptual evaluation though is the most important in determining whether or not a patient needs to have surgery or some other intervention. Nasometry has helped to assess the severity of the problem, although it is not consistently done, and x‑rays and endoscopy are complementary also in the workup. With regard to the speech/language pathologist, there are two basic parts that he or she is responsible for at the outset. The perceptual testing part is again the most important. It is important to realize that basically all sounds except for N and M in speech require velopharyngeal closure, and basically perceptual testing detects VPI when a patient is asked to do things other than these sounds. You can get hypernasality and nasal air emission which is a part of this workup, and you also get weak omitted consonants. Their utterances or sentences are short and their speech tends to take on a choppy pattern because of the leak. Then the pathologist can identify various compensatory articulations which basically occur at the larynx, pharynx, or sometimes the nasal level where the patient tries to mimic sounds that are ordinarily made at the velopharyngeal level in these anatomic areas. You can also see grimacing sometimes which helps with these compensatory articulations. Nasometry quantifies air escape through the nose and compares it with air escape through the mouth during speech. It gives a score that really requires careful interpretation because sometimes really severe VPI can cause a low score and vice versa. Radiologic evaluation, really the most important part of this, is the videofluoroscopy. I have static images here, some images obtained during fluoro. Generally you get the sagittal view that we are seeing here as well as a base view and AP view. And patients are studied during speech. Barium, you can see here, is often instilled in the nose to help outline the structures. There is a little bit here too. The top series here shows a patient who is trying to speak and articulate and is making an effort at closure but you can still see a persistent gap here. This is the velum, posterior pharyngeal wall—they are kind of labeled over here—and here is a gap. Again, pay attention to the level. This is the level of C1. The bottom is a patient after sphincteroplasty where you can see there is more contrast here, but there is better closure. This is the area of the sphincteroplasty and here he has better closure, a smaller gap. These MRI images and CT reconstruction are presented just as something that may be in the future. You see here the velum and posterior pharyngeal wall at rest and during speech or during VP closure. Here you can see again how high contact is, this is actually the adenoid pad. These things may one day be quite common, the workup of VPI. This is again a 3-D reconstruction obtained with CT. This is the larynx not the velopharyngeal area but one day this may provide noninvasive means to look at the anatomy in three dimensions, similar to what we are doing with endoscopy now. Next, we are going to try and look at some cases. The first two patients, one is with velocardiofacial syndrome, that is the first patient. The second one just had the isolated submucous cleft. You can see that this child was fairly anxious. There was no great look there but the palate did not elevate normally. This is a nasopharyngeal view. This is basically inadequate wall motion and you can see this gap. You are supposed to be seeing closure here between the soft palate and the posterior pharyngeal wall and obviously there was none. Now it is quite short. And this is another patient. She has a submucous cleft palate. I will go back and we will show that endoscopy at the end after I come back off of this presentation again; but there are some characteristic findings on nasal endoscopy and the patient with the submucous cleft palate that we will take a look at later. So then, we are going to move onto treatment for now. There are basically several different types of treatment. One is speech therapy. This is generally not enough in itself for structural problems related to VPI. It is, however, valuable when you see small gaps or inconsistent closure and it is very valuable either before or after surgery, or both, in order to eliminate these compensatory strategies that patients develop over time. Biofeedback is a remedy by some people, but we will talk mainly about prostheses and surgery. Prostheses come in two basic types. There are obturators and palatal lifts. The obturators like this one, which is called a speech bulb, just provides a bulky apparatus for the pharynx against which the lateral walls and the palate can close during speech. Lifts actually elevate the palate towards the pharyngeal walls and the residual palate motion does the rest. These are sometimes used during therapy to help stimulate the muscles, and it is felt they sometimes limit the amount of surgery the patient needs if these lifts are used during speech therapy before surgery. Generally, especially in kids, prostheses are not well tolerated and they can be lost and children can outgrow them. They can, however, be used when surgical risk is prohibitive. In terms of velopharyngeal insufficiency surgery, there are really dozens of techniques that have been used and many of them are subtle variations on a theme or combinations of approaches. We will cover some of the most common which fall into four main groups: the static flaps, dynamic flaps, palate lengthening maneuvers, and/or palate repair and posterior wall augmentation. It is important to realize that the work I mentioned before is not just to determine if VPI exists or not, but it is supposed to help tailor surgery to define a defect. Some of the things you should look at before deciding on which type of surgery a patient would benefit from is the severity of the gap or gaps, which structures are deficient and/or dysfunctional, what closure pattern is most likely to be the best, and then again—as I mentioned—the level of contact should be identified. That being said, there are a number of institution or surgery-specific algorithms that seem to limit the choices in various places. Basically, many surgeons or institutions have a favorite procedure or two, and they make modifications as needed. Others seem to start with one type of procedure and then use another if the first type of procedure fails. These are presented just as an example of how different people have come up with different algorithms. These reflect the practices in Seattle, Florida, Taiwan, and England and you do not have to look at them in any detail. We are going to discuss many of these different procedures in a second. First, we will talk about the pharyngeal flap. This was and probably remains the most commonly performed type of surgery for VPI. It provides a static obturator for contact of the lateral pharyngeal walls during speech. Again, it is very commonly used, but it is probably best with a central defect. Many think it is the best thing to use with a large defect, either alone or in combination with other methods, and it is best when you have good lateral wall movement. It can be superiorly based or inferiorly based. Most done today, I think, are superiorly based since this is felt to provide better reach. You have to remember that the palate wants to move up and back and an inferiorly based flap would tether it somewhat. However, a superior-based flap is considered somewhat more difficult to perform. The flap can be “tuned” to a defect by controlling its width and, therefore, the size of its lateral ports. Dr. Hogan here was mentioned in the slide. He was, I believe, the first to publish an article that called for control of ports with artificial airway. We will see in a second the methodology. Many now line the raw surface of the pharyngeal flap with mucosa rotated from the nasal aspect of the palate to keep the flaps from contracting. This has been associated with the flap being smaller and less wide and, therefore, providing less obturation and it can compromise results in the long term. And then again you have to pay attention to the height at which the flap is based so that it is close to where the natural movement of the pharynx wants to be maximum. This is a quick view of the methodology. Basically, most divide the palate in the midline and then harvest the flap from the posterior wall. The depth of the flap is down to the prevertebral fascia so it includes the superior constrictor muscle. You see on the image to your right, most people do close the donor defect. There is some discussion of how high to close it. I think that most people would like to stop just before the flap starts to “tube.” You can see if you narrow this anymore that it results in a tube. And then here you can see catheters placed through the lateral ports for control of these ports. These little guidelines reflect incisions in the nasal surface of the palate for insetting of this flap. Here you can see how it is insetting at the nasal mucosa. Many people would take this opportunity then to correct the levator sling. We did mention that the levator muscles were inserted in a cleft or submucous cleft into the posterior aspect of the hard palate, and you have a chance here to correct that. And then this is where the tissue comes from. You rotate the flap from here and when you close the palate again you can put those down and cover this raw edge of the pharyngeal flap to prevent contracture and closure as in several layers again addressing the levator sling. VPI surgery of all types carries some risk to the airway since you are narrowing it somewhat or closing it off. Many feel, however, that these complications have been more severe and common with pharyngeal flap surgery, and this has spurred a movement away from pharyngeal flap surgery. So this is a pretty good time to talk about these particular complications. Airway obstruction or obstructive sleep apnea in the perioperative period has caused several deaths in the past and these have been reported. And some authors have published papers revealing increased incidence of obstructive sleep apnea after pharyngeal flap. More recent papers have tried to work out how much of a problem this is. Essentially, it seems that it is really quite common in the first 48 hours after surgery and this rarely persists really beyond a few months. Postop management, then, is a controversy and many keep patients in the ICU and it is fairly common now or almost standard now to keep some sort of artificial airway in place for some period of time both for control of the ports as well as to prevent this obstruction in the postop period. Many try to prevent obstruction of the ports by having the patient undergo tonsillectomy several weeks prior to the pharyngeal flap so that the ports can stay open. Hyponasality, the opposite of hypernasality, when there is too little air flow through the nose, is a known risk with all VPI surgery but again this has been most closely linked to pharyngeal flaps. These effects can be long term and have also contributed then to the movement away from pharyngeal flap surgery. Another method of surgery, another broad method, is recreation of the dynamic velopharyngeal sphincter, called sphincter pharyngoplasty or sphincteroplasty. This is supposed to create a dynamic sphincter, however interestingly, EMG studies are very inconsistent and seem to indicate that the transplant muscle flaps do not remain contractile. Nevertheless, these procedures seem to work and many think they may just provide a really good obturating effect to the posterior wall. Keep in mind that they are supposed to be dynamic. They are best used when lateral wall movement is poor, and it has been described as a good procedure for stress VPI which we discussed earlier. There have been a lot of methods of sphincteroplasty published over the years. Dr. Hyde in the 50s published this one which is still used. Basically—and I should mention at first the palate is not split in any of the sphincteroplasty operations as a matter of course, it is just done here for exposure—but you start with an inverted U-shaped incision and then you harvest superiorly based posterior tonsillar pillar flaps. These contain the palatopharyngeus muscles right through here. You basically rotate those in to the horizontal part of the U-shaped incision and in the Hyde repair as initially described you overlap them in this manner. You try to sew these in high near where you think the velum will want to contact the posterior wall. This gentleman in Columbia modified the sphincteroplasty technique in the 60s. He creates the artificially low sphincter by rotating the palatopharyngeus muscles into an inferiorly based posterior wall flap or pharyngeal flap. He has published quite good results with this method. And finally, Jackson and colleagues published several papers modifying the sphincteroplasty. Initially—and I do not have a good picture of this—there was a superior pharyngeal flap involved that more or less flipped over the palatopharyngeus muscle flaps. Most recently that has not been the case and, basically, some of the Hyde method except for the fact that the flaps meet in this manner is opposed to overlapping. The palate is really drawn quite high here. This area is supposed to be an area of normal closure, quite a bit higher than this. The third broad category of surgery is veloplasty. These are basically techniques that treat the palate primarily, and they are variations of procedures generally used to repair cleft palates. They are best with inadequate palate length or movement, and in general they either lengthen the palate or recreate the levator sling or both. These are oftentimes combined with other types of flaps as well, and I mentioned earlier the veloplasty portion in particular can be done with numerous other methods. These are types of incisions for a pushback or a Y-to-Y pushback. You make the incision and you elevate back and this is a really good depiction of where the levator muscles can be seen in surgery on the posterior aspect of the hard palate. These are released and the sling is recreated here, and then the closure allows the palate to be pushed back and this lengthens it. You leave these small raw surface areas on the hard palate, which heal by secondary intention. Dr. Furlow introduced this technique in the 80s and it basically also is a veloplasty technique. It is called a double opposing Z-plasty. This is a patient with a true cleft of the secondary palate but this is also an incision that you make if you’re doing it for other reasons and you elevate these flaps. You leave the levator muscle attached to a mucosal surface, one on the nasal side, one on the oral side, and you reorient those so the levator sling is transverse and then the mucosal segment is also included in the Z-plasty as the palate is lengthened. A fourth broad category is posterior pharyngeal wall augmentation. This is basically a static augmentation of the posterior wall to allow a compromised palate to achieve contact. It is best with a small gap and with good palate movement, and it has been especially good with patients who get VPI after adenoidectomy. The level of augmentation is always important and the important thing about these, and the reason why they are not often advocated, several of the materials have been used and all of which have the well-documented reported consequences of extension, migration, atrophy in the case of autogenous tissues, and rejection. There is one method that is the folded superior pharyngeal flap technique that still is being advocated to be used in patients with small gaps. Here we see basically any type of alloplastic material can be used. Again, the level is very important. This is the folded superior pharyngeal flap technique where you raise the flap and you fold it on itself, again, right at the place where the velum would like to contact. It is very difficult to get a good feel for how truly effective this type of surgery is by reading the literature. These two tables are from review articles and they just illustrate how much variation there is in their reported rates of success, especially here in the lower table you can see that. In the bibliography that I provide you can actually find papers that document success in 22 to 90% of pharyngeal flaps, 38 to 100% of sphincteroplasties, and 40 to 98% of Furlow veloplasties. There was a randomized study of pharyngeal flap versus sphincteroplasty down in Mexico, which showed similar rates of success with these two procedures. Meanwhile, papers out of Seattle seem to indicate that they really do not do pharyngeal flaps anymore. It is not part of their algorithm. This lack of consensus is caused by several things. One is the methods that determine success differ greatly, whether objective or subjective. The amount of residual hypernasality that is tolerated is different, and these two are related concepts. Basically if the patient is happy and speaking better, some just stop there. Others do rigorous objective testing, and any type of leak is considered a failure. Papers and institutions also differ in terms of how much hyponasality is allowed. Some consider hyponasality to be a necessary evil. Others consider it to be a failure by definition. And then the various techniques as I described often differ a bit, as does the experience of those doing the surgery. So, I have to say basically there is no clearly right answer in terms of all these methods. It is basically an effort to tailor the surgery to the defect as well as to the surgeons going on preferences and experience. So, in summary, you should consider the etiology of VPI when you are designing your treatment. You define individual defects in detail using a variety of tests. You should do workup and treatment as a team including a speech pathologist and a geneticist. You should become knowledgeable about multiple management techniques and then choose a treatment that is based on the characteristics of the defect at hand as well as individual experience. I would like to acknowledge these people for their help in doing things and I still wanted to show, if you would not mind, the endoscopies. You can see a bifid uvula there and poor elevation of the palate. The patient is trying to speak. This is a four-year-old. This is a nasal endoscopy, and I wanted to point out here it is this central concavity which is due to muscular diastasis. It is very characteristic. You do not see a hump at the musculus uvulae area which you often see otherwise. This is the pharyngeal flap patient I was talking about. He has had his cleft repaired, and his palate really does not move much when he speaks. This is the view of the nasopharynx. He has got reasonable lateral wall motion and here you can see, initially you get a glimpse and then you get a better view of the flap, this is the flap we are looking at right here, mucosalized, and lastly these lateral ports on the side that are closed off dynamically during speech by the lateral pharyngeal wall. Case Presentation Case #2 : Four-year-old female without a history of cleft palate. She has known velopharyngeal insufficiency that has not responded to speech therapy. She is generally intelligible. She has no contributing medical conditions or delays in speech. Case #3 : An eleven-year-old male with a history of unilateral complete cleft lip and palate. He developed velopharyngeal insufficiency after his initial palatoplasty and was treated with a superiorly-based pharyngeal flap three years ago. He has experienced significant improvement after this procedure and post-operative speech therapy. However, he continues to exhibit hypernaslity during speech. He has no evidence of sleep-disordered breathing. Bibliography: Bentz ML. Pediatric Plastic Surgery. Stamford, Connecticut: Appleton and Lange; 1998. pp.121-128. Bucholtz RB, Chase RA, Jobe RP, Smith H. The use of the combined palatal pushback and pharyngeal flap operation: a progress report. Plast Reconstr Surg 1967;39:554-561. Cable BB, Mair EA. Avoiding perils and pitfalls in velocardiofacial syndrome: an otolaryngologist’s perspective. Ear Nose Throat J 2003;82:56-60. Canady JW, Cable BB, Karnell MP, Karnell LH. Pharyngeal flap surgery: protocols, complications, and outcomes at the University of Iowa. Otolaryngol Head Neck Surg 2003;128:321-326. Chen PK, Wu J, Hung KF, Chen YR, Noordhoff MS. Surgical correction of submucous cleft palate with Furlow palatoplasty. Plast Reconstr Surg 1996;97:1136-1146. Cotton RT, Meyer CM. Practical Pediatric Otolaryngology. Philadelphia: Lippincott-Raven; 1999. pp. 825-838. de Serres LM, Deleyiannis FW, Elben LE, Gruss JS, Richardson MA, Sie KC. Results with sphincter pharyngoplasty and pharyngeal flap. Int J Pediatr Otorhinolaryngol 1999;48:17-25. Eblen LE, Sie KC. Perceptual and instrumental assessment of velopharyngeal insufficiency. Plast Reconstr Surg 2002;109:2589-2590. Finkelstein Y, Nachmani A, Ophir D. Surgical treatment of neurogenic velopharyngeal insufficiency. J Oral Maxillofac Surg 1996;54:244-245. Fraulin FO, Valnicek SM, Zuker RM. Decreasing the perioperative complications associated with the superior pharyngeal flap operation. Plast Reconstr Surg 1998;102:10-18. Furlow LT. Cleft palate repair by double opposing z-plasty. Plast Reconstr Surg 1986;78:724-736. Gosain AK, Conley SF, Marks S, Larson DL. Submucous cleft palate: diagnostic methods and outcomes of surgical treatment. Plast Reconstr Surg 1996;97:1497-1509. Gray SD, Pinborough-Zimmerman J, Catten M. Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 1999;121:107-112. Hofer SO, Dhar BK, Robinson PH, Goorhuis-Brouwer SM, Nicolai JP. A 10-year review of perioperative complications in pharyngeal flap surgery. Plast Reconstr Surg 2002;110:1393-1397. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg 1951;3:128. Jackson IT. Sphincter pharyngoplasty. Clin Plast Surg 1985;12:711-717. Jackson IT, Silverton JS. The sphincter pharayngoplasty as a secondary procedure in cleft palates. Plast Reconstr Surg 1977;59:518-524. James NK, Twist M, Turner MM, Milward TM. An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty. Br J Plast Surg 1996;49:197-201. Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg 1969;43:29-41. Laitung JK, Smith S, Bradley JP. The use of a balloon catheter in assessing velopharyngeal incompetence and determining the effect of pharyngoplasty. Br J Plast Surg 1999;52:160-161. McCarthy JG. Plastic Surgery. Philadelphia: W.B. Saunders; 1990. pp. 2903-2921. McVicar R, Edmonds J, Kearns D. Sphincter pharyngoplasty for correction of stress velopharyngeal insufficiency. Otolaryngol Head Neck Surg 2002;127:248-250. Meek MF, Henk Coert J, Hofer SO, Goorhuis-Brouwer SM, Nicolai JP. Short-term and long-term results of speech improvement after surgery for velopharyngeal insufficiency with pharyngeal flaps in patients younger and older than 6 years old: 10-year experience. Ann Plast Surg 2003;50:13-17. Morris HL, Bardach J, Jones D, Christiansen JL, Gray SD. Clinical results of pharyngeal flap surgery: the Iowa experience. Plast Reconstr Surg 1995;95:652-662. Netter FH. Atlas of Human Anatomy. Summit, New Jersey: Ciba-Geigy; 1989. Plates 46B and 48B. Netterville JL, Fortune S, Stanziale S, Billante CR. Palatal adhesion: the treatment of unilateral palatal paralysis after high vagus nerve injury. Head Neck 2002;24:721-730. Orticochea M. Physiopathology of the dynamic muscular sphincter of the pharynx. Plast Reconstr Surg 1997;100:1918-1923. Orticochea M. The timing and management of dynamic muscular pharyngeal sphincter construction in velopharyngeal incompetence. Br J Plast Surg 1999;52:85-87. Peat BG, Albery EH, Jones K, Pigott RW. Tailoring velopharyngeal surgery: the influence of etiology and type of operation. Plast Reconstr Surg 1994;93:948-953. Pigott RW. Velopharyngeal incompetence treated by the Orticochea pharyngoplasty. Br J Plast Surg 1997;50:471. Potsic WP, Cotton RT, Handler SD. Surgical Pediatric Otolaryngology. New York: Thieme; 1997. pp.226-229. Seagle MB, Mazaheri MK, Dixon-Wood VL, Williams WN. Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience. Ann Plast Surg 2002;48:464-470. Shprintzen RJ. Pharyngeal flap surgery and the pediatric upper airway. Int Anesthesiol Clin 1988;26:79-88. Sie KC, Gruss JS. Results with Furlow palatoplasty in the management of velopharyngeal insufficiency. Plast Reconstr Surg 2002;109:2588-2589. Sie KC, Tampakopoulou DA, de Serres LM, Gruss JS, Eblen LE. Sphincter pharyngoplasty: speech outcome and complications. Laryngoscope 1998;108:1211-1217. Sie KC, Tampakopoulou DA, Sorom J, Gruss JS, Eblen LE. Results with Furlow in management of velopharyngeal insufficiency. Plast Reconstr Surg 2001;108:17-25. Stoll C, Hochmuth M, Meister P, Soost F. Refinement of velopharyngoplasty in patients with cleft palate by covering pharyngeal flap with nasal mucosa from the velum. J Craniomaxillofac Surg 2000;28:171-175. Trier WC. The pharyngeal flap operation. Clin Plast Surg 1985;12:697-710. Vandevoort MJ, Mercer NS, Albery EH. Superiorly based flap pharyngoplasty: the degree of postoperative “tubing” and its effect on speech. Br J Plast Surg 2001;54:192-196. Wells MD, Vu TA, Luce EA. Incidence and sequelae of nocturnal respiratory obstruction following posterior pharyngeal flap operation. Ann Plast Surg 1999;43:252-257. Wilging JP. Velopharyngeal insufficiency. Curr Opin Otolaryngol Head Neck Surg 2003;11:452-455. Witt P, Cohen D, Grames LM, Marsh J. Sphincter pharyngoplasty for the surgical management of speech dysfunction associated with velocardiofacial syndrome. Br J Plast Surg 1999;52:613-8. Witt PD, O’Daniel TG, Marsh JL, Grames LM, Muntz HR, Pilgram TK. Surgical management of velopharyngeal dysfunction: outcome analysis of autogenous posterior pharyngeal wall augmentation. Plast Reconstr Surg 1997;99:1287-1296. Witt PD, Marsh JL, McFarland EG, Riski JE. The evolution of velopharyngeal imaging. Ann Plast Surg 2000;45:665-673. Ysunza A, Pamplona MC, Mendoza M, Molina F, Martinez P, Garcia-Velasco M, Prada N. Surgical treatment of submucous cleft palate: a comparative trial of two modalities for palatal closure. Plast Reconstr Surg 2001;107:9-14. Ysunza A, Pamplona C, Ramierez E, Molina F, Mendoza M, Silva A. Velopharyngeal surgery: a prospective randomized study of pharyngeal flap and sphincter pharyngoplasties. Plast Reconstr Surg 2002;11:1401-1407. BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005
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