Injection Pharyngoplasty With Calcium Hydroxyapatite for Treatment of Velopalatal Insufficiency

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114, USA.
Archives of Otolaryngology - Head and Neck Surgery (Impact Factor: 2.33). 04/2008; 134(3):268-71. DOI: 10.1001/archotol.134.3.268
Source: PubMed


To evaluate the efficacy of injectable calcium hydroxylapatite for treatment of velopalatal (VP) insufficiency (VPI).
Observational case series of 7 patients treated with injectable calcium hydroxylapatite for VPI and followed for 10 to 24 months.
Academic pediatric otolaryngology practice.
Seven children aged 6 to 16 years with clinically significant VPI stemming from documented small VP gaps and who did not benefit from speech therapy were treated with calcium hydroxylapatite injection pharyngoplasty.
Posterior pharyngeal wall augmentation with calcium hydroxylapatite.
Treatment success was defined as (1) speech improvement to the degree that parents felt no additional treatment was needed and (2) meeting postoperative nasometric measures. Treatment failure was defined as parental report of insufficient improvement in speech. Complications and additional treatments for VPI were noted.
There were no major complications in any of the 7 children injected with calcium hydroxylapatite. There was 1 minor complication: 1 patient was readmitted for postoperative pain and dehydration. Of the 7 patients, 4 experienced a satisfactory result for up to 17 months. Findings from postoperative nasometry were either within reference range, or less than 1 SD greater than the reference range, for all sounds. There were 3 treatment failures, each with preexisting craniofacial abnormality. Two patients in the group that failed treatment later underwent revision superior pharyngeal flap surgery without complication or hindrance from the calcium hydroxylapatite injection. Four children underwent subsequent magnetic resonance imaging evaluations up to 1 year after injection, which revealed no evidence of migration.
The data from this small series suggest that posterior pharyngeal wall injection with calcium hydroxylapatite is safe and may be effective in treating select patients with VPI. Further longitudinal studies, with a larger series of patients, examining the safety, efficacy, and patient selection are warranted to better understand the possible use of posterior pharyngeal wall injection of calcium hydroxylapatite in children with symptomatic VPI.

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    • "All patients were fulfilling the following criteria: -The hypernasal speech started after adenoidectomy with a history of pre-adenoidectomy normal speech. -No speech improvement for at least 3 months after adenoid removal [8] [9] [10]. -No history of cleft palate repair. "
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    ABSTRACT: Persistent hypernasality after adenoidectomy is an infrequent problem in children with normal palate. However if it happened, it can render a child's speech unintelligible resulting in serious affection of social life. We aimed in this study to identify the causes of persistent post-adenoidectomy velopharyngeal insufficiency and to assess the efficacy of sphincter pharyngoplasty in the treatment of such problem. This study was conducted on 18 patients complained of hypernasal speech following removal of their adenoids after variable periods of failed expected spontaneous improvement. Their hypernasality was rated as being mild, moderate and severe, all cases were subjected to conservative treatment in the form of speech therapy for 3 months to correct the problem, and patients that did not respond to speech therapy were subjected to surgical intervention in the form of sphincter pharyngoplasty. Velopharyngeal closure was assessed using flexible nasopharyngoscopy, while speech was assessed using auditory perceptual assessment and nasometry. Hypernasality was mild in 9 cases, moderate in 7 cases and severe in 2 cases. Flexible nasopharyngoscopy showed occult submucous cleft in 5 cases, short palate in 2 cases, and deep nasopharynx in 3 cases. Speech improvement was achieved in 8 cases after completion of speech therapy program (all had mild hypernasality with no anatomical palatal defects). Ten patients that had palatal defects were subjected to sphincter pharyngoplasty, 8 of them showed complete recovery, while 2 cases with severe hypernasality showed partial improvement of their speech. Persistent post-adenoidectomy velopharyngeal insufficiency may be due to anatomical abnormalities of the palate such as an occult submucous cleft, short palate or deep nasopharynx; such conditions may be overlooked during the preoperative preparation for adenoid removal. Speech therapy is an effective method in mild hypernasality especially if there is no anatomical abnormality, while surgical correction is usually needed in moderate and severe cases, and sphincter pharyngoplasty is a useful choice for those patients.
    International journal of pediatric otorhinolaryngology 08/2009; 73(10):1329-33. DOI:10.1016/j.ijporl.2009.05.026 · 1.19 Impact Factor
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    ABSTRACT: To discuss principles of evaluation and treatment of children with velopharyngeal insufficiency, and to review recent reports of surgical outcomes. Velopharyngeal insufficiency significantly impacts both quality-of-life and speech intelligibility in children. Diagnosis is made through history and physical, perceptual speech assessment, and instrumental measures including nasendoscopy and radiographic multiplanar videofluoroscopy. Treatment options for velopharyngeal insufficiency consist of prosthetic management or surgery, supplemented with speech therapy when appropriate. Surgical interventions are palatal, palatopharyngeal or pharyngeal in nature. Despite some controversy, most recent reports identify no significant difference in outcomes following pharyngeal flap or sphincter pharyngoplasty. Complications of surgical therapy relate to postoperative obstructive breathing or persistent velopharyngeal insufficiency. Although there is no universally accepted measure to assess velopharyngeal insufficiency severity, nasendoscopy and multiplanar videofluoroscopy are most commonly used for clinical diagnosis. A speech pathologist is an integral member of the velopharyngeal insufficiency team, and momentum toward a standardized reporting system of perceptual speech measurements is increasing. Treatment of velopharyngeal insufficiency should be tailored to the specific needs of the child and family. Surgical therapy may improve velopharyngeal function but may negatively impact upper airway patency and respiration during sleep. The otolaryngologist should be familiar with strengths and limitations of different surgical options for velopharyngeal insufficiency.
    Current opinion in otolaryngology & head and neck surgery 01/2009; 16(6):530-5. DOI:10.1097/MOO.0b013e328316bd68 · 1.84 Impact Factor
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    ABSTRACT: Journal articles relevant to the diagnosis and treatment of velopharyngeal insufficiency were reviewed. All studies ascertained by PubMed search were included. Studies reported on the application of magnetic resonance scanning, reliability tests of the International Working Group diagnostic protocol, the use of nasometry, and techniques designed to assess the function of the velopharyngeal mechanism. Treatment studies focused on outcomes in small samples of cases and complication rates from pharyngeal flap. One study discussed ineffective speech therapy procedures. There were relatively few studies this past year. Those that were published were hindered by small and heterogeneous sample sizes and occasionally by inappropriate methods for assessing outcomes. None of the findings will have a major impact on the current state-of-the-art for diagnosis of velopharyngeal insufficiency. The speech therapy study has a very important message that should be taken to heart by all clinicians involved in the management of children with clefts and craniofacial disorders.
    Current opinion in otolaryngology & head and neck surgery 06/2009; 17(4):302-7. DOI:10.1097/MOO.0b013e32832cbd6b · 1.84 Impact Factor
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