velopharyngeal insufficiency(VPI) - structural origin and includes structural problems associated with the velum or the side walls at the level of the nasopharynx with insufficient tissue to accomplish adequate closure
velopharyngeal mislearning -mislearning or functional origin
Velopharyngeal dysfunction – all encompassing term for the above and does not imply a specific etiology
Previously thought that VP closure resulted from a short velum. And thus the push back procedures were used with little success. Now known that the closure of the VP is a complex mechanism and thus need accurate Ix
Four closure patterns (Skolnick)
Coronal - mostly palate (most common)
Sagittal - mostly lateral wall (least common)
Circular - both palatal and lateral wall
Circular with Pasavants ridge – posterior, palatal and lateral walls
info on size of gap, pattern of closure and degree of palate elevation
barium paste instilled intranasally which coats the surface of the oropharynx and then the pt is asked to duplicate certain sounds while the fluoroscopic images are taken with the lateral , frontal and submental views being the most important
when the adenoids are enlarged the Townes view demonstrates the VP orifice better than the basal views
direct visualization of the velopharyngeal mechanism
recommended in conjunction with video fluoroscopy giving mainly quantitative information and the nasendoscopy giving mainly qualitative information
Nasalance is a ratio of the nasal acoustic output relative to oral plus nasal acoustic output and is expressed as a percentage.
sensitivity and specificity of nasometry in correctly identifying subjects with more than mild hypernasality in their speech - 89% and 95%, respectively.
CT and MRI angiography
useful in picking up abnormal medial displacement of the carotid artery
abnormality of the internal carotid is common in VCF syndrome
10% found to be located just under the pharyngeal mucous membrane and thus can be endangered in raising pharyngeal flap
Sommerlad (Cleft Palate Craniofac J. 2004 Jul) - Examination and palpation of the pharyngeal walls after the patient is positioned for surgery appear to be reliable in detecting abnormal pulsations and allow accurate surgical planning. Routine vascular imaging, even in patients with pulsations on preoperative nasendoscopy is not essential and may not always be reliable, as shown by the variation in endoscopic, MRA, and intraoperative findings.
generally not enough in itself for structural problems related to VPI.
It is, however, valuable for small gaps or inconsistent closure
very valuable either before or after surgery, or both, in order to eliminate compensatory strategies that patients develop over time.
Poorly tolerated in children. Mainly indicated where surgical risks are prohibitive.