Relationship between pre-operative Nasalance Scores, Velopharyngeal, Closure Patterns, and Pharyngeal Flap Revision rate in patients with Velopharyngeal Insufficiency.

Abstract

Velopharyngeal insufficiency (VPI) is a disorder that results from the improper contact of the soft palate, lateral pharyngeal walls, and posterior pharyngeal wall. These muscle groups make up the velopharyngeal sphincter. This closure is necessary for the production of oral speech sounds. Improper closure leads to the production of nasal emissions during speech and an inability to produce pressure consonants. VPI is commonly treated surgically. A successful outcome of the surgery is determined by perceptual judgments of a Speech-Language Pathologist and with detailed objective instrumental evaluation (Losken, Williams, Burstein, Malick, & Riski, 2003). It is also necessary to examine the occurrence of surgical revision rates, as this directly relates to the success rate of a chosen surgical technique for a patient with VPI. Past studies have assessed the relationship between patient’s closure patterns with VPI and/or the type of revisions necessary when pharyngoplasty failed (Loksen, et. al, 2003 ; Kasten, Buchman, Stevenson, & Berger, 1997; Witt, Marsh, Marty-Grames, & Muntz, 1995; Amour, Fischbach, Klaiman, & Fisher, 2005; Schultz, Heller, Gens & Lewin, 1973). Fewer studies have systematically studied pre-surgical implications that exist, which could offer valuable information to patients and surgeons. This study investigated if pre-operative oral word and sentence nasometric values and velopharyngeal closure pattern identified patients requiring revision surgery after an initial pharyngeal flap. Fifty-nine patients who were diagnosed with VPI and underwent a pharyngeal flap surgery were included in this study. All patients underwent an evaluation of velopharyngeal function by the craniofacial team at Women's and Children's Hospital of Buffalo (WCHOB). The evaluation included perceptual and quantitative speech measures, clinical screening of velopharyngeal closure, and an oral peripheral examination. Perceptual ratings of speech were determined through live speech samples of the production of single words, sentences, and conversational speech. Resonance was categorized as hypernasal, hyponasal, mixed, or normal. Patients, who were categorized as having hypernasal speech, hyponasal speech, or nasal air emissions, were evaluated using nasometric instrumentation and multiview video fluoroscopy/nasoendoscopy. A regression analysis was performed at an alpha level of ρ ≤ 0.05; indicating pre-operative nasometry scores were significantly higher for those patients who eventually required a revision to the initial pharyngeal flap for alveolar, bilabial, and velar words and affricate sentences. Other comparisons of closure pattern, gap size, diagnosis, age, nasal utterances, low pressure context utterances, and high pressure utterances to revision rate resulted in no significant relationship. Post-operative results were not analyzed. When high nasometric values for oral word and sentence productions are noted pre-operatively, the likelihood of a revision surgery is increased. Nasometry can aid surgeons and Speech-Language Pathologists with preoperative patient counseling.