Injection Pharyngoplasty With a Hyaluronic Acid and Dextranomer Copolymer to Treat Velopharyngeal Insufficiency in Adults

Abstract

ObjectiveTo describe the treatment of adult velopharyngeal insufficiency (VPI) with injection of a hyaluronic acid and dextranomer copolymer (Dx/HA).Patients and MethodsThis was a retrospective case series of 25 consecutively treated adults with VPI who underwent Dx/HA injection pharyngoplasty in a multidisciplinary clinic from January 1, 2011, to December 31, 2014. Data recorded included etiology of VPI, perceptual analysis of resonance, nasalance scores, and estimation of velopharyngeal gap characteristics on video nasendoscopy before and after the intervention. Statistical comparisons were made using a 2-tailed Wilcoxon signed rank test and the Kruskal-Wallis test.ResultsPatients had VPI due to a neurologic etiology, due to a benign anatomic etiology, or acquired after treatment for a head and neck malignancy. Injections were performed with local anesthesia, monitored anesthesia care, or general anesthesia. There were statistically significant improvements in speech resonance, nasalance, and velopharyngeal gap size after treatment. Patients with neurologic or benign anatomic etiologies of their VPI had more significant improvement than those with VPI after treatment of malignancy. Nineteen of the 25 patients required only 1 injection to achieve their final result.ConclusionInjection pharyngoplasty with a readily available Dx/HA is an effective treatment for VPI that allows for titration to complete velopharyngeal closure under local anesthesia or light sedation. It is most effective in patients with nonmalignant etiologies of VPI and in those with good lateral wall motion. Complications experienced were postoperative neck pain and occult retropharyngeal fluid collection, highlighting the importance of follow-up.

Update on injection augmentation pharyngoplasty in the treatment of velopharyngeal insufficiency

“…This real-time feedback allowed for appropriate location and volume of injection. An intermediate approach was adopted by Peck et al [3] who used a combination of local anaesthesia and light sedation, with the patient under monitored anaesthesia care. This allowed for real-time speech samples and titration of injection with improved patient comfort [3].…”

“…Transoral injection is usually performed under endoscopic guidance (30 or 70-degree rigid scope or nasopharyngeal flexible scope). Although most publications advocate submucosal injection [1 ▪▪ ,3,5,20], a deep injection at the level of the retropharyngeal space between the deep layer of the superior pharyngeal constrictor and the prevertebral fascia has been adopted in some centres [6,17]. Mazzola et al [6] cautioned against injecting fat too deeply, ‘in the loose space that exists immediately anterior to the bodies of the vertebrae which may result in dislocation of the graft caudally, along the natural cleavage plane’ [6].…”

“…In addition, histologic studies have demonstrated that the hyaluronic acid portion acts as a transport medium and dissipates from the site of injection within several weeks. The tissue bulking effect is primarily driven by an immunologic reaction to the dextranomer microspheres, which stimulates collagen synthesis and an influx of fibroblasts and myofibroblasts, creating a consolidated bulking of tissue [3].…”

“…Genetic associations with VPI have also been described, with up to 75% of patients having 22q11 genetic deletions [2]. In adults, VPI is most commonly a consequence of neurologic disease or loss of functional tissue after treatment of benign or malignant lesions [3].…”

Mucosal Injection as treatment for rectal prolapse in children with corrected anorectal malformation

“…Animal studies with injection into different tissues did not seem to induce DNA-or major tissue changes [8,9]. Also, Dx/HA agents have been successfully used for a multitude of purposes [22][23][24] including rectal prolapse in children without anorectal malformations [7] over ten years, without any long-term issues.…”