Management of the Hypodynamic Velopharynx

Abstract

Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.

Submucous cleft palate: outcomes after primary repair with repositioning of the levator muscle in 51 consecutive patients

“…Poor surgical outcomes after intravelar procedures in patients with 22q11 deletion syndrome are probably the result of a combination of velar muscle hypoplasia, hypodynamic velopharynx, minimal or absent adenoidal tissue, and a deep nasopharynx. [20][21][22] While we found a strong correlation between the clinical grade of cleft at presentation and postoperative hypernasality, we found no correlation between the clinical grade of cleft and the preoperative severity of hypernasality. This is in keeping with clinical experience -for example, grade I clefts may present with severe, and grade III clefts with mild, hypernasality.…”

Evaluation of the levator veli palatini muscle thickness in patients with velocardiofacial syndrome using magnetic resonance imaging

“…This surgical method is often used in patients with large-gap coronal, circular velopharyngeal closure, bow-tie closure, or hypodynamic velopharyngeal movement. 26,27 Losken et al investigated the results of sphincter pharyngoplasty in VCFS patients, and they compared the results to non-VCFS patients. 6 They demonstrated that sphincter pharyngoplasty was safe and effective for correcting VPI in VCFS patients.…”

Surgical Outcomes for Velopharyngeal Insufficiency in Velocardiofacial Syndrome and Nonsyndromic Patients

“…Patients with a deficiency of lateral and posterior pharyngeal wall motion underwent SP. Patients with a hypodynamic velopharynx were characterized by an overall lack of palatal and pharyngeal motion on attempted closure (Witt et al, 1995). Our study defined this as weak velopharynx (VP) motion on nasendoscopy and a residual VP port size of greater than 50% on attempts at maximum closure.…”