Velopharyngeal dysfunction (VPD) refers to the improper control of airflow through the nasopharynx. The term VPD denotes the clinical finding of incomplete velopharyngeal closure. Other terms used to describe VPD include velopharyngeal insufficiency, inadequacy and incompetence. However, the use of VPD has gained popularity over these terms as they may be used to infer a specific etiology of impaired velopharyngeal closure.1
Control of airflow through the nasopharynx is dependent on the simultaneous elevation of the soft palate and constriction of the lateral and posterior pharyngeal walls. Disruptions of this mechanism caused by structural, muscular or neurologic pathology of the palate or pharyngeal walls can result in VPD. VPD can result in a hypernasal voice with compensatory misarticulations, nasal emissions and aberrant facial movements during speech.2
The assessment of velopharyngeal function is best preformed by a multispecialty team evaluation including speech-language pathologists, prosthodontists, otolaryngologists and plastic surgeons. The initial diagnosis of VPD is typically made with voice and resonance evaluation conducted by a speech-language pathologist. To better characterize the patient’s VPD, video nasopharyngeal endoscopy or speech videofluoroscopy can be used to visualize the velopharyngeal mechanism during speech.
VPD may first be managed with speech-language therapy and removable prostheses. For those who are good surgical candidates and do not fully respond to speech-language therapy, surgical intervention may be pursued.
Surgical management of VPD is most commonly accomplished by pharyngeal flap procedures or sphincter pharyngoplasty. In this video, a superiorly based pharyngeal flap with a uvular mucosal lining flap was preformed for VPD in a five-year-old patient with 22q11 Deletion Syndrome and aberrantly medial internal carotid arteries.
1. Following intubation a shoulder roll was placed and the Dingman retractor mouth gag was inserted.
2. The superiorly based pharyngeal flap was designed and five insertion sites on the soft palate were marked.
3. 1% lidocaine with epinephrine was injected at the surgical site.
4. The posterior pharyngeal wall was incised with a 15-blade scalpel and the pharyngobuccal plane was located to elevate the pharyngeal flap.
5. The nasal surface of the soft palate was incised with an angled Beaver blade and a pocket was extended past the insertion sites creating the recipient site.
6. The pharyngeal flap was advanced into the recipient pocket with 3-0 vicryl sutures in a mattress fashion.
7. The nasopharynx was cannulated with two 14-French suction catheters to ensure adequate port size.
8. The uvula flap was released, unfurled and tacked down with 4-0 vicryl in the midline and interrupted 4-0 vicryl on either side to achieve at least 90% coverage of the pharyngeal flap.
9. The donor site was closed vertically and laterally to achieve partial closure of the donor site.
10. Finally, the area was irrigated and the stomach was suctioned. A tongue stitch was placed to help with ventilation in the event of airway obstruction during the immediate postoperative recovery period.
Velopharyngeal Dysfunction
1. Pre-existing obstructive sleep apnea
2. Note that medially aberrant internal carotid arteries can be considered a relative contraindication and should be approached on a case-by-case basis.
1. Place a Shoulder roll following intubation
2. Dingman retractor and secure endotracheal tube
3. Prepare 1% lidocaine with epinephrine for injection
4. Prepare oxymetazoline irrigation to control bleeding in the surgical field
5. Obtain 3-0 vicryl for the pharyngeal flap and 4-0 vicryl for the uvular flap
1. Voice and resonance evaluation by speech-language pathology
2. Video nasopharyngeal endoscopy
3. Speech videofluoroscopy
1. Uvula
2. Oroharynx and nasopharynx
3. Soft and hard palates
4. Aberrantly medial internal carotid arteries
Pharyngeal flaps bring tissue into the central portion of the velopharynx and are theoretically best suited for impaired sagittal or circular patterns of velopharyngeal closure. Despite this theoretical advantage, there is little evidence to support the use of pharyngeal flap over sphincter palatoplasty (Ysunza et. al, 2002).
1. Obstructive Sleep Apnea
2. Hyponasal voice
3. Excessive mouth breathing
4. Bleeding, especially in patients with coagulopathies, those requiring anticoagulation, or in patients with medially aberrant internal carotid arteries
5. Infection
The contributors to this video have no conflicts of interest to disclose.
The contributors would like to thank the Department of Otolaryngology at Arkansas Children’s Hospital and the University of Arkansas for Medical Sciences.
1. Woo AS. Velopharyngeal dysfunction. Semin Plast Surg. 2012;26(4):170-177. doi: 10.1055/s-0033-1333882 [doi].
2. Lewis JR, Andreassen ML, Leeper HA, Macrae DL, Thomas J. Vocal characteristics of children with cleft lip/palate and associated velopharyngeal incompetence. J Otolaryngol. 1993;22(2):113-117.
3. Ysunza A, Pamplona C, Ramirez E, Molina F, Mendoza M, Silva A. Velopharyngeal surgery: A prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg. 2002;110(6):1401-1407. doi: 10.1097/01.PRS.0000029349.16221.FB [doi].
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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