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Table of Contents
ORIGINAL ARTICLE
Year : 2012  |  Volume : 14  |  Issue : 2  |  Page : 63-66

Role of x-ray lateral view nasopharynx in the diagnosis of subtle velopharyngeal incompetence


1 Otolarngology-Head & Neck Surgery Department, Suez Canal University, Ismailia-, Egypt
2 Radiology Department .Suez Canal University, Ismailia-, Egypt

Date of Web Publication3-Jan-2020

Correspondence Address:
MD Wael Mohammad Adel Abdelkafy
Department of Otolaryngology-Head & Neck Surgery (ENT) Faculty of Medicine, Suez Canal University, Round Road, Ismailia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274776

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  Abstract 


Introduction: Velopharyngeal dysfunction following adenoidectomy is not uncommon. Incidence range from 1 per 1,500 to 1 per 10,000 patients. Children at risk can be identified including cleft palate, sub mucous cleft, and palatal hypotonia, but if it occurred in the absence of structural abnormalities, increased pharyngeal width or short soft palate has been proposed.
Methods: The study included 227 children, 71 females and 156 males. Plain x-ray lateral view nasopharynx was done during pronouncing the vowel Eeee aiming to assess the degree of closure and the point of contact between the contracted soft palate and the adenoid pad. Children with cleft palate, bifid uvula , mythsenia gravis and congenital abnormality of the hard palate were excluded from the study
Results: Thirteen patients out of 227 were included with a median age of 5.8 years having short functional length of the soft palate. Only 4 (1.7 %) among the studied patients developed velopharyngeal incompetence. All patients with short functional length of the soft palate demonstrate attachment to the adenoid anterior surface rather to others show posterior pharyngeal wall attachment. Results showed that there was an increased incidence of velopharyngeal incompetence with patients having short functional length of the soft palate.
Conclusion: Plain x-ray lateral view nasopharynx during phonation of the vowel Eeee could be cheap and sensitive method in predicting velopharyngeal incompetence in children undergoing adenoidectomy.

Keywords: Velopharyngeal incompetence, lateral x-ray of nasopharynx,velopharyngeal dysfunction, cleft palate


How to cite this article:
Adel Abdelkafy WM, El Tabbakh MT, Gad KA. Role of x-ray lateral view nasopharynx in the diagnosis of subtle velopharyngeal incompetence. Saudi J Otorhinolaryngol Head Neck Surg 2012;14:63-6

How to cite this URL:
Adel Abdelkafy WM, El Tabbakh MT, Gad KA. Role of x-ray lateral view nasopharynx in the diagnosis of subtle velopharyngeal incompetence. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2012 [cited 2022 Oct 6];14:63-6. Available from: https://www.sjohns.org/text.asp?2012/14/2/63/274776




  Introduction Top


Velopharyngeal dysfunction (VPD) results from a variety of causes that include structural abnormalities of the palate, dynamic impairment of a structurally normal palate, and functional abnormalities not associated with anatomic or dynamic palatal defects. Overt cleft palate, either before or after repair, is by far the most common cause of VPD. This condition occurs in approximately 1 of 2000 live births. VPD has been reported in as many as 30-50% of patients following palate repair [1].

A submucous cleft palate is defined by the presence of a bifid or double uvula, muscular diastasis of the soft palate (zona pellucida), and notching of the posterior border of the hard palate. This is usually evident on examination of the oral cavity, especially with elevation of the palate when pronouncing the phoneme /ah/. By contrast, an occult submucosal cleft palate is an absence or deficiency of the musculus uvulae with a diastasis of the levator veli palatini but without the presence of a bifid uvula or grooving of the oral surface of the soft palate. An occult submucous cleft is best visualized endoscopically as midline notch on the nasal surface of the soft palate during palate elevation.

Transient VPD with hypernasal resonance following adenoidectomy, with or without tonsillectomy, is not uncommon. This condition may persist for several days to weeks and usually resolves spontaneously. Some nasal regurgitation of liquids may be present during this period. Incidence of persistent VPD after adenoidectomy has been reported to range from 1 per 1,500 to 1 per 10,000 patients. While the adenoid pad is not necessary normal for velopharyngeal closure (VPC), it may assist in closure in children with structural or functional abnormalities of the soft palate. Children at risk of developing persistent VPD after adenoidectomy often can be easily identified preoperatively by the presence of repaired cleft palate, submucous cleft palate, and palatal hypotonia [2]. Velopharyngeal dysfunction following adenoidectomy has been attributed to increased pharyngeal width and the abnormal function of the velopharyngeal port [3],[4]. Abnormal function centers on inadequate velopharyngeal function, including poor palatal motion, and results in inadequate velopharyngeal closure. Poor palatal motion is believed to be secondary to abnormal muscular anatomy within the soft palate, as is seen with a preexisting cleft of the soft palate (overt or submucous). In addition, inadequate muscular activity (i.e., muscular hypotonia) may contribute to VPD.

A predisposition to VPD is also present in patients with trisomy 21 (ie, Down syndrome). The combination of oromotor and developmental delays, generalized hypotonia, and intellectual delays constitute significant risk factors for development of VPD following adenoidectomy. Because patients with trisomy 21 often have a narrow velopharynx and a shallower skull base, resulting in less distance for the palate to traverse to effect closure, this risk is somewhat balanced.

Evaluation of the velopharynx include videofluoroscopy (VF) which is performed by the Speech and Language Pathologist in conjunction with a radiologist. Unlike nasopharyngoscopy, VF enables the examiner to see through tissues, so that movement can be discerned at all vertical and horizontal planes within the pharynx. A 3-dimensional perspective can be gained using frontal and lateral projections, along with base or Towne projections [5]. Recently dynamic near-real time MRI, where thin slices have been used for evaluation and analysis of the velopharyngeal movement it has the advantage of visualization of the pharyngeal walls movements and role of the tongue which support the soft palate during swallowing an issue that is not visualized by routine videofluoroscopy, however the cost and age of the patients are limiting factors [6]. It is expensive, hence it is non-applicable for screening for velopharyngeal dysfunction regarding the number of cases submitted for adenoidectomy.

The goal of this research was to use the plain x-ray lateral view nasopharynx to predict the possibility of velopharyngeal dysfunction by measuring the functional length of the soft palate in relation to the point of attachment of the soft palate to either adenoid surface or posterior pharyngeal wall.


  Subjects and Methods Top


Two hundred and twenty seven patients complaining of nasal obstruction due to adenoidal hypertrophy were included in this study from 2007 to 2010. All patients underwent plain x-ray of the nasopharynx examination using a dynamic lateral view while saying Eeee (pronouncing the letter E). The images were sent to a mini workstation “Millinsys webview” to obtain measurements of the soft palate.

The point of attachment of between the posterior surface of the soft palate and anterior adenoidal surface or posterior pharyngeal wall was estimated..

Measurements of the soft palate functional length from the posterior nasal spine (PNS) to the angle of the soft palate which is created when the soft palate contracts during the pronunciation of the vowel (E) line in every patient [Figure 1] was made.
Figure 1: right lateral view nasopharynx showing enlarged adenoid encroaching on the air column. (Left) lateral view nasopharynx of the same patient while saying (Eeeeee), note closure of the nasopharyngeal air column by a short (functional) soft palate measured from the posterior nasal spine to the point of contact with the anterior adenoidal surface (14.20 mm) compared to the longer distance from the posterior nasal spine to the posterior pharyngeal wall (32.96 mm).

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Figure 2: lateral view nasopharynx showing enlarged adenoid of a child while saying (Eeeeee), note closure of the nasopharyngeal air column by the contracted soft palate touching the posterior pharyngeal wall inferior to the adenoids instead of touching the anterior surface of the adenoids.

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Patients were divided into two groups according to the point of attachment of the nasal surface soft palate to either the anterior surface of the adenoids group (A) and to the posterior pharyngeal wall group (B). Patients with cleft palate, bifid uvula and trisomy 21 were excluded from the study. Patients were followed up after adenoidectomy for the detection of the velopharyngeal insufficiency detected by velopharyngeal insufficiency symptoms ( nasal regurgitation of fluids and /or foods, hypernasality) and the duration for its persistence postoperatively for two months.


  Results Top


Two hundred and twenty seven patients were included in this study. There were 156 males and 71 females with a median age of 5.8 year. All patients were submitted for history, clinical examination and radiological examination of the nasopharynx then adenoidectomy under general anesthesia.

Results showed that the functional length of the soft palate is shorter in patients with attachment to anterior surface of the adenoid in comparison to those with attachment to the posterior pharyngeal wall. This difference was statistically significant [Table 1].
Table 1: Measurements of the functional length of the soft palate group (A) and group (B).

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Patients with short functional length of the soft palate group (A) had more incidence of velopharyngeal incompetence in comparison to patient with usual functional i.e.group (B), [Table 2].
Table 2: shows frequency of velopharyngeal incompetence among both groups.

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  Discussion Top


Velopharyngeal dysfunction is a distressing condition for children, their parents and the treating otorhinolaryngologists. The VPD which occurs after adenoidectomy is not uncommon, however it is too costly to conduct a thorough velopharyngeal study using the videofluoroscopy or real-time MRI for each patients that will undergo adenoidectomy especially in developing countries where the cost/effective studies should be implemented in their economy. The use of the plain x-ray lateral view of the nasopharynx is a cheap, readily available, relatively harmless, non-exhausting, non-painful and familiar technique for most of the radiologist and otorhinolaryngologists. It could offer an attractive tool for prediction of suspected patients with subtle VDP. The aim was to select the suspected cases and send them for more in depth investigation to avoid the persistent velopharyngeal dysfunction.

Despite the absence of an overt or submucous cleft of the palate, certain children manifest persistent nasality after adenoidectomy. Removal of the adenoid tissue has unmasked an underlying anatomic or physiologic deficit in the velopharyngeal mechanism. In an effort to identify the premonitory signs of potential difficulties, children with suspected velopharyngeal dysfunction were studied prior to consideration of adenoidectomy. Four evaluative techniques were used: 1- clinical speech evaluation, 2- cinefluorography, 3- cephalometrics, and 4- coordination pattern recordings. Each method of assessment contributed information that can serve as an “alert” to the potential consequences of a total adenoidectomy. These methods may be used secondary to selected individuals with the use of lateral view x ray of the nasopharynx with the vowel (Eeee) as a simple measure to the functional length of the soft palate.

Functional length of the soft palate is the part that moves efficiently and closes the lower entrance of the nasopharynx. . When VPD occurs in the absence of cleft palate, then other stigmata of abnormal palate anatomy, such as a bifid uvula, muscular diastasis of the soft palate, and midline notching of the posterior hard palate, may be present [7],[8].When these stigmata are absent, it is difficult to explain post adenoidectomy VPD [6]. The presence of an underlying chromosomal abnormality may shed light on the occurrence of this unusual problem. However the disproportion between the velum and the depth of the nasopharynx offers an explanation for the development of velopharyngeal dysfunction post-adenoidectomy in the absence of definite structural and functional abnormalities.



 
  References Top

1.
Rudnick EF, Sie KC. Velopharyngeal insufficiency: current concepts in diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2008; 16(6):530-5 (ISSN: 1531-6998).  Back to cited text no. 1
    
2.
Parton MJ, Jones AS. Hypernasality following adenoidectomy: a significant and avoidable complication. Clin Otolaryngol Allied Sci. 1998; 23(1):18-9 (ISSN: 0307-7772).  Back to cited text no. 2
    
3.
Jackson IT, McGlynn MJ, Huskie CF, Dip IP. Velopharyngeal incompetence in the absence of cleft palate: results of treatment in 20 cases. Plast Reconstr Surg. 1980;66(2):211-213.  Back to cited text no. 3
    
4.
Ren YF, Isberg A, Henningsson G. Velopharyngeal incompetence and persistent hypernasality after adenoidectomy in children without palatal defect. Cleft Palate Craniofac J. 1995;32:476-482.  Back to cited text no. 4
    
5.
Conley SF, Gosain AK, Marks SM, Larson DL. Identification and assessment of velopharyngeal inadequacy. Am J Otolaryngol. 1997; 18(1):38-46 (ISSN: 0196-0709).  Back to cited text no. 5
    
6.
Ambros J Beer, Paul Hellerhoff, Angela Zimmermann, Katalin Mady, Robert Sader, Ernst J Rummeny, Christian Hannig. Dynamic near-real-time magnetic resonance imaging for analyzing the velopharyngeal closure in comparison with videofluoroscopy. JMRI. 2004;20(5):791-7.  Back to cited text no. 6
    
7.
Shprintzen RJ, Schwartz RH, DanillerA, Hoch L. Morphologic significance ofbifid uvula. Pediatrics. 1985;75:553-561.  Back to cited text no. 7
    
8.
Krueger LJ, Morris HL, Bumsted RM. Indications of congenital palatal incompetence before diagnosis. Ann Otol Rhinol Laryngol. 1982;91:115-118.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Subjects and Methods
Results
Discussion
References
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