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Table of Contents
ORIGINAL ARTICLE
Year : 2015  |  Volume : 17  |  Issue : 2  |  Page : 55-58

Velopharyngeal insufficiency after adenotonsillectomy in children


Associate Professor of Pediatric Otolaryngology College of Medicine, King Khalid University, Saudi Arabia

Date of Web Publication2-Jan-2020

Correspondence Address:
MD, FRCSC, FACS Nasser A Fageeh
Associate Professor of Pediatric Otolaryngology College of Medicine King Khalid University P. O. Box 25488 Abha 61466
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274659

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  Abstract 


Objective: To evaluate preoperative risk factors of velopharyngeal insufficiency (VPI) after adenotonsillectomy in children.
Settings: Tertiary cares medical centres. Design: Retrospective study using patient’s charts review. The aim of this study is to look at the associated risk factors that may explain the presentation of VPI in children following adenotonsillectomy.
Methods and Material: Retrospective chart review of 32 children presented with VPI following adenotosillectomy between January 1, 2008 and December 30, 2014 at Asser Central Hospital (ACH) and Abha Private Hospital (APH). The data collected included the total number of adenotonsillectomy cases, patient age at surgery, gender, date of surgery, indications and outpatient postoperative notes. Exclusion criteria included; patients older than 12 years, children diagnosed having velocardiofacial syndrome, submucous clefts and those who had follow up less than 6 months.
Results: Total numbers of ten thousand and eighty adenotonsillectomy cases were done in 7 years period. Thirty-two patients (0.3%) presented with postoperative hypernasality and nasal regurgitation. The mean age was 6 years. Females were more predominant than males (21 F, 11 M). The most common indication for surgery was mouth breathing and snoring in 19 (59.38%) patients. Short soft palate was the main cause of VPI in 20 (62.50%) patients.
Conclusions: Velopharyngeal Insufficiency, although uncommon, is a well-known complication of adenotosillectomy. Patients presenting with obstructive symptoms and signs of adenotonsillectomy in presence of short soft plate or deep pharyngeal wall should be counseled for possible development of postoperative VPI. Most of symptoms of postoperative VPI resolve spontaneously.

Keywords: Velopharyngeal Insufficiency, Adenotonsillectomy, Children, Pharyngeal Flap, complications


How to cite this article:
Fageeh NA. Velopharyngeal insufficiency after adenotonsillectomy in children. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:55-8

How to cite this URL:
Fageeh NA. Velopharyngeal insufficiency after adenotonsillectomy in children. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2022 Dec 8];17:55-8. Available from: https://www.sjohns.org/text.asp?2015/17/2/55/274659




  Introduction Top


Velopharyngeal insufficiency (VPI) is a result of incomplete closure of the velopharyngeal sphincter during speech production that result in nasal air emission and hypernasal resonance [1]. Separation of the nasal and oral cavities occurs secondary to contraction of velopharyngeal muscles. This consists of elevation the velum (soft palate) superiorly and posteriorly with associated medial motion of the lateral pharyngeal walls, and occasionally some anterior motion of the posterior pharyngeal wall [2],[3]. Appropriate function of the velopharyngeal sphincter is considered normal mandatory physiology to prevent nasal regurgitation of food and at the same time to prevent production of hypernasal speech. Hypernasality is a term used to describe the perception of excessive nasal resonance during speech. Velopharyngeal closure is expected on vowels and consonants with the exception of “m,” “n,” and “ng”. VPI in children is most commonly due to anatomical defect (i.e., cleft palate, velo-cardio-facial syndrome, etc.) or neuromuscular defect (i.e., hypotonia, cerebral palsy, etc.). In addition to hypernasality, children with VPI may also exhibit nasal regurgitation, nasal congestion, or otitis media [2]. The majority of children who develop VPI following adenotonsillectomy will recover from their symptoms within a few weeks or months [4],[5]. Patients with anatomical or neurological defects compromise only one third of patients whom can be identified preoperatively as having increased risk of VPI by history and physical examination [5],[6],[7]. Others are usually missed to diagnose preoperatively and they may include patients with congenital short soft palate and patients having deep pharyngeal wall.

Clinical evaluations of VPI include perceptual speech evaluation, nasometry and nasal endoscopy. Nasal endoscopy and videofluoroscopy provide visual information to the surgeon to assess the size of the velopharyngeal gap and movement of the lateral pharyngeal walls and velum during speech. Nasal endoscopy found to be more predictive of VPI severity [8].

Many surgical procedures are available for repairing VPI; Furlow palatoplasty, posterior pharyngeal wall augmentation, posterior pharyngeal flap (PPF), and sphincter pharyngoplasty (SP) are the most commonly described procedures for the correction of VPI [9].

The aim of this study was to look at the risk factors that resulted in VPI after adenotonsillectomy in children who have no known anatomical or neurological defects on their preoperative initial physical examination.


  Subjects and Methods Top


After obtaining institutional review board approval at college of medicine, King Khalid University at Abha, a retrospective chart review was conducted for 32 paediatric patients who presented with VPI after adenotonsillectomy procedure between January 1st, 2008 and December 30th, 2014 at Asser Central Hospital (ACH) and Abha Private Hospital (APH). All cases were operated with one surgeon. Tonsillectomy and adenoidectomy were done in all cases using monopolar cautery and adenoid curettage respectively. These subjects were identified after exclusion of patients with inadequate medical records, children older that 12 years of age and those with pre-existing anatomical or neurological velopharyngeal deficit prior to surgery. Data collected included age at surgery, gender and indications for adenotonsillectomy. The collected 32 hospital charts for patients presented with VPI to the outpatient clinic after adenotonsillectomy led us not only to retrieve and study these cases but also to look at the electronic database of the medical records for the total number of patients underwent adenotonsillectomy during the period of the study.

Indications for adenotonsillectomy included three and more recurrent throat infections per year. Obstructive airway symptoms that may include obstructive apnoea, snoring, mouth breathing. It is the surgeon routine to book all cases for follow up one month postoperatively for final assessment of patients prior to discharge.

All patients who reported postoperative hypernasality underwent oral examination, fibrooptic nasal endoscopy and then refereed to speech pathologist for evaluation and treatment. Cases that continued to have annoying persistent hypernasality and did not improve after one year were counseled for reparative surgery. Superiorly based PPF was the procedure done in those who persist to have hypernasality.


  Results Top


Thirty-two patients of 1080 cases (0.3%) presented one month after adenotosillectomy complaining of hypernasality. Three (0.02%) patients hd VPI persisting more than one year and required surgical repair. The mean age was 6 years and range of (3-12) years. Females presented with VPI were more predominant than males (F21/M11) [Table 1]. Twenty (62.5%) patients of those presented with VPI were operated due to presence of preoperative symptoms and signs of airway obstruction; 19 (59.38%) patients presented with preoperative snoring and mouth breathing and 11 (34.38%) patients had preoperative obstructive sleep apnoea. Recurrent infection was the indication for adenotonsillectomy in 8 (25.00%) patients. Six (18.75%) patients had more that on indication for adenotonsillectomy [Table 2].
Table 1: Preoperative Data

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Table 2: Indications of Surgery

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The most common postoperative finding in those patients presented with VPI was the presence of short soft palate; 20 (62.50%) patients. All patients had normal soft plate mobility but incomplete closure of the velopharyngeal sphincter. The approximate measured distance between the posterior end of the soft plate and the posterior wall was more than 1 cm in these cases. Deep pharyngeal wall was seen in 9 (23.13%) patients and bifid uvula in 3 (9.37%) patients [Table 3].
Table 3: Risk Factors Data

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During the first follow up, which is usually scheduled one month after surgery, parents of these children not only complained from hypernasality but some of them even reported nasal regurgitation of food.

Twenty-nine (90.60%) patients recovered their hypernasality within the first year of having adenotonsillectomy. Three (9.40%) patients had persistent annoying hypernasality that continued for more than one year but no nasal regurgitation [Table 4]. Those persist hypernasality cases underwent PPF with good results.
Table 4: Results of Follow up

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  Discussion Top


Clinically significant VPI occurs in 1 in 1500 to 1 in 3000 adenoidectomies [8],[10]. One third only of these patients can be identified preoperatively as having increased risk of VPI by history and physical examination [10],[11]. Many other studies have reported hypernasality after removal of adenoid tissue and palatine tonsils [3],[4],[12],[13]. We perform 30-60 adenotonsillectomy procedures a week. The average number of adenotonsillectomy cases done annually is 1440 cases. In this study the prevalence of VPI after adenotonsillectomy was 0.3%. The incidence of VPI that persisted more than one year and required surgical intervention was 0.02 % i.e. 1 in 3350 cases and this was found comparable to was previously published in the literature [8],[10]

The primary etiological factor of hypernasality is usually an underlying congenital abnormality of the soft palate, which is unmasked by removing the adenoid-tonsillar tissue. Some studies reported that tonsillectomy had a significantly greater effect on hypernasality than adenoidectomy, and adenotonsillectomy had the greatest effect [13]. It is possible to identify children with congenital short soft palate, deep pharyngeal wall and bifid uvula by careful history and physical examination [7],[8]. We observed in our study that female patients are more prone to develop hypernasality as compared to male patients. We assume that female predominance is most likely related to their natural tendency to have more nasal resonance as compared to males. The female gender predominance in developing VPI post adenotonsillectomy needs further investigation in future studies.

In this study, we also in found that the majority of patients presented with postoperative VPI are those whom were treated for obstructive symptoms. Children having obstructive symptoms in presence of short soft palate usually present with hyponasal voice that is reversed after adenotonsillectomy and result into hypernasality that becomes annoying to their parents postoperatively. This association of obstructive hypertrophic adenoid and tonsillar tissue and short soft palate is usually missed to diagnose especially in busy clinics. In general the risk factors in our patients include; female children, preoperative obstructed children, presence of short soft palate and presence of deep pharyngeal wall. It is our observation that presence of bifid uvula in absence of other factors does not result in VPI.

Spontaneous improvement and full recovery from VPI can be expected up to one year after adenotonsillectomy in children with unknown preoperative risk factors [7],[8],[9]. The majority of our patient did not require any surgical intervention and their symptoms of hypernasality totally disappeared within the first year after surgery and they required no further surgical intervention. We also observed that VPI symptoms including hypernasality and nasal regurgitation of food that appear in the first weeks following surgery. This is most likely related to the postoperative pain that may result in a delay of the velum (soft palate) and closure of the velopharyngeal sphincter. This subsequently results in hypernasality and nasal regurgitation of drinks and food. Some had reported post tonsillectomy neurological damage of the vagus and glossopharyngeal nerves through the lingual rami resulting in VPI [14]. None of our patients had neurological damage. Three (0.02%) patients of ours developed hypernasality that did not recover after one year of follow up and intensive speech therapy. Careful physical examination of these cases indicated congenital short soft palate associated with obstructive adenoid-tonsillar tissues that were most likely missed at the initial preoperative clinical evaluation. Their hypernasality was annoying to their parents; therefore they were surgically repaired. PPF procedure was performed in these cases and it was sufficient to treat the post-surgical VPI in all of them.


  Conclusion Top


Velopharyngeal insufficiency is a well-known complication that can occur not only after adenoidectomy alone but it may occur after tonsillectomy and adenotonsillectomy as well. Careful preoperative evaluation of the soft palate and velopharyngeal sphincter closure is mandatory to minimize and possibly to avoid postoperative VPI occurrence. It is our observation that, female children presenting with obstructive adenoid and or tonsillar tissue and having an associated short soft palate carry higher risk of developing VPI postoperatively. In general most cases of VPI resolve spontaneously within the first year of their surgery and rarely require surgical repair.

Potential Conflicts of interest: None

Competing interest: None

Ethical Approval: Research ethics Committee, College of Medicine, King Khalid University



 
  References Top

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11.
Witzel M, Rich R, Margar-Bacal F, Cox C. Velopharyngeal insufficiency after adenoidectomy: an 8-year review. Int J Pediatr Otorhinolaryngol 1968;11:15-20.  Back to cited text no. 11
    
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Chaco J, Yulers RB. Velopharyngeal Incompetence post tonsillo-adenoidectomy. An electromyographic study. Acta Otolaryngol (Stockh).1969; 68:276-278.  Back to cited text no. 12
    
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Williams RG, Preece M, et al. (1992) The effect of adenoid and tonsil surgery on nasalance. Clin Otolaryngol Allied Sci. 1992; 17(2):136-40  Back to cited text no. 13
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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