Pediatric otolaryngological relations of velopharyngeal insufficiency

On the basis of his examinations, the author presents data and gives his opinion on the classification, etiopathogenesis, diagnostics, phonosurgery, and therapy of the otological complications of velopharyngeal insufficiency (VPI). VPI may be organic or functional, produced by congenital or acquired causes, due to paresis or local disorders, but most frequently occurs as a result of cleft palate. Usually, diagnosis is evident; however, the verification of the milder cases of anatomic disproportion and/or muscular dysfunction is sometimes difficult. For the examination of dubious cases the author suggests, apart from the well-known methods (auditive evaluation, function tests, nasopharyngoscopy, velopharyngometry, supersound, X-ray, manometric measurements, speech intelligibility tests, acoustic analyses, etc.), electrophysiological and enzyme-histochemical measurements. Careful examination is most important, also on account of the possible indication of phonosurgery. An operation is to be proposed when a progressive neuro-myogenic process can thus be excluded, or when logopedic treatment is hopeless. The author has done 500 flap operations (as well as 2500 cleft palate and cleft lip ones) in the course of 30 years with a 98% result of anatomical healing. According to the pathological situation he employed 10 variants of the operation. As a result, hyperrhinophony ceased or became minimal in 90% of the cases; speech intelligibility was judged good or excellent in 74%. Functional effects can be influenced by the following: the width of the flap, the functional ability of the pharyngeal muscles, the cause of VPI, the patient's age, and the state of ears and hearing. In case of VPI otological and audiological examinations are routinely required. The author considers adenoidectomy and grommet-insertion to be alternative methods. One of the most important factors in achieving good results is teamwork, which the author discusses on the basis of the model developed at the Heim Pál Hospital for Sick Children, Budapest.