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Otolaryngologic Clinics of North America Dec 2016Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with... (Review)
Review
Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.
Topics: Humans; Hyoid Bone; Mandible; Mandibular Advancement; Muscle, Skeletal; Oral Surgical Procedures; Preoperative Care; Sleep Apnea, Obstructive
PubMed: 27720459
DOI: 10.1016/j.otc.2016.07.006 -
The Journal of Histochemistry and... Mar 2022The soft palate is the only structure that reversibly separates the respiratory and gastrointestinal systems. Most species can eat and breathe at the same time. Humans...
The soft palate is the only structure that reversibly separates the respiratory and gastrointestinal systems. Most species can eat and breathe at the same time. Humans cannot do this and malfunction of the soft palate may allow food to enter the lungs and cause fatal aspiration pneumonia. Speech is the most defining characteristic of humans and the soft palate, along with the larynx and tongue, plays the key roles. In addition, palatal muscles are involved in snoring and obstructive sleep apnea. Considering the significance of the soft palate, its function is insufficiently understood. The objectives of this study were to document morphometric and immunohistochemical characteristics of adult human soft palate muscles, including fiber size, the fiber type, and myosin heavy chain (MyHC) composition for better understanding muscle functions. In this study, 15 soft palates were obtained from human autopsies. The palatal muscles were separated, cryosectioned, and stained using histological and immunohistochemical techniques. The results showed that there was a fast type II predominance in the musculus uvulae and palatopharyngeus and a slow type I predominance in the levator veli palatine. Approximately equal proportions of type I and type II fibers existed in both the palatoglossus and tensor veli palatine. Soft palate muscles also contained hybrid fibers and some specialized myofibers expressing slow-tonic and embryonic MyHC isoforms. These findings would help better understand muscle functions.
Topics: Adult; Aged; Female; Humans; Immunohistochemistry; Male; Middle Aged; Myosin Heavy Chains; Palatal Muscles; Palate, Soft
PubMed: 34957888
DOI: 10.1369/00221554211066985 -
Sleep Medicine Clinics Mar 2019Although continuous positive airway pressure is the first-line and gold-standard management for obstructive sleep apnea (OSA), surgery is the only mainstream treatment... (Review)
Review
Although continuous positive airway pressure is the first-line and gold-standard management for obstructive sleep apnea (OSA), surgery is the only mainstream treatment without the use of a device. Palatal surgery is the paragon and core value among various sleep surgeries in treating snoring and OSA. It has transformed from radical excision to functional reconstruction. The integrated treatment of palatal surgery includes reconstruction of airway, restoration of airflow and rehabilitation of muscle.
Topics: Continuous Positive Airway Pressure; Humans; Palate; Plastic Surgery Procedures; Sleep; Sleep Apnea, Obstructive; Snoring
PubMed: 30709533
DOI: 10.1016/j.jsmc.2018.10.006 -
The Annals of Otology, Rhinology, and... Feb 2021To compare the size of Ostmann's fat pad (OFP) between healthy ears and ears with chronic otitis media with cholestatoma (COMwC) using magnetic resonance imaging (MRI).
OBJECTIVE
To compare the size of Ostmann's fat pad (OFP) between healthy ears and ears with chronic otitis media with cholestatoma (COMwC) using magnetic resonance imaging (MRI).
METHODS
Twenty-six patients with unilateral COMwC underwent mastoidectomy. Pre-operative MRI records were reviewed retrospectively. The healthy ears served as the control group. OFP is represented by the maximum diameter of the high intensity area medial to the tensor veli palatini muscle (TVP); M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle; M2. Values of M1, M2 and the ratio of M1:M2 was compared between the healthy and pathological ear in each patient.
RESULTS
All 26 patients (16 females,10 males) had unilateral cholestatoma. Mean age was 37.6 years (range 19-83). In the healthy () ears group, mean M1 was 2.04 ± 0.53 mm, mean M2 was 9.57 ± 2.57 mm.In the pathological () ears group; mean M1 was 2.03 ± 0.55 mm, mean M2 was 9.86 ± 2.37 mm. A comparison of M1 and M2 values between the healthy and pathological ear groups was not statistically significant ( = .853 and = .509, respectively).Mean M1:M2 ratio in the healthy ears group was 0.22 ± 0.05, mean M1:M2 ratio in the pathological ear group was 0.21 ± 0.06. A comparison between these ratios found no significant statistical correlation ( = .607).
CONCLUSION
The size of Ostmann's fat pad does not affect the development of chronic otitis media with cholestatoma in adults.
Topics: Adipose Tissue; Adult; Aged; Aged, 80 and over; Case-Control Studies; Cholesteatoma, Middle Ear; Chronic Disease; Eustachian Tube; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Otitis Media; Palatal Muscles; Pterygoid Muscles; Retrospective Studies; Young Adult
PubMed: 32700549
DOI: 10.1177/0003489420943219 -
Annals of Plastic Surgery Dec 2017The success rate of the surgical repair of palatal fistula after palatoplasty is often unsatisfactory. This study is a review of 15 years of single surgeon's experience... (Comparative Study)
Comparative Study
BACKGROUNDS
The success rate of the surgical repair of palatal fistula after palatoplasty is often unsatisfactory. This study is a review of 15 years of single surgeon's experience with the evolution of a reliable surgical technique with high success rate.
METHODS
This is a retrospective chart review of consecutive cleft cases undergoing repair of palatal fistula from 2000 to 2015. The study included 37 consecutive fistula repair cases with wide elevation and mobilization of the palatal tissues and nasal and oral layer repair. Group 1 (n = 20) were treated earlier in the study using either midline, von Langenbeck, or 2-flap palatoplasty with 3-layer suturing. Group 2 (n = 17) were treated through a Dorrance-type incision and additional repair of the oral periosteum for a total of 4-layer suturing.
RESULTS
The overall fistula closure rate was 94.6% (90% in group 1 and 100% in group 2). The difference in outcome between the 2 groups was statistically insignificant (P > 0.05). Most patients (83.8%) had concomitant velar muscle retropositioning for treatment of velopharyngeal incompetence.
CONCLUSIONS
Fistula repair using wide mobilization of the entire palate through previous repair incisions and multilamellar suturing technique has a very low fistula recurrence rate. Addition of the fourth layer of suturing and the use of a Dorrance-type incision further improves the outcome. This approach provides wide tissue release and access to tissue layers for better repair and tension-free closure. Combining intravelar veloplasty with fistula repair is safe and allows management of the fistula and its possible consequences on palatal function in a single procedure.
Topics: Adolescent; Adult; Age Factors; Child; Child, Preschool; Cleft Palate; Cohort Studies; Female; Follow-Up Studies; Humans; Male; Oral Fistula; Palatal Muscles; Palate, Soft; Plastic Surgery Procedures; Recovery of Function; Retrospective Studies; Risk Assessment; Suture Techniques; Treatment Outcome; Velopharyngeal Insufficiency; Young Adult
PubMed: 29053517
DOI: 10.1097/SAP.0000000000001216 -
The Journal of Craniofacial Surgery Oct 2017Cleft palate is one of the challenging problems in the field of craniofacial surgery. In particular, the conventional methods of bilateral and severe cleft palate...
Cleft palate is one of the challenging problems in the field of craniofacial surgery. In particular, the conventional methods of bilateral and severe cleft palate repairs have failed to achieve normal speech. In most instances, secondary procedures such as pharyngoplasty and pharyngeal flap surgery are performed to improve speech.This study introduces secondary palatal elongation (SPE) as a new approach to cleft palate repair. The patients included usually had a short palate and unrepaired palatal muscles. The authors' procedure involved dissecting the previously repaired palatal mucosa and pushing back and cutting the nasal mucosa of the palate horizontally and further pushing it back. Then, 1 or 2 buccal mucosal flaps were used to repair the nasal mucosal defect of the palate. In case of unrepaired veloplasty from the primary surgery, the levator muscles were dissected and sutured together to perform veloplasty. The range of palatal elongation was 15 to 25 mm.Secondary palatal elongation has been performed on 17 patients since 2007 with a high rate of speech improvement. Based on this 9-year experience with performing SPE, SPE is a radical anatomic technique of palatal elongation as compared with pharyngoplasty and pharyngeal flap surgery. All 17 patients who underwent SPE showed improvement in speech, from very poor to poor speech and from normal to good speech.
Topics: Cleft Palate; Humans; Mouth Mucosa; Nasal Mucosa; Palatal Muscles; Plastic Surgery Procedures; Speech Disorders; Surgical Flaps; Velopharyngeal Insufficiency
PubMed: 28708641
DOI: 10.1097/SCS.0000000000003609 -
Nature and Science of Sleep 2014Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and... (Review)
Review
Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.
PubMed: 25429246
DOI: 10.2147/NSS.S46818 -
Clinical Oral Investigations Jun 2016Surgical techniques to obtain adequate soft palate repair in cleft palate patients elaborate on the muscle repair; however, there is little available information... (Review)
Review
OBJECTIVE
Surgical techniques to obtain adequate soft palate repair in cleft palate patients elaborate on the muscle repair; however, there is little available information regarding the innervation of muscles. Improved insights into the innervation of the musculature will likely allow improvements in the repair of the cleft palate and subsequently decrease the incidence of velopharyngeal insufficiency. We performed a literature review focusing on recent advances in the understanding of soft palate muscle innervation.
MATERIAL AND METHODS
The Medline and Embase databases were searched for anatomical studies concerning the innervation of the soft palate.
RESULTS
Our literature review highlights the lack of accurate information about the innervation of the levator veli palatini and palatopharyngeus muscles. It is probable that the lesser palatine nerve and the pharyngeal plexus dually innervate the levator veli palatini and palatopharyngeus muscles. Nerves of the superior-extravelar part of the levator veli palatini and palatopharyngeus muscles enter the muscle form the lateral side. Subsequently, the lesser palatine nerve enters from the lateral side of the inferior-velar part of the levator veli palatini muscle. This knowledge could aid surgeons during reconstruction of the cleft musculature. The innervation of the tensor veli palatini muscle by a small branch of the mandibular nerve was confirmed in all studies.
CONCLUSION
Both the levator veli palatini and palatopharyngeus muscles receive motor fibres from the accessory nerve (through the vagus nerve and the glossopharyngeal nerve) and also the lesser palatine nerve. A small branch of the mandibular nerve innervates the tensor veli palatini muscle.
CLINICAL RELEVANCE
Knowledge about these nerves could aid the cleft surgeon to perform a more careful dissection of the lateral side of the musculature.
Topics: Cleft Palate; Humans; Palatal Muscles; Palate, Soft
PubMed: 27020913
DOI: 10.1007/s00784-016-1791-6 -
The Cleft Palate-craniofacial Journal :... Mar 2021To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and...
OBJECTIVE
To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech.
METHODS
Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech.
RESULTS
Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, = .004), decreased α angle (13.2°, = .37), and longer (5.1 mm, = .32) and thinner (4 mm, = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls.
CONCLUSIONS
The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.
Topics: Child; Child, Preschool; Cleft Palate; Humans; Palatal Muscles; Palate, Soft; Pharyngeal Muscles; Velopharyngeal Insufficiency
PubMed: 32909827
DOI: 10.1177/1055665620954749 -
Journal of Speech, Language, and... Jul 2022The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and...
PURPOSE
The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.
METHOD
A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.
RESULTS
Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP ( = .003) and CLP ( = .002) patients but higher frequency than OSMCP ( = .002) and non-CP ( = .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).
CONCLUSIONS
CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.
Topics: Adult; Cleft Lip; Cleft Palate; Humans; Phonetics; Retrospective Studies; Velopharyngeal Insufficiency
PubMed: 35858260
DOI: 10.1044/2022_JSLHR-21-00679