Secondary Treatments | Otolaryngology

Velopharyngeal Insufficiency (VPI)

Velopharyngeal Insufficiency (VPI) is a problem where the soft palate does not close off the nose from the mouth. This results in air escaping through the nose while talking and sometimes liquids escaping through the nose while drinking. Children with a history of a cleft palate (with or without a cleft lip) are at risk of developing this problem. Other children can also have this problem as well.

VPI is usually diagnosed by a speech and language pathologist analyzing the way your child's voice sounds with difference phrases and in conversational speech. This assessment is called perceptual speech analysis. Speech and language pathologists also may perform a test comparing the amount of air that escapes from the mouth and nose during speech (called naso-metry). When there is concern for some degree of VPI, we often need to understand the anatomy at the back of the nose/throat to help guide treatments (see below for details about this part of the exam)

VPI and Quality of Life

In addition to making it hard to understand what your child is saying, having VPI can have a negative impact on your child's life. Another term for this "impact" is quality of life. One of our surgeons, Dr. Skirko, has done extensive research on the impact VPI has on quality of life. Part of this work developed and tested a new VPI specific quality of life instrument. This instrument is now being translated to several other languages and is being used by cleft teams around the globe.

While these are important milestones for VPI research, Dr. Skirko's studies also highlight two problems that are often overlooked in managing children with VPI:

1) Children with 'mild' VPI can have severely impacted quality of life.

Even children with more 'mild' categories of VPI can have a low (or worse) quality of life than children without VPI and treatment improves nearly always improves their quality of life. Depending on these children's flexible exam, these children often can have a large improvement in their quality of life with surgery for VPI.

2) Parents of older children often don't understand the full impact VPI has on their child's life.

While parents of children with VPI usually know if their child is having problems or not, the degree of trouble they are having is often underestimated by parents. When parents and children both complete the questionnaire, there is often a difference between a child's response and their parents. Reviewing both parent and child's responses help to identify areas that children haven't fully shared with their parents. This can be very helpful in understanding the problems our surgeons are going to try improving with treatment, usually surgery.

The 'Scope' Exam

To see the area behind the palate (the velum), a small flexible telescope is inserted through the nose. Most kids tolerate this very well after getting used to the funny feeling. With the camera in position, your child will then say some specific phrases with the speech and language pathologist listening and helping. The way throat closes behind the palate while your child is talking will help guide the treatment your surgeon's plans. We perform this endoscopic exam many times per day on children to help understand problems in the nose, throat and voice box.

Treatment of VPI

Occasionally, Children with VPI need treatment for their hypernasality (VPI) but are not a candidate for surgery. While this is uncommon, it can include severe airway obstruction, progressive disease causing the VPI or medical problems that reduces the advisability of surgery. These children are often treated with a prosthetic. This is a device that is clasped to the teeth and the back of the device blocks air from escaping through the nose. The device can be removed at night, so it can be helpful in children with airway obstruction/sleep apnea.

Most children with VPI require surgery to correct the problem leading to VPI. There are several surgeries that are used to treat VPI and the decision for which surgery is the best option for your child will depend on how their palate moves and the way the back of the nose/throat looks. Your pediatric facial plastic surgeons and speech pathologist will review all the information (including the flexible exam) to develop the best plan for your child.

Furlow Palatoplasty for VPI

If your child has a persistent abnormality of the muscles in the palate, a surgery to lengthen the palate and re-align the muscles in the palate may be needed. This surgery is similar to the surgery used to close the soft palate in children with a cleft of the soft palate alone. This surgery lengthens the soft palate and moves the muscles so that they are running across the palate (the normal orientation) rather than running front to back (the orientation in children with a cleft palate). The decision to perform this surgery alone usually depends on the size of the gap and the orientation of the muscles.

Sphincter Pharyngoplasty for VPI

Some children have a palate with muscles that have been moved to the correct orientation, but still have a palate that is too short to reach the back of the throat. Depending on the size and shape of the gap, many of these children have significant improvement with a surgery to create a "speed bump" at the back of the throat. This procedure called a Sphincter Pharyngoplasty takes a piece of tissue that runs behind the tonsil and moves it to run across the throat behind the palate. Usually there is one on each side except for rare problems. These pieces of tissue are often called a 'flap' by your surgeons. If the flaps are too big, sit too low or end in the wrong location, they can cause problems. These problems range from not being able to breathe very well through your child's nose (uncommon) to scarring that blocks off the space between the nose and throat (rare). While it is uncommon, your child can also develop sleep apnea after the procedure.

Tailored Care

Nearly every Sphincter Pharyngoplasty is customized to fit your child's gap. From the size of the flaps, to the position on the side of the throat, to the height of placement of the flaps. Customizing the procedure to treat your child's VPI but not over doing it helps to minimize the risk of sleep apnea.

Pharyngeal Flap for VPI

Some children with VPI have a large gap or a palate that does not move enough to make a sphincter a viable option. For these children, a pharyngeal flap is usually the best surgical option. In this procedure, a piece of tissue from the back for the throat is connected to the back of the soft palate. This blocks the air escaping through the nose but allows your child to breathe through their nose.

Tailored Care

This flap is often customized and minor adjustments are made to treat your child's VPI but minimize the risk of sleep apnea and scaring.

What Sets Us Apart?

Our surgeons focus their work on children with conditions of the face, head, throat and neck. This provides us with unique training and experiences. We have also developed tools to help other surgeons and cleft team measure VPI outcomes in a new way. By asking children and families how much of a problem they are having. Some surgeons forget the reason we are operating is to improve your child's daily interactions. While tests of nasal emission are sometimes helpful, our VPI quality of life instrument (the VELO) measures the very thing we are trying to improve. Quality of Life.

We are passionate about helping your child as well as helping surgeons around the globe provide better care to children just like yours.

Orthodontic and Dental Care

Orthodontics and dental care are important to optimize outcomes in children with cleft lip and palate. Children with clefts have typical dental needs as well as special problems that are unique to cleft care. Dental hygiene is important as unhealthy teeth and gums compromise future orthodontic and surgery of the jaws. It also contributes to low self-esteem and psychosocial issues. The orthodontist will help monitor facial growth positioning bony segments to provide the underlying framework for the facial soft tissue. If the bone of the face and teeth are not in the correct place, the facial appearance will suffer.

Palate Expansion

Sometimes the teeth can be slowly moved into a more favorable position, but if the bone is in the wrong position there is only so much that an orthodontist can do. Children with a cleft lip and palate have differences in the way the alveolar ridges (the arches holding the teeth) are lined up. If they are too narrow (and with a narrow roof of your mouth), they may need to be moved by a palatal expansion devices. If children are over a certain age or if their palate is severely narrowed, the palate expansion device may not work as well. In these cases, your surgeons may need to perform a surgery to allow the gum lines to be moved to the proper location. This is called surgically assisted rapid palate expansion. After we carefully make cuts in the bone to allow the palate bones to move, the palate expansion device is able to carefully and quickly move the teeth into the proper position.

Relationship of Narrow Palate and Narrow Nasal Passage

When the upper jaw is collapsed in and narrow, the nasal passage is often quite narrow as well. This is because the roof of the mouth is the floor of the nose. Sometimes the bone on inside of the nasal passage (the inferior turbinates) are enlarged and pushed in towards the center of the nose. As Pediatric ENTs (or Ear, Nose and Throat Surgeons), we are experts in the anatomy of the mouth and nose. Occasionally we can take advantage of moving the teeth and palate into the correct position and open the narrow nose at the same time. This can be accomplished by adjusting where we cut the bones before moving the palate. Our understanding of the face and nose allow us to optimize your child's outcomes.

Other times we may need to remove the excess bone at the front of the inferior turbinate (swelling just inside the nostril). Your surgeons may also think shrinking some of the soft tissue of the turbinate would help your child breathe through his/her nose better. Your Pediatric Facial Plastic & ENT Surgeons can assess how best to help your child breathe best through their nose and these surgeries when you meet them.

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we operate on the facial skeleton for many reasons. For example we use these types of surgeries to remove tumors from deep in the nose; repair broken facial bones; treat infections of the teeth, nose and face; changing the position of facial bones to improve the airway in children with sleep apnea and more. We operate on these structures for many reasons and it gives us a deep understanding of the anatomy and function. Your child's face is in good hands with our surgeons.

What To Expect:

Children often stay in the hospital overnight after this surgery to make sure their pain is controlled. Older children often can often go home after palate expansion procedure.
The sutures above the gum line are dissolvable.
Your child will use an antiseptic mouth wash for a week to help prevent infection.
Your child will receive pain medication and this will be adjusted to ensure their pain is well controlled.
Your child will be closely monitored for pain control, breathing and how much they are eating/drinking.
Your child may wear 'Arm Straighteners' that help prevent them from accidently hurting themselves while they are healing; depending on their age
You will begin expanding the palate a couple days after the surgery and slowly
Occasionally children have a small nosebleed after surgery. This is often because the breathing tube is placed in the nose to allow full access to the mouth and jaws. Usually a nasal decongestant spray is all that is needed. We are experts at managing nose bleeds if this spray does not fix the problem.
The nursing staff at Diamond Children’s care for many children that have these types of surgeries. They will provide you with many pointers in addition to compassionate post operative care.

Common Questions

Are there restriction on how my child can eat and drink?

Our surgeons don't put restrictions on how you child eats or drinks. Problems with healing are very uncommon and these restrictions don't seem to decrease the likelihood of having a problem.

Will my child be able to eat and drink after their surgery?

Most children do well eating and drinking after jaw surgery. They have a sore jaw and will want to avoid certain types of foods.

Will my child have breathing problems after palate surgery?

While we will monitor your child closely for breathing problems jaw, it is unlikely that he/she will have a problem.

Will my child's teeth be numb after surgery?

Temporary numbness to the upper teeth can happen after surgery but is usually temporary.

Midface Surgery

Children with a cleft lip and palate often also have difficulty with a sunken in face (midface) around the nose (maxillary hypoplasia). This usually results in a hollow appearance of their face but also causes dental and chewing problems because the teeth don't line up properly. If your child has this problem, they will eventually need a surgery where the bones in the central face and upper jaw are moved forward. This is called a LeFort 1 osteotomy (cutting the bone of the midface) and maxillary advancement (bringing the midface forward). This can be done slowly or all at once. If a child has a severe sunken in midface, they may require this in grade school (usually between the ages of 6 and 9). Slowly moving the upper jaw bone involves distraction osteogenesis. For this procedure the upper jaw is cut and then after a 'bone scar' forms, the upper jaw is slowly advanced to its final position. The midface is slowly pulled forward in one of two ways. Sometimes we are able to place devices in the tissue with a flexible arm (or activator) sitting in the upper gum line that allows us to advance the device slowly. Sometimes we need to use a type of 'headgear' that is more stable (HALO device). The force of slowly moving the upper jaw forward stimulates bone growth at the 'bone scar.' After the upper jaw is in the desired position, the bone continues to harden over several weeks.

The disadvantage of early treatment is that the upper jaw could have continued trouble growing as your child continues to grow, so there is a chance that another surgery would be needed. When the procedure is done after the facial bones are fully grown, the upper jaw may be moved to its final position and stabilized with firm plates. Some children that need their midface moved a large distance require distraction osteogenesis (slowly moving the midface to stimulate bone growth) as they reach adulthood. When the LeFort surgery is done in adulthood, it is usually done before definitive rhinoplasty (nose job) to give the nose a firm foundation in the correct position.

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we operate on the facial skeleton for many reasons. For example we use these types of surgery to remove tumors from deep in the nose; repair broken facial bones; treat infections of the teeth, nose and face; changing the position of facial bones to improve the airway in children with sleep apnea. We operate on these structures for many reasons and it gives us a deep understanding of the anatomy and function.

What To Expect:

Younger children often stay in the hospital overnight after this surgery to make sure their pain is controlled. Older children getting an advancement can sometimes go home the evening of surgery depending on their pain control.
The sutures above the gum line are dissolvable.
Your child will use an antiseptic mouth wash for a week to help prevent infection.
Your child may take an oral antibiotic to help prevent an infection in bone scar. Usually this is only needed during active distraction. If your child has drainage or concern for infection, your surgeons may restart antibiotics after evaluation. Infection after distraction osteogenesis can result in weak new bone. This is uncommon in the midface.
Your child will receive pain medication and this will be adjusted to ensure their pain is well controlled.
Your child will be closely monitored for pain control, breathing and how much they are eating/drinking. Usually children do well after surgery.
The nursing staff at Diamond Children’s care for many children that have these types of surgeries. They will provide you with many pointers in addition to compassionate post operative care.

Common Questions

Are there restriction on how my child can eat and drink?

Our surgeons don't put restrictions on how you child eats or drinks. Problems with healing are very uncommon and these restrictions don't seem to decrease the likelihood of having a problem.

Will my child be able to eat and drink after their surgery?

Most children do well eating and drinking after jaw surgery. They have a sore jaw and will want to avoid certain types of foods. We will work to find the best pain control for your child after surgery.

Will my child have breathing problems after palate surgery?

While we will monitor your child closely for breathing problems jaw, it is unlikely that he/she will have a problem.

Will my child's teeth be numb after surgery?

Temporary numbness to the upper teeth can happen after surgery but is usually temporary.

Cleft Rhinoplasty (Nose Job)

Children with a cleft lip and palate often have a nose that doesn't look like other kids. Even if the outside appearance of the nose is normal, the inside of the nose tends to be twisted. Rhinoplasty (or a 'nose job') is a nasal reconstruction to improves the appearance of the nose as well as a child's ability to breathe through their nose. Ideally, we wait until a patient's face reaches their adult size to perform definitive (final) nasal surgery. The reason we try to wait is due to concern that the nose will not grow as well if we operate earlier. Studies that have carefully evaluated this possibility have not shown a clear answer.

Sometimes there are reasons to perform the rhinoplasty surgery earlier. For example some children have a very deformed nose and are teased by their peers. Other children that are a little older can have nasal obstruction (can't breathe through his or her nose) that interfere with their quality of life. Understanding the risks and benefits of performing the surgery earlier helps us decide if an early rhinoplasty (or intermediate rhinoplasty) is in your child's best interest. In these situations, we trade the theoretic risk of nasal growth problems for the real benefit of being teased less and improved self confidence. Your Pediatric Facial Plastic & ENT Surgeons can discuss the pros and cons of either decision with your family during a visit.

During the surgery, a small incision is hidden on the bottom of the nose (columella). This allows us to access the cartilage inside the nose. This cartilage structure inside the nose that keeps your nose's shape and keeps it springing open is often collapsed and weakened. During surgery we realign the collapsed cartilage, removed 'twisted' cartilage and provide support where it is needed. If the bone of your child's nose is twisted, this will be addressed too. The goal with rhinoplasty is to change the way your child's nose looks so that it looks like other noses. You don't want your child's nose to like it's been "done."

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we have a deep understanding of the anatomy and function of the inside and the outside of the nose. We perform numerous surgeries on the inside and outside of the nose. In addition to rhinoplasties, we often improve breathing with a variety of internal and external nasal surgeries; remove tumors from the outside of the nose as well as tumors on inside of the nose and skull base.

As Pediatric Otolaryngologists (or ENTs), we cannot always wait to remove a tumor from a child's nose until they reach skeletal maturity. Our outcomes from these surgeries and other times when we need to intervene earlier help provide us experience with how to perform this surgery in younger children to minimize the risk of decreased nasal growth. Your surgeons can review the risks and potential benefits of earlier surgery to help determine if it is the right decision for your family.

A number of children and young adults have deformed noses from trauma, nasal masses and cleft lip. Our experience children with these types of nasal surgeries helps us achieve the best form (the way the nose looks) and function (how well your child can breathe). There is often a balance between the form and function of the nose; we aim to optimize both. If the appearance and/or the way your child breathes is affecting their life in a way that can't wait until they reach adulthood, our surgeons can discuss other options including the theoretic risks of an early surgery.

Nose Scars

In cleft rhinoplasty, there are often scars and asymmetries in the base of the nose and just inside the nostril. This area is known as the 'external nasal valve.' While it is not really a 'valve,' correcting scars in this area is different than a non-cleft rhinoplasty. Fixing these problems usually involves small incisions inside the nose and moving the tissue to correct location. The incisions are usually hidden on the inside of the nostril and usually this does not make recovery worse than a rhinoplasty without the nasal scar revision.

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we often help children with scarring and narrowing inside their noses. Our deep understanding of the anatomy and function of the inside and the outside of the nose helps us both improve the way the nose looks as well as how it functions (allows your child to breathe). Your surgeons can discuss the specifics of what is needed to help your child.

Turbinate Reduction

The turbinates are structures on the inside of the nose that warm and humidify the air we breathe in. When they are swollen, it can make breathing through the nose much harder (stuffy nose or even nasal obstruction). Children with a cleft lip and palate often have a 'twisted' septum. This usually narrows the nose in the front on one side and in the back on the other side. The turbinates have usually grown to fill the area of the nose. When the septum is straightened during the rhinoplasty, your child may not be able to breathe through their nose. Fortunately, the enlarged turbinates can be reduced in size by a variety of surgical techniques. Your surgeons can discuss what is needed based on the way your child's turbinates look.

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we often help children with nasal congestion and obstruction. Part of our comprehensive evaluation will involve understanding the inside of your child's nose. Sometimes children with a cleft lip and palate have narrowing of the nose in front of the turbinates that makes examining them in clinic very challenging. Your surgeons can discuss the specifics of what you child's nose look like and will tailor their treatment to your child's specific problems.

What To Expect:

After surgery, your child will usually have dissolvable sutures on the bottom of their nose and inside their nose. They will also have splints in their nose that help the inside of their nose to heal.
Both younger and older children can usually go home after this surgery. On occasion, a younger child will have trouble with pain control and need to stay overnight. If your child has obstructive sleep apnea, your surgeons may want him/her to stay overnight depending on how severe it is.
Your child will have some oozing of mucous and blood while they are healing. This causes the mucous in their nose to become thick and patients usually experience slowly worsening nasal congestion. Using antibiotic ointment and saline spray helps to keep this drainage thin and lets your child breath through their nose. You and your child should be careful not to bump the inside of the nose because it will be sore and the reconstruction is somewhat delicate.
Your child may take an oral antibiotic to help prevent a local infection in nose from having the splints in place.
Your child will receive pain medication and this will be adjusted to ensure their pain is well controlled.
The nursing staff at Diamond Children’s care for many children that have these types of surgeries. They will provide you with many pointers in addition to compassionate post operative care.

Common Questions

Will my child be able to breathe through their nose right after surgery?

Usually children need soft splints to help the nose heal. These splints get clogged with secretions or 'buggers.' Salt water spray several times a day and ointment usually help to thin out the mucous that clogs the nose and splints. After the splints are removed, children are often able to breathe through their nose much better. Sometimes children report it 'feels weird' or stings when they breathe through their nose. Usually this is because they haven't had much air moving through the nose before. Saline spray, ointment and time usually helps with this sensation. After the splints are removed, the tissue inside the nose often slowly swells and the nose gets more stuffy over a week. The swelling goes down over a couple of weeks and your child's nose will be their 'new normal.'

Do the splints in the nose hurt?

The soft splints inside the nose often are sore. Sometimes we can avoid the splints in the nose but usually this is in kids with less complex nasal reconstruction. Most kids with a cleft nasal deformity have a severe problem and we often need to use the splints to give them the best chance of healing. Your surgeons should be able to tell you before surgery if the splints are likely to be required or not.

Cleft Lip Scar Revision

Unfortunately, sometimes a well repaired cleft lip scars in an unfavorable way. Each cleft scar is a little different than the rest. When to address a cleft scar depends on how it is impacting your child. Children can be quick to point out differences and so we often try to improve the scar before a child starts school to help minimize any 'teasing' they may experience. Improving the appearance of the lip in early childhood can be an important step in ensuring your child has confidence in themselves.

Fixing some scars requires a small surgery while others requires a larger surgery. Designing the surgical plan can be more challenging than the initial surgery. Our experience with cleft lip revisions have helped our surgeons design better primary cleft lip repairs and make subtle adjustments in our techniques over the years. Your surgeon can discuss your child's needs as well as help to coordinate any additional procedures they may need to help minimize surgical burden. Coordinating these procedures in a thoughtful way can help limit the impact of multiple surgeries on your child and your family.

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we often help children with scars from a variety of problems. Children's lip scars come from a variety of sources including: scaring from previous cleft lip repair, dog bites, car crashes, falls, other trauma or previous surgery. These provide us with in depth understanding of optimizing your child's lip and just inside their nose.

Nearly no two cleft lip scar revision is the same. Your surgeon will work to develop the best plan for your child's care.

What To Expect:

Recovery after scar surgery usually depends on how extensive the surgery is to repair the scar. Sometimes there will be a small incision to move a small amount of tissue around and sometimes much of the incision need to be opened to reorient the muscle. Even the larger revision surgeries are usually not as challenging a recovery as some of the other surgeries your child has healed from. The soreness is usually only in the lip. The lip may swell up depending on how extensive the surgery.
After surgery, your child will usually have dissolvable sutures along the lip and sometimes on the inside of the lip. If your child has a tendency to scar, your surgeon may elect to use non dissolvable sutures. These are usually removed 7-10 days later.
Almost all children go home after a scar surgery unless it is combined with another.
Your surgeon will have you put either antibiotic ointment or another ointment on the incision 2 or 3 times a day to help it to heal. This will help the skin to heal underneath any crusting scab.
Your child will receive pain medication and this will be adjusted to ensure their pain is well controlled.
The nursing staff at Diamond Children’s care for many children that have these types of surgeries. They will provide you with many pointers in addition to compassionate post operative care.

Common Questions

Is there anything that can be done to prevent scarring after this surgery?

Most children heal well without thickened or red scars. If your child tends to form thick scars, your surgeon will monitor them closely after surgery. If they start to have this trouble, they may need an injection of a medication into the scar to help it heal. This is usually a steroid and in older kids can be done in clinic. Younger kids might need to be done in the operating room with a brief sedation.

To help prevent scaring, your surgeon will have you apply ointment early after the scar. Once there is no more crusting/scab present, your surgeon will help prevent to two types of problems with scars:

Scars can become a different color than the surrounding skin.

To prevent this, your child should use sunscreen (SPF 45 or higher) every time they go outside. There are even sun rays present on cloudy days so it best to make it part of your child's daily routine for one year after facial surgery. Using a hat or other physical barrier from the sun is often helpful.

Scars can become thicker and feel different than the skin next to it.

This is best prevented with gentle massage starting about 2-3 weeks after your child's surgery. You can take this opportunity to apply scar mitigation products such as Scar Fade or other products. Lotion or Vitamin E works well if you can't afford these special products. Your surgeon will show you how hard to massage at your follow up visit.

Cleft Lip Surgical Burden & Surgical Burnout

Often a child with cleft lip and/or palate will undergo several surgical procedures over a lifetime to repair the defects. The information found here highlights many of the common potential problems and interventions to help improve your child's life experiences. You can imagine that if every surgery was done alone, this would be a severe burden on your family and your child. Our surgeons are all too aware of this burden and will work to consolidate as many procedures as can be done together as possible to minimize this burden.

In addition to having placed an unnecessary burden on your family, too many children decide not to have some of their recommended surgeries when they reach adulthood because they have already had too many surgeries. It can even cause a child to be conditioned to fear further surgeries or become ambivalent about the problem the family feels they are experiencing.

Our team recognizes this problem and can help to minimize the difficulties associated with numerous surgeries. By helping consolidate some of the surgeries together and waiting until children are a little older for some surgeries, your child may not need to spend as much of their young life recovering from surgery. While it makes for a longer day for the surgeons, that is little price to pay for the improvement in your child's life experience. Hopefully this decreases the burden on your family and allows your child to follow through with the definitive surgeries they are recommended by the team (usually LeFort advancement and cleft rhinoplasty).

What Sets Us Apart?

As Pediatric Facial Plastic & ENT Surgeons, we often help children with conditions that need staged surgery where we need time between groups of surgeries. We recognize the burden of repeated surgeries and will work to minimize this burden on your family for many types of surgeries. We will work to be thoughtful in planning your child's surgeries to help limit the times your family is recovering from a surgery.