Surgeons Share Their Thoughts on Treating Velopharyngeal Insufficiency with Injectables

Velopharyngeal insufficiency (VPI) causes significant quality of life issues for people affected—speech can sound hypernasal, as if too much air is coming out of the nose, and swallowing can send fluid back up through the nose, resulting in nasal regurgitation. A disorder in the velopharyngeal sphincter or valve that separates the nasal and oral cavities, VPI has a variety of etiologies.

In children, the most common causes are craniofacial abnormalities, including neuromuscular hypotonia and cleft palate (the most frequent cause of VPI in children). It also can occur in children after an adenoidectomy. In adults, the most common causes are degenerative neurological conditions and late effects or consequences of oropharyngeal and head and neck cancer treatments, including cranial neuropathies. 

Correctly identifying the origin or cause of VPI is critical to successful treatment, which essentially involves closing the gap between the soft palate and the posterior wall of the throat. Surgery is a mainstay of treatment for more significant gaps, but physicians increasingly opt for a nonsurgical approach in select patients. In this procedure, called augmentation pharyngoplasty, injectable fillers are used to close the gap. Typically, this is used for small gaps, but it has been used successfully on medium gaps as well.

Shelagh Cofer, MD, a pediatric otolaryngologist at the Mayo Clinic in Rochester, Minn., who wrote her Triological Society Candidate Thesis on her results after using an injectable filler on children with VPI, is someone who has successfully closed small to medium gaps in both children and adults with VPI (Laryngoscope. doi.org/10.1002/lary.26227). She’s been using an off-label injectable dextranomer and hyaluronic acid copolymer (Dx/HA) since 2010 after looking for a more durable filler than other available fillers. She got the idea of trying the filler after noting that it had been used safely and effectively for years in the treatment of pediatric urinary reflux in Europe. Dx/HA is now also approved by the U.S. Food and Drug Administration. The product is commercially packaged as Deflux (Salix Pharmaceuticals, Inc., Raleigh, N.C.).

“This filler has a long track record in children, so almost 15 years ago, I started gingerly offering this to patients and developed a protocol for using it that a lot of people now follow,” she said. The protocol is available as a supplement to her thesis, as is a second appendix on how the procedure is performed.

The thesis described and reported on the results of a retrospective series of 50 children in which she used Dx/HA to fill small to medium gaps in the nasopharynx to treat VPI. She used the Golding–Kushner technique outlined by the International Working Group to estimate gap size (Cleft Palate Journal. doi.org/10.1597/1545-1569_1990_027_0337_sftron_2.3.co). It was the first series of patients to undergo augmentation pharyngoplasty with this new filler, and the results showed its benefits over traditional surgical approaches to correcting this problem: shorter procedural time to correct VPI, easier recovery, and, importantly, longer durability than reported with other types of fillers.

In 2017, Dr. Cofer and her colleagues also published a retrospective analysis on the efficacy and durability of Dx/HA in the treatment of 25 adult patients with VPI caused by neurologic etiology or benign anatomic etiology, or acquired following treatment for head and neck cancers (Mayo Clin Proc Innov Qual Outcomes. doi: 10.1016/j.mayocpiqo.2017.06.003).

In both the children and the adult series, Deflux has demonstrated longer durability to date than other fillers on the market. In the series on children, 80% of patients had a durable result at the end of one year, and 10-15% needed a touch-up injection. Of these latter patients, Dr. Cofer attributed the need for a touch-up to the change in pharynx volume that can be caused by a growth spurt in children and the potential need to open up the gap a bit. In 5% of the pediatric patients, the filler did not stay in the tissue. In the adult series, most patients (19 of 25) needed just one injection, and six patients needed a second injection. 

I’m kind of a hole surgeon. If you have a big hole, you put something big in it; if you have a hole to the left, move everything to the left; if you have a tiny hole, you can do a lesser operation, and this is where I tend to use injectables for these tiny gaps. —Paul Willging, MD

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