Surgeons Share Their Thoughts on Treating Velopharyngeal Insufficiency with Injectables

Paul Willging, MD, a pediatric otolaryngologist in the division of pediatric otolaryngology–head and neck surgery and director of the Velopharyngeal Insufficiency Clinic at Cincinnati Children’s Hospital Medical Center in Ohio, is now also using Deflux in his patients, largely for small gaps. He was introduced to the idea by Dr. Cofer in 2010 when she came to Cincinnati to demonstrate its superior benefits over other fillers. Before that, Dr. Willging had tried several fillers that did not have the same durability as Deflux. He used medical-grade injectable Teflon in the early 1990s until it was no longer available; in the mid-1990s, he started using other fillers such as collagen products like Cymetra, often used for vocal cord paralysis, as well as calcium hydroxylapatite (Radiesse), often used for facial augmentation. Neither of these products proved to be a good long-term solution due to their relatively fast absorption (three to four months with Cymetra and six to 12 months with Radiesse).

Unlike Dr. Cofer, who has used Deflux in middle-sized gaps, Dr. Willging uses it only to close small gaps. “I’m kind of a hole surgeon,” he said. “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.”

Dr. Willging determines the size of gaps with the “eyeball” approach when viewing the velopharyngeal sphincter area with a flexible endoscope. “If you see a tiny gap that looks like it is 2 mm in size and not extending all the way across, that is a gap I’ll inject,” he said.

Deflux has shown the longest durability to date compared to other common fillers used for VPI, but no head-to-head studies have been done, and the data is based on retrospective reviews of relatively small patient populations. Other fillers are still being used in this setting, and a sampling of how some laryngologists are using them is provided below.

Other Fillers Used

Jonathan M. Bock, MD, a professor in the division of laryngology and professional voice, department of otolaryngology and communication sciences, at the Medical College of Wisconsin in Milwaukee, mentioned several injectables, including hyaluronic acid (Restylane, Juvederm) for shorter-term temporary duration of six to 12 months, that may be suitable for augmenting Passavant’s ridge. He said if it is injected superficially, it can last longer. Another option for a longer-term duration is the use of autologous fat harvested directly from the patient via a small abdominal incision or liposuction technique and then injected directly into the posterior pharyngeal wall. A newer product that some physicians are trying is a silk protein microparticle–hyaluronic acid called Silk Voice. He cautioned, however, that both hyaluronic acid and Silk Voice carry the potential risk of allergic reaction and hypersensitivity.

Dr. Bock underscored the idea that the efficacy of these injectables is good as long as the palatal gap is not too large. “I generally try one to two injections with hyaluronic acid and, if beneficial, proceed to fat augmentation of the posterior pharynx in the operating room,” he said.

Noting that VPI has become a really huge issue in the quality of life of patients who have undergone nasopharyngeal and oropharyngeal cancer, Mark A. Fritz, MD, an associate professor in the division of laryngology, department of otolaryngology–head and neck surgery at the University of Kentucky College of Medicine in Lexington, said that filler injections for VPI have improved their quality of life.

For example, he noted that some patients have trouble swallowing after cancer treatment and, despite being treated for their esophageal stricture, are still so fearful of nasal regurgitation that it limits their willingness to go out to eat in public. They are afraid that something they swallow will come through their nose at the table. To correct this, he uses carboxymethylcellulose as a temporary injection to the posterior oropharyngeal wall and the soft palate that lasts two to three months, similar to its use in vocal fold injection augmentation. “If they get improvement with this temporary injection, oftentimes done concomitantly with another procedure such as vocal fold injection or esophageal dilation, then I will move towards doing an autologous fat injection augmentation again in the operating room as a way to get more permanent improvement,” he said.

Paul C. Bryson, MD, MBA, an associate professor of otolaryngology–head and neck surgery and head of the section of laryngology, department of otolaryngology–head and neck surgery at the Cleveland Clinic in Ohio, sees a lot of patients in his practice with late effects of head and neck cancer treatment and neurodegenerative conditions that cause VPI. He said injections are the predominant way he treats VPI. “There are surgeries, but often patient preference is for less intense treatment,” he said. “In addition, sometimes in a setting of prior surgery and radiation, the tissue healing and flexibility in this area is harder to predict.”

For Dr. Bryson, a key issue to keep in mind is the broad heterogeneity of VPI in patients, including gap size, tissue integrity, and symptoms. “I am careful to tell patients that this is definitely not a one-size-fits-all approach,” he said. “There are patients for whom it is hard to get a full response or to completely eradicate VPI with an injection. There is nuance and diversity in what you’ll see, and it is good to be aware of the ladder of options for patients.”

Best Practices

Patient selection is key to whether or not to use injectable fillers for VPI. To determine which patients meet the criteria for VPI, a thorough workup should be performed to determine the etiology of the VPI and the symptoms caused. This includes involving an interdisciplinary team of otolaryngologists, speech pathologists, and radiologists in conducting a thorough history, physical exam, assessment of speech production, and instrumentation evaluation (Table 1) (StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK563149/). A speech pathologist provides the gold standard for VPI diagnosis by asking patients to produce sounds to assess for hypernasal speech, misarticulation, or compensatory facial grimacing.