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Figure 1.
Velopharynx of Trombone Player
Velopharynx of Trombone Player

A, Velopharynx of trombone player while playing instrument prior to injection augmentation. Note the escape of air. B, Velopharynx of trombone player after lipoinjection.

Figure 2.
Velopharynx of Saxophone Player
Velopharynx of Saxophone Player

A, Velopharynx of saxophone player while playing instrument prior to injection augmentation. Note the air bubbles. B,Velopharynx of saxophone player shortly after second lipoinjection augmentation.

1.
Weber  J  Jr, Chase  RA.  Stress velopharyngeal incompetence in an oboe player.  Cleft Palate J. 1970;7:858-861.PubMedGoogle Scholar
2.
Dibbell  DG, Ewanowski  S, Carter  WL.  Successful correction of velopharyngeal stress incompetence in musicians playing wind instruments.  Plast Reconstr Surg. 1979;64(5):662-664.PubMedGoogle ScholarCrossref
3.
Ruda  JM, Krakovitz  P, Rose  AS.  A review of the evaluation and management of velopharyngeal insufficiency in children.  Otolaryngol Clin North Am. 2012;45(3):653-669, viii.PubMedGoogle ScholarCrossref
4.
Fisher  DM, Sommerlad  BC.  Cleft lip, cleft palate, and velopharyngeal insufficiency.  Plast Reconstr Surg. 2011;128(4):342e-360e.PubMedGoogle ScholarCrossref
5.
Eckstein  H.  Demonstration of a paraffin prosthesis in defects of the face and palate.  Dermatologica. 1904;11:772-778.Google ScholarCrossref
6.
Blocksma  R.  Correction of velopharyngeal insufficiency by Silastic pharyngeal implant.  Plast Reconstr Surg. 1963;31:268-274.PubMedGoogle ScholarCrossref
7.
Bluestone  CD, Musgrave  RH, McWilliams  BJ.  Symposium on synthetics in maxlloacial surgery. II. Teflon injection pharyngoplasty--status 1968.  Laryngoscope. 1968;78(4):558-564.PubMedGoogle ScholarCrossref
8.
Lypka  M, Bidros  R, Rizvi  M,  et al.  Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: a 40-year experience.  Ann Plast Surg. 2010;65(1):48-51.PubMedGoogle ScholarCrossref
9.
Bishop  A, Hong  P, Bezuhly  M.  Autologous fat grafting for the treatment of velopharyngeal insufficiency: state of the art.  J Plast Reconstr Aesthet Surg. 2014;67(1):1-8.PubMedGoogle ScholarCrossref
10.
Desgain  O, de Burbure  C, Mazy  C, Verheyden  PJ, Monnoye  JP, Levie  P.  Autologous costochondral cartilage implant in two cases of velopharyngeal insufficiency.  B-ENT. 2006;2(1):39-42.PubMedGoogle Scholar
11.
Denny  AD, Marks  SM, Oliff-Carneol  S.  Correction of velopharyngeal insufficiency by pharyngeal augmentation using autologous cartilage: a preliminary report.  Cleft Palate Craniofac J. 1993;30(1):46-54.PubMedGoogle ScholarCrossref
12.
Coleman  SR.  Structural fat grafts: the ideal filler?  Clin Plast Surg. 2001;28(1):111-119.PubMedGoogle Scholar
13.
Von Gaza  W.  Free retropharyngeal fat grafting in cleft palate.  Arch Klin Chir. 1926;142:590.Google Scholar
14.
Dejonckere  PH, van Wijngaarden  HA.  Retropharyngeal autologous fat transplantation for congenital short palate: a nasometric assessment of functional results.  Ann Otol Rhinol Laryngol. 2001;110(2):168-172.PubMedGoogle ScholarCrossref
15.
Lau  D, Oppenheimer  AJ, Buchman  SR, Berger  M, Kasten  SJ.  Posterior pharyngeal fat grafting for velopharyngeal insufficiency.  Cleft Palate Craniofac J. 2013;50(1):51-58.PubMedGoogle ScholarCrossref
16.
Leuchter  I, Schweizer  V, Hohlfeld  J, Pasche  P.  Treatment of velopharyngeal insufficiency by autologous fat injection.  Eur Arch Otorhinolaryngol. 2010;267(6):977-983.PubMedGoogle ScholarCrossref
17.
Klotz  DA, Howard  J, Hengerer  AS, Slupchynskj  O.  Lipoinjection augmentation of the soft palate for velopharyngeal stress incompetence.  Laryngoscope. 2001;111(12):2157-2161.PubMedGoogle ScholarCrossref
18.
Schwab  B, Schultze-Florey  A.  Velopharyngeal insufficiency in woodwind and brass players.  Med Probl Perform Art. 2004;19:21-25.Google Scholar
19.
Evans  A, Driscoll  T, Ackermann  B.  Prevalence of velopharyngeal insufficiency in woodwind and brass students.  Occup Med (Lond). 2011;61(7):480-482.PubMedGoogle ScholarCrossref
20.
Evans  A, Driscoll  T, Livesey  J, Fitzsimons  D, Ackermann  B.  Nasendoscopic evaluation of stress velopharyngeal insufficiency in wind musicians: a pilot study.  Med Probl Perform Art. 2015;30(1):47-53.PubMedGoogle Scholar
21.
Bauer  CA, Valentino  J, Hoffman  HT.  Long-term result of vocal cord augmentation with autogenous fat.  Ann Otol Rhinol Laryngol. 1995;104(11):871-874.PubMedGoogle ScholarCrossref
22.
Solomon  BD, Patel  A, Cheung  SW, Pineda-Alvarez  DE.  VACTERL association and mitochondrial dysfunction.  Birth Defects Res A Clin Mol Teratol. 2011;91(3):192-194.PubMedGoogle ScholarCrossref
23.
Malick  D, Moon  J, Canady  J.  Stress velopharyngeal incompetence: prevalence, treatment, and management practices.  Cleft Palate Craniofac J. 2007;44(4):424-433.PubMedGoogle ScholarCrossref
24.
Raol  N, Diercks  G, Hersh  C, Hartnick  CJ.  Stress velopharyngeal incompetence: two case reports and options for diagnosis and management.  Int J Pediatr Otorhinolaryngol. 2015;79(12):2456-2459.PubMedGoogle ScholarCrossref
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Original Investigation
February 2017

Injection Pharyngoplasty With Autologous Fat as Treatment for Stress Velopharyngeal Insufficiency in Brass and Woodwind Musicians

Author Affiliations
  • 1Cleveland Clinic Voice Center, Section of Laryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
 

Copyright 2017 American Medical Association. All Rights Reserved.

JAMA Otolaryngol Head Neck Surg. 2017;143(2):142-146. doi:10.1001/jamaoto.2016.1920
Key Points

Question  Is lipoinjection to the posterior pharyngeal wall an effective treatment for patients who play brass and woodwind instruments who have stress velopharyngeal insufficiency (SVPI)?

Findings  In a report of 2 patients direct visualization via nasopharyngoscopy while the patients played their instrument was critical to defining the location and extent of SVPI. One patient resumed full play with complete resolution and the other patient received temporary resolution.

Meaning  Autologous fat injection pharyngoplasty offers a potentially permanent surgical option for some patients.

Abstract

Importance  Stress velopharyngeal insufficiency (SVPI) is an uncommon but often career-threatening condition affecting professional brass and woodwind musicians.

Objectives  To review the evaluation of and treatment for SVPI in professional musicians with lipoinjection to the posterior pharyngeal wall.

Design, Setting, and Participants  A retrospective medical record and literature review. Two professional musicians with SVPI treated with autologous lipoinjection to the posterior pharyngeal wall were included. Nasopharyngoscopy was performed while patients played their instrument both before and after injection.

Main Outcomes and Measures  To assess the effectiveness of autologous fat injection to the posterior pharyngeal wall to treat stress velopharyngeal insufficiency in 2 professional instrumentalists. Successful treatment was the absence of VPI during playing as visualized by flexible nasopharyngoscopy.

Results  After autologous lipoinjection of the posterior pharyngeal wall, 1 patient resumed full play with complete resolution, now 3 years after lipoinjection pharyngoplasty. The other patient received temporary resolution. Both had no surgical complications. Stress VPI is often a career-threatening condition for professional brass and woodwind musicians, with a cited incidence of 34%. Various treatment options in the literature include observation, speech and language pathology referral for pharyngeal strengthening, lipoinjection of the soft palate, and more invasive options, such as sphincter pharyngoplasty, pharyngeal flaps and V-Y pushback.

Conclusions and Relevance  Autologous fat injection pharyngoplasty of the posterior pharyngeal wall may be a less invasive treatment option for musicians with SVPI.

Stress velopharyngeal insufficiency/incompetence (SVPI) is a particular form of velopharyngeal insufficiency/incompetence (VPI) in which there is an escape of air from the oral cavity to the nasal cavity while playing brass or woodwind instruments and was first described in the literature in 1970.1 In SVPI the intraoral pressures greatly exceed those generated during normal speech and have been noted to “reach as high as 130 mm Hg whereas normal speech pressures rarely exceeds 5-6 mm Hg.”1 This condition, if left untreated, is largely career ending for a professional instrumentalist because it impairs their ability to “play high and long.”2

Various treatment modalities have been shared in the literature ranging from conservative observation and speech language pathology referral to surgical intervention with sphincter pharyngoplasty, pharyngeal flap (V-Y pushback, etc).1 Surgical repair has been associated with significant risks including bleeding, airway compromise, and obstructive sleep apnea.3,4 Specifically, augmentation of the posterior pharyngeal wall for nonstress VPI has been documented with materials including paraffin, silastic, Teflon, Goretex among a host of other alloplastic fillers which have been documented to migrate, extrude, or cause a foreign body reaction.5-9

Thus, the use of autologous materials such as cartilage were investigated but found to be less than desirable owing to the complications associated with harvest as well as the resorption.10,11 The use of autologous fat augmentation of the velopharynx has been of particular interest because it serves as an intermediary between surgical repair and synthetic injections and has been lauded as the “ideal filler” given its ease of harvest and relatively low rate of complications.12 The use of autologous fat for posterior pharyngeal augmentation in the treatment of VPI has been documented as early as 1926 and soft palate lipoaugmentation specifically for SVPI has an isolated documentation in the literature.13-17 However, to our knowledge, there are currently no reports or accounts of lipoaugmentation to the posterior velopharynx for SVPI.17 As such, the aim of this study was to document an additional indication for lipoaugmentation.

Methods
Study Design

This study was a retrospective medical chart review of patients with stress velopharyngeal insufficiency. Medical charts reviewed were through an Otolaryngology specialty clinic, with all participants having medical record documentation of injection of autologous fat into the velopharynx in the operating room. Patients provided written informed consent for the procedure, and this study was approved by the institutional review board of the Head and Neck Institute, Cleveland Clinic.

Patients

Eligible patients were patients initially presenting with velopharyngeal present only while playing a musical instrument. Two patients were identified, 1 man and 1 woman. Both professional musicians aged in their 20s.

Patients were first assessed in the outpatient setting with flexible videolaryngoscopy demonstrating clear central nasooral escape of air when playing their instruments. The condition was confirmed to be present even after a course of speech therapy and autologous lipoaugmentation of the posterior pharyngeal wall was offered in conjunction with the options to continue with therapy or formal sphincteroplasty. Both patients opted for fat injection and 1 patient was offered a trial of injection with temporary cosmetic filler, which was declined.

Written informed consent was obtained and the risks, benefits, and alternatives to the procedure were discussed in detail with both patients including possible complete absorption of the injected fat with return of symptoms, and possible lack of benefit. Patients were not compensated for their participation. Both harvest and injection were performed under general anesthesia.

Fat Harvest and Injection

The female patient opted for fat harvest via liposuction. Fat harvested via liposuction was decanted and directly loaded into the Bruening syringe for injection. The male patient opted for open abdominal fat harvest. The fat was then placed in lactated Ringer's solution, cleaned, and manually fragmented into lobules with removal of fibrous attachments. Lobules were soaked in a dexamethasone solution prior to loading into the syringe.

Once the fat was appropriately prepared, nasal endoscopy was performed with the patients under general anesthesia but in the upright position. Under direct view, approximately 6 mL of harvest fat was injected transorally into the area of bulk deficit noted on office endoscopy—central area at the level of Passavant ridge. Areas were slightly overinjected in anticipation of resorption. Palpation of the palate also indicated that the patients would have good palatal closure against the posterior pharyngeal wall.

Results
Case 1

An otherwise healthy woman in her 20s who was an aspiring professional trombone player presented to the laryngology clinic with a 2-year history of difficulties of nasal air escape while playing her instrument. She reported that the air escape occurred shortly after she begins playing. She typically practices for 4 to 5 hours per day. As a result of this, she felt that she had less stamina, loss of efficiency, and that the sound was somewhat compromised. She denied any history of surgery, such as tonsillectomy or adenoidectomy. She was a normal-term delivery with no medical history of prior facial abnormalities. Initial flexible scope examination revealed a small area of central incompetence with obvious mucus bubbling. The lateral pharyngeal walls appeared to constrict normally.

She initially underwent several months of strengthening exercises under the direction of a speech language pathologist. She was instructed to perform a conscious dry swallow and a prolonged candle blow maneuver. These maneuvers are reflexive and associated with maximal sphincteric action. She was instructed to do these maximum 5-minute exercise regimens at least 8 to 10 times per day, and just prior to her trombone practice. However despite 3 months of this regimen, she continued to have refractory SVPI and underwent lipoaugmentation. The procedure was performed without complication, but the patient did have some bleeding from the injection site that required an emergency department visit the night of the procedure. She was seen 2 weeks postoperatively with complete resolution of her symptoms and instructed to gradually increase her trombone playing and to call with any return of symptoms or problems (Figure 1). Three years following lipoinjection she was successfully playing her trombone for an international orchestra.

Case 2

A male in his 20s with a medical history of VACTERL presented to the outpatient laryngology office. Congenitally, he was deaf in his right ear, had abnormalities of his vertebrae and lower GI tract, but no evidence of tracheoesophageal fistula or clefts. His chief complaint was increased nasal air escape when he played his saxophone. In addition, he experienced throat tightness and throat fatigue when he played his instrument. As an aspiring music teacher, this had a significant impact on his training and job prospects at the time. He had not previously undergone tonsillectomy or adenoidectomy and, on examination, he was noted to have some subtle air escape when speaking. On scope examination he clearly demonstrated central air leakage when he played his instrument. He appeared to have adequate lateral closure and the palate did not appear foreshortened.

A month later, he was also evaluated in the facial plastic and reconstructive clinic and the decision was made to proceed with fat augmentation. Two weeks following the procedure, postoperative examination revealed some posterior pharyngeal augmentation, however, with playing of his saxophone, there was evidence of persistent VPI and emission in the midline and just left of midline. As such, fat augmentation was performed again with directed injection in the persistent deficient area. Assessment 2 weeks following his second procedure demonstrated that the posterior pharyngeal wall was significantly augmented and the preoperative concavity at the base of the adenoid pad was now convex. Playing the saxophone now showed significantly reduced velopharyngeal escape and he was able to resume playing his saxophone (Figure 2). However, assessment 2 months following his revision showed that his benefits lasted only 2 to 3 weeks before returning to baseline. He has subsequently undergone sphincter pharyngoplasty with early successful outcome 3 months following surgery.

Discussion

Stress velopharyngeal incompetence is a unique condition that may not always be within the familiar territory for practicing otolaryngologists. In a 2007 study by Malick et al,23 only 45% of board-certified otolaryngologists and facial plastic and reconstructive surgeons were familiar with the term, with only 27% having seen a patient with SVPI.1 Conversely, incidence of SVPI in the recent literature varies, with 30% to 40% of musicians reporting symptoms at some point in their careers.18,19 Given this, there is a need for appropriate education on the evaluation and treatment of these patients. It has been immensely helpful in our experience to have any professional voice user demonstrate their vocal problem by having them recreate the conditions under which the issue occurs in our office. Similarly, when treating instrumentalists, it is important to have them bring their instrument and to replicate the conditions under which their SVPI occurs.20 This may involve having them warm up or play prior to their appointment to simulate the fatigue that they would experience during regular play or performances. In the case of SVPI, playing the instrument is critical to the diagnosis, as the insufficiency is by definition not present otherwise.

The use of or access to video nasolaryngoscopy is immensely helpful, not only to show the patient but to identify the area of insufficiency anatomically so that injection location can be carefully planned. In addition, resolution of the insufficiency can be confirmed by comparing preoperative and postoperative videos or the disappearance or reduction in air bubbles. One must be mindful also to review the images preoperatively to make note of anatomical variations that may make the injection risky, such as aberrant carotid arteries.16 In both cases, the injections were directed to fill the site of air on the posterior velum (seen as bubbles) confirmed in the operating room with flexible video nasopharyngoscopy. We indicated that the area was slightly overinjected based on visual inspection. The overinjection was based on a visual assessment of fullness beyond what we feel necessary without airway compromise. The principle of overinjection is driven by the major disadvantage of autologous fat injection: fat resorption—which is thought to be owing to both initial necrosis of fat at the time of transfer and gradual resorption.21 While largely unpredictable, Leuchter et al16 cited a fat resorption rate of 30% to 50% in a series of 28 fat injections to the posterior velum.

The saxophone player demonstrated some initial benefit after his second injection but did not have any lasting benefit. While the resorption rate is variable, as stated earlier, we feel that his short-lived benefit may be attributed to his underlying VACTERL/VATER syndrome or an actual subclinical VPI. While the literature does not show a strong association of VACTERL with palatal clefts, there was a hint of nasal escape of air noted on regular speech in the initial assessment. Thus, one could argue that this patient did not have a true isolated SVPI. In addition, there is an association with mitochondrial defects that can ultimately affect fat metabolism in VACTERL syndrome, but the exact impact of these remains to be elucidated.22

In contrast, the trombone player achieved great benefit and functionality from only 1 injection. Thus, our experience with autologous fat injection to the posterior pharyngeal wall has been variable. For both patients, it provided an intermediary option between speech therapy and more formal surgical sphincteroplasty, which is a more invasive permanent measure that alters a larger portion of anatomy. Malick et al23 makes mention of the possibility that such surgeries may impair an instrumentalist’s ability to engage in “circular breathing.” Circular breathing is a technique of breathing that allows a player to sustain airflow through the instrument using the cheeks as bellows while inhaling nasally, thereby allowing them to hold sound over a long period of time.23

One notable observation lies in the initial anatomical location of the patient’s leaks. Both of these patients had central leakage of air during play. While we have not observed eccentric leakage in our practice, we can perhaps attribute this to their embrasures, in conjunction with Poiseuille's law of laminar air flow in a pipe, which dictates that the air velocity is greatest in the center of the tube thereby making incompetence most prone at the site of greatest velocity. Thus, individuals with an eccentric embrasure may have initial eccentric sites of leakage, but, to our knowledge, this has not been investigated. There are several limitations to this report incuding very small sample size, its retrospective nature, lack of controls, and lack of randomization. More patients would have strengthened our conclusions; however, stress VPI is infrequently encountered clinically and we believe that there is value in sharing the presurgical evaluation and technique of lipoinjection pharyngolasty in this patient population. The relative infrequency of presentation made controls and randomization impractical.

Conclusions

Stress VPI is often a career-threatening condition for professional brass and woodwind musicians. Because only 12 cases of stress VPI have been described in the English-language medical literature, we offer 2 additional cases with a new application for autologous fat injection.24 While the lasting results may be variable, the option to undergo a less invasive, potentially permanent treatment option for SVPI with autologous fat injection pharyngoplasty of the posterior pharyngeal wall can serve as a valuable tool in the armamentarium for treatment.

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Article Information

Corresponding Author: Paul C. Bryson, MD, Cleveland Clinic Voice Center, Head and Neck Institute, 9500 Euclid Ave, A-71 Cleveland, OH 44195 (brysonp@ccf.org)

Accepted for Publication: May 24, 2016.

Published Online: October 27, 2016. doi:10.1001/jamaoto.2016.1920

Author Contributions: Dr Bryson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bryson.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Study supervision: Bryson.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patients for granting permission to publish this information.

Previous Presentation: This paper was presented at the Laryngology/Bronchoesophagology/Sleep Medicine Scientific Poster Competition at the Triological Society Combined Section Meeting; January 21 to 24, 2016; Miami Beach, FL.

References
1.
Weber  J  Jr, Chase  RA.  Stress velopharyngeal incompetence in an oboe player.  Cleft Palate J. 1970;7:858-861.PubMedGoogle Scholar
2.
Dibbell  DG, Ewanowski  S, Carter  WL.  Successful correction of velopharyngeal stress incompetence in musicians playing wind instruments.  Plast Reconstr Surg. 1979;64(5):662-664.PubMedGoogle ScholarCrossref
3.
Ruda  JM, Krakovitz  P, Rose  AS.  A review of the evaluation and management of velopharyngeal insufficiency in children.  Otolaryngol Clin North Am. 2012;45(3):653-669, viii.PubMedGoogle ScholarCrossref
4.
Fisher  DM, Sommerlad  BC.  Cleft lip, cleft palate, and velopharyngeal insufficiency.  Plast Reconstr Surg. 2011;128(4):342e-360e.PubMedGoogle ScholarCrossref
5.
Eckstein  H.  Demonstration of a paraffin prosthesis in defects of the face and palate.  Dermatologica. 1904;11:772-778.Google ScholarCrossref
6.
Blocksma  R.  Correction of velopharyngeal insufficiency by Silastic pharyngeal implant.  Plast Reconstr Surg. 1963;31:268-274.PubMedGoogle ScholarCrossref
7.
Bluestone  CD, Musgrave  RH, McWilliams  BJ.  Symposium on synthetics in maxlloacial surgery. II. Teflon injection pharyngoplasty--status 1968.  Laryngoscope. 1968;78(4):558-564.PubMedGoogle ScholarCrossref
8.
Lypka  M, Bidros  R, Rizvi  M,  et al.  Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: a 40-year experience.  Ann Plast Surg. 2010;65(1):48-51.PubMedGoogle ScholarCrossref
9.
Bishop  A, Hong  P, Bezuhly  M.  Autologous fat grafting for the treatment of velopharyngeal insufficiency: state of the art.  J Plast Reconstr Aesthet Surg. 2014;67(1):1-8.PubMedGoogle ScholarCrossref
10.
Desgain  O, de Burbure  C, Mazy  C, Verheyden  PJ, Monnoye  JP, Levie  P.  Autologous costochondral cartilage implant in two cases of velopharyngeal insufficiency.  B-ENT. 2006;2(1):39-42.PubMedGoogle Scholar
11.
Denny  AD, Marks  SM, Oliff-Carneol  S.  Correction of velopharyngeal insufficiency by pharyngeal augmentation using autologous cartilage: a preliminary report.  Cleft Palate Craniofac J. 1993;30(1):46-54.PubMedGoogle ScholarCrossref
12.
Coleman  SR.  Structural fat grafts: the ideal filler?  Clin Plast Surg. 2001;28(1):111-119.PubMedGoogle Scholar
13.
Von Gaza  W.  Free retropharyngeal fat grafting in cleft palate.  Arch Klin Chir. 1926;142:590.Google Scholar
14.
Dejonckere  PH, van Wijngaarden  HA.  Retropharyngeal autologous fat transplantation for congenital short palate: a nasometric assessment of functional results.  Ann Otol Rhinol Laryngol. 2001;110(2):168-172.PubMedGoogle ScholarCrossref
15.
Lau  D, Oppenheimer  AJ, Buchman  SR, Berger  M, Kasten  SJ.  Posterior pharyngeal fat grafting for velopharyngeal insufficiency.  Cleft Palate Craniofac J. 2013;50(1):51-58.PubMedGoogle ScholarCrossref
16.
Leuchter  I, Schweizer  V, Hohlfeld  J, Pasche  P.  Treatment of velopharyngeal insufficiency by autologous fat injection.  Eur Arch Otorhinolaryngol. 2010;267(6):977-983.PubMedGoogle ScholarCrossref
17.
Klotz  DA, Howard  J, Hengerer  AS, Slupchynskj  O.  Lipoinjection augmentation of the soft palate for velopharyngeal stress incompetence.  Laryngoscope. 2001;111(12):2157-2161.PubMedGoogle ScholarCrossref
18.
Schwab  B, Schultze-Florey  A.  Velopharyngeal insufficiency in woodwind and brass players.  Med Probl Perform Art. 2004;19:21-25.Google Scholar
19.
Evans  A, Driscoll  T, Ackermann  B.  Prevalence of velopharyngeal insufficiency in woodwind and brass students.  Occup Med (Lond). 2011;61(7):480-482.PubMedGoogle ScholarCrossref
20.
Evans  A, Driscoll  T, Livesey  J, Fitzsimons  D, Ackermann  B.  Nasendoscopic evaluation of stress velopharyngeal insufficiency in wind musicians: a pilot study.  Med Probl Perform Art. 2015;30(1):47-53.PubMedGoogle Scholar
21.
Bauer  CA, Valentino  J, Hoffman  HT.  Long-term result of vocal cord augmentation with autogenous fat.  Ann Otol Rhinol Laryngol. 1995;104(11):871-874.PubMedGoogle ScholarCrossref
22.
Solomon  BD, Patel  A, Cheung  SW, Pineda-Alvarez  DE.  VACTERL association and mitochondrial dysfunction.  Birth Defects Res A Clin Mol Teratol. 2011;91(3):192-194.PubMedGoogle ScholarCrossref
23.
Malick  D, Moon  J, Canady  J.  Stress velopharyngeal incompetence: prevalence, treatment, and management practices.  Cleft Palate Craniofac J. 2007;44(4):424-433.PubMedGoogle ScholarCrossref
24.
Raol  N, Diercks  G, Hersh  C, Hartnick  CJ.  Stress velopharyngeal incompetence: two case reports and options for diagnosis and management.  Int J Pediatr Otorhinolaryngol. 2015;79(12):2456-2459.PubMedGoogle ScholarCrossref
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