Procedure for Multi-View Videofluoroscopy
If you would like us to review information about the treatment of velopharyngeal insufficiency, it would be important for us to see the actual examinations performed (not the reports of the examinations) to provide opinions to the people who will be applying the treatments. We prefer to have the information from both videofluoroscopic and nasopharyngoscopic examinations. Multi-view videofluoroscopy is a short and well-tolerated procedure that has few compliance problems even in young children. The radiation from the procedure is a very low dose, especially when performed on modern equipment. All examinations must be recorded on video.
Among our experts are clinicians who have performed and reviewed thousands of fluoroscopic examinations. Dr. Shprintzen was the first Ph.D. student of M. Leon Skolnick, M.D. who developed the procedure of multi-view videofluoroscopy to assess velopharyngeal function in 1969. Since that time, he has published many papers, chapters, and texts on the procedure. This information sheet reflects the combined experience of our staff and the 38 years of experience of Dr. Shprintzen.
Age at Examination
Because videofluoroscopy involves ionizing radiation, although a low dose, we prefer to have this examination done only once and that should be immediately prior to surgical management of velopharyngeal insufficiency (VPI) if surgery is being contemplated. Therefore, we prefer not to do this test before 4 years of age.
The Use of Contrast
In order to see the soft tissues of the pharynx, it is necessary to use contrast material. The preferred procedure is to use a barium sulfate suspension. We prefer using a barium powder mixed with water to the consistency of heavy cream and instilled into the nose with a pipette or dropper, about 1 ml in each nostril. This is best done with the person being studied lying supine (on their back) on the fluoroscopy table.
It is important to have a comprehensive speech sample prepared that the person being examined will repeated in a short period of time to minimize radiation exposure. Because there is time limit on fluoroscopy, we prefer to use a quick but comprehensive sample. That sample should also included in nasopharyngoscopy for comparison. There, we recommend the following sample, one we have been using for many years:
ssssssss (sustained s)
Suzy sees Sally
ffffffff (sustained f)
Stop the bus
Catch a fish
1-2-3-4-5-6-7-8-9-10 (counting to 10)
Structures and Functions That Must Be Assessed
The following structures should be visualized and recorded:
1.The relative length of the velum, both at rest and during speech. Attention should be paid to seeing if the velum thickens when it elevates.
2.The size, position and shape of the adenoid.
3.Both lateral pharyngeal walls during speech, both at the level of the velum and below.
4.The posterior pharyngeal wall and the possible presence of Passavant’s ridge.
5.The palatine tonsils (if visible).
6.The lingual tonsil (if visible).
7.The tongue, teeth, and lips during articulation.
On request, we will make a sample video available for review by the clinicians who will be performing the procedure.
The minimum required views are the frontal (P-A, or posterior-anterior) and lateral (mid-sagittal). The same speech sample should be used in both views. In the frontal view, the person has their back against the radiographic table and is looking straight at the camera (See Figure 1).
Frontal view videofluoroscopy showing the lateral pharyngeal walls during speech (arrows).
For lateral view, the subject is turned 90 degrees with one shoulder against the upright table (See Figure 2). Although the base (axial) and Townes views can also be done, they are unnecessary when nasopharyngoscopy is done and eliminating them reduces radiation exposure.
Lateral view videofluoroscopy showing the palate (arrow) with absence of closure allowing air and sound to escape through the nose.
Reporting of the Results
A standardized method for the reporting of nasopharyngoscopy was published by an International Working Group as reported by Golding-Kushner et al. in 1990. Click on this link for a free reprint of this article from the web site of The Cleft Palate-Craniofacial Journal. Although we will be reviewing the video of the fluoroscopy, we will be providing a description of the examination using the system outlined in the article.