Description:
Velopharyngeal dysfunction (VPD) refers to excessive nasal resonance or hypernasality during speech as the consequence of anatomical abnormalities of the velopharyngeal sphincter involving the velum (soft palate) and/or pharyngeal walls that compromise the seal between the nasopharynx and oral cavity. Normal phonation requires the generation of a column of air that flows from the subglottis into the upper airway. When (VPD) is present, air escapes through the nose during speech, resulting in the characteristic nasal resonancy. VPDis most commonly associated with cleft palate. It may be the only sign of a submucous cleft palate, or may persist after closure of an overt cleft palate.

Velopharyngeal dysfunction can usually be diagnosed by the speech/language pathologist based on the presence of hypernasal speech, compensatory misarticulations, escape of air through the nose, insufficient oral pressure for consonant production and aberrant facial movements. Imaging options include fiberoptic nasoendoscopy and videofluoroscopy.

Videofluoroscopy is a noninvasive radiologic technique intended to assess the competency of velopharyngeal closure. Videotape recording produces a continuous record of the velopharyngeal mechanism. A barium coating of the pharyngeal structures can be used to provide contrast in the videofluoroscopic image. Frontal and basal viewing angles can be used alone or in combination. The procedure is used to assess various forms of velopharyngeal insufficiency, including cleft palate. Videofluoroscopy is frequently performed as an adjunct to surgical planning in patients who do not respond to conservative treatment such as speech therapy.

Videostroboscopy provides detection of vibratory asymmetries, structural abnormalities, small masses, submucosal scars and other conditions that might not be visible under continuous light. It provides not only valuable information concerning the motion of the normal vocal cord movements. In contrast, stroboscopic examination revealed that half of the same patients had reduced mobility. A careful videostroboscopic examination can differentiate, to a certain extent, epithelial hyperplasia and dysplasia from invasive carcinoma of the vocal cords. Videostroboscopy is also useful for evaluating patients with vocal cord paralysis.

Policy:
Based on a strict evidence-based approach, videofluoroscopic evaluation is considered INVESTIGATIONAL as a technique to assist in surgical planning for treatment of velopharyngeal insufficiency. (CPT codes 70370 and 70371)

RATIONALE:
Evaluation of a diagnostic technology typically involves a 3-pronged approach, i.e., determining the technical feasibility of the test, its diagnostic parameters (i.e., sensitivity, specificity, positive and negative predictive value) compared to a gold standard, and whether or not management based on the results of the diagnostic test is associated with an improved health outcome. In the absence of a gold standard, it is particularly important to determine that the diagnostic test ultimately results in an improved health outcome.

Videofluoroscopy of velopharyngeal closure has been performed for many years, and in many articles and textbooks, it is identified as a standard component of surgical planning for velopharyngeal insufficiency. In 1988, an international working group established a system for quantifying, recording and describing movements of the relevant anatomy. A recommendation was also made that suggested that all patients with velopharyngeal deficiency be studied with both videofluoroscopy and nasopharnygoscopy,¹ and the Ad Hoc Committee of the American Cleft Palate-Craniofacial Association suggests videofluoroscopy as one technique that may be helpful in evaluating velopharyngeal insufficiency.² For example, it is thought that defining the velopharyngeal closure pattern is particularly important to determine the appropriate surgical intervention. The 3 most common surgical approaches to velopharyngeal dysfunction include pharyngoplasty, pharyngeal flap or posterior wall augmentation. However, even within these broad categories of surgical approaches, the results of videofluoroscopy have been used to tailor the surgery to the individual patient.³ Therefore, it is not surprising that a search of the literature did not identify any controlled studies that were specifically designed to investigate the role of videofluoroscopy in surgical planning. In addition, pre- and postsurgery videofluoroscopy would be ideally necessary to compare clinical assessments of speech and anatomic function. Postoperative studies are not routinely performed. In the future, MRI may replace videofluoroscopy.^4,5

References:

1. Golding-Kushner KF, Argamaso RV, Cotton RT et al. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an international working group. Cleft Palate J 1990; 27(4):337-48.
2. Dalston RM, Marsh JL, Vig KW et al. Minimal standards for reporting the results of surgery on patients with cleft lip, cleft palate or both: a proposal. Cleft Palate J 1998; 25(1):3-7.
3. Ysunza A, Pamplona C, Ramirez E et al. Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg 2002; 110(6):1401-7.
4. Vadodaria S, Goodacre TE, Anslow P. Does MRI contribute to the investigation of palatal function? Br J Plast Surg 2000; 53(3):191-9.
5. Witt PD, Marsh JL, McFarland EG et al. The evolution of velopharyngeal imaging. Ann Plast Surg 2000; 45(6):665-73.
6. Singh A, Kazi R, Venkitaraman R, et al. Does flexible videostroboscopy compare with rigid videostroboscopy in the assessment of the neoglottis? A preliminary report. Clin Otolaryngol. 2008;33(1):60-63.
7. Grøntved AM, Faber CE, Jakobsen J. Assessment of thyroplasty for vocal fold paralysis. Ugeskr Laeger. 2009;171(3):117-121.
8. Kazi R, Rhys-Evans P, Nutting CM, Harrington KJ. The great debate: Stroboscopy vs high-speed imaging for assessment of alaryngeal phonation. J Cancer Res Ther. 2009;5(2):121-123.
9. Verikas A, Uloza V, Bacauskiene M, et al. Advances in laryngeal imaging. Eur Arch Otorhinolaryngol. 2009;266(10):1509-1520

Coding Section

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