Velopharyngeal Insufficiency And Secondary Palatal Management

Characterizing Interventions and Family Assistance of a Nurse Navigation Program in Orofacial Cleft Care

OBJECTIVE

Characterize the interventions and assistance employed by a cleft nurse navigator (CNN) which have mediated improvement in care equity at our institution.

DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

PATIENTS, PARTICIPANTS

Patients presenting with cleft lip and/or cleft palate presenting between August 2020 and August 2021 with exclusions for syndromic diagnosis, Pierre-Robin sequence, late (> 6 months) presentation, and prior cleft surgery at outside institutions.

INTERVENTIONS

Multidisciplinary cleft nurse navigator program.

MAIN OUTCOME MEASURE(S)

Family interactions with the CNN by phone, text, and email across the first year of life including feeding support, nasoalveolar molding (NAM) assistance, appointment scheduling, financial assistance, addressing perioperative concerns, and facilitating physician consults. Patient weight and surgical timing were also recorded.

RESULTS

Sixty-nine patients were included with a total of 639 interactions between the CNN and families. Scheduling support (30%), addressing perioperative concerns (22%), and feeding support (20%) were the most common interactions. Feeding support and NAM assistance were heavily distributed in the first 3 months of life compared to after 3 months (P < .001). Median age at first contact was 1 week (range: 22 weeks gestation-14 weeks). There was no difference in the proportion of families receiving feeding support, NAM assistance, or scheduling assistance based on insurance status or race (P > .05 for all).

CONCLUSIONS

Scheduling assistance, addressing perioperative concerns, and feeding support are the predominant methods by which the CNN interacts with and assists families of patients with cleft conditions. CNN service distribution is largely equitable between demographic groups.

Strip pharyngoplasty as a secondary functional surgery for persistent velopharyngeal insufficiency in cleft palate

Despite a satisfactory primary repair, velopharyngeal insufficiency (VPI) may be a sequel of soft palate clefts, resulting in hypernasality and phonation disorders. In order to increase the function of the pharyngeal flap during a secondary pharyngoplasty, we have developed a strip pharyngoplasty technique involving the middle constrictor muscle of the pharynx. This article describes the successive steps of the intervention and discuss its indications, advantages and limitations. Strip pharyngoplasty as a secondary functional surgery for persistent VPI after primary cleft palate repair is an attractive surgical procedure, particularly adapted to cases with defective muscle contraction by providing a muscle contingent in addition to the mucosal flap.

Videofluoroscopy Versus Nasopharyngoscopy of Lateral Pharyngeal Wall Movement for Assessment of Velopharyngeal Insufficiency

BACKGROUND

Competent speech requires closure of the velopharyngeal sphincter by dynamic apposition of the velum and posterior and lateral pharyngeal walls. An accurate estimation of lateral pharyngeal wall motion is an important determinant in the planning and the outcome of any operation to correct velopharyngeal insufficiency (VPI). The purpose was to compare the assessment of lateral pharyngeal wall movement by videofluoroscopy (VP) versus nasopharyngoscopy (NP).

METHODS

The authors retrospectively reviewed the charts of 269 consecutive patients in our cleft lip/palate clinic from 1982 to 2008 and culled those treated with a pharyngeal flap for VPI. The authors included patients who were evaluated preoperatively by both VP and NP, and had studies of suitable quality. Percentage of lateral pharyngeal wall motion was estimated with each technique and compared for each patient.

RESULTS

The authors identified 25 patients who underwent both VP and NP at the same median age (4.7 years). The estimated percentage of lateral pharyngeal wall motion between the 2 techniques was significantly different ( P <0.001). Average lateral pharyngeal wall motion was estimated to be 59±25% (range: 5%-90%) by VP and only 40%±25% (range: 0%-95%) during NP.

CONCLUSIONS

VP and NP are complementary, but assessment of lateral pharyngeal wall motion can vary between the 2 methods. The surgeon should be aware of the difference in estimated lateral pharyngeal wall movement when planning a procedure to correct VPI.

Inspiration After Posterior Pharyngeal Flap Palatoplasty: A Preliminary Study Using Computational Fluid Dynamic Analysis

Posterior pharyngeal flap palatoplasty (PPF) is one of the most commonly used surgical procedures to correct speech, especially for patients suffering from velopharyngeal insufficiency (VPI). During PPF, surgeons use the catheter to control the lateral velopharyngeal port on each side. Airway obstruction and sleep apnea are common after PPF. To understand the air dynamics of the upper airway after PPF, we used computational fluid dynamics (CFD) to demonstrate the airflow. In our previous study, we have revealed the expiration process of the upper airway after PPF and shown the features of how PPF successfully restores the oral pressure for speech. In this study, we focus on examining the inspiration process. Normal airway structures were included. For the normal velopharyngeal structure, one cylinder was applied to each model. For recapitulating the velopharyngeal structure after PPF, two cylinders were used in each model. The ports for borderline/inadequate closure, which can help the oral cavity get the required pressure, were chosen for this study. A real-time CFD simulation was used to capture the airflow through the ports. We found that the airflow dynamics of the upper airway's inspiration were dependent on the velopharyngeal structure. Although the airflow patterns were similar, the velocities between one-port and two-port structures were different, which explained why patients after PPF breathed harder than before and suggested that the one-port structure might be a better choice for secondary VPI reconstruction based on the CFD analyses.

Airflow of the Two-Port Velopharyngeal Closure: Study Using Computational Fluid Dynamics

Posterior pharyngeal flap palatoplasty is used to restore the function of velopharyngeal (VP) closure, after which 2 ports remain between the nasal and oral cavity. The authors hypothesized that the airflow dynamics of the upper airway is different in PPF patients compared to health subjects, who only has 1 movable port. Twenty adults who have multislice spiral computed tomography scan were included in this study. Two cylinders (radius, 2.00 mm; height, 4.5 mm) were used to recapitulate the 2-port VP structure after PPF palatoplasty. The areas of ports were modified by changing the radius of 2 cylinders. Real-time computational fluid dynamics simulation was used to capture the airflow velocity and pressures through the 2 ports. The airflow velocity and pressure of upper airway were recorded as the total areas of 2 VP ports increased. The total orifice areas of the 2-port VP closure for 4 VP conditions, including adequate closure, adequate/borderline closure, borderline/inadequate closure, and inadequate closure, were demonstrated. Significant differences between the 2-port VP function for demonstrating PPF reconstruction and the 1-port VP function were found. Airflow dynamics is dependent on the VP structure. The 2-port airflow model for mimicking VP closure after PPF palatoplasty demonstrated airflow characteristics that were significantly different from the 1-port model in normal VP closure.

Immediate effects of voice focus adjustments on hypernasal speakers' nasalance scores

OBJECTIVES

To explore the immediate effects of voice focus adjustments on the oral-nasal balance of hypernasal speakers, measured with nasalance scores.

METHODS

Five hypernasal speakers (2 M, 3 F) aged 5-12 (SD 2.7) learned to speak with extreme forward and backward voice focus. Speakers repeated oral, nasal, and phonetically balanced stimuli. Nasalance scores were collected with the Nasometer 6450.

RESULTS

From the average baseline of 34.27% for the oral stimulus, nasalance increased to 46.07% in forward and decreased to 30.2% in backward focus. From the average baseline of 64.53% for the nasal stimulus, nasalance decreased to 64.13% in forward and decreased to 51.73% in backward focus. From the average baseline of 51.33% for the phonetically balanced stimulus, nasalance increased to 58.87% in forward and decreased to 46.2% in backward focus.

CONCLUSIONS

Forward voice focus resulted in higher and backward voice focus resulted in lower nasalance scores during speech for a group of hypernasal speakers. However, there was an exception: One male speaker showed decreased nasalance in forward voice focus. Future research should investigate the longer-term effectiveness of the intervention.

Speech outcome after intravelar veloplasty

OBJECTIVE

Cleft lip and palate is the main craniofacial malformation in France. Many surgical techniques had been described to restore cleft palate. In this study, we evaluate phonation in a homogeneous series of patient with isolated unilateral non-syndromic cleft lip and palate before (and after) alveolar cleft closure, operated according to our surgical protocol.

METHODS

We included retrospectively 71 patients with isolated non-syndromic unilateral cleft lip and palate (UCLP), operated in our department from 2009 to 2013. All patients underwent the same surgical protocol: modified Millard cheilorhinoplasty (from 5 to 9-month-old); direct hard palatal closure (from 12 to 20-month-old); alveolar cleft closure with cancellous iliac bone graft (from 4 to 6-year-old). The phonation and clinical statute were evaluated before and after alveolar cleft closure. Fistula rate and speech evaluation were recorded.

RESULTS

The rate of oronasal fistula was 12.7%. About phonation, 76% and 86% of patients were competent or borderline competent respectively before and after gingivoperiostoplasty.

CONCLUSION

This surgical protocol provided speech results in patients with isolated unilateral non-syndromic cleft lip and palate. The gingivoperiostoplasty improved the speech intelligibility.

The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study

Objective:

To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.

Design:

Retrospective case series.

Setting:

Tertiary care children’s hospital.

Participants:

Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children’s hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.

Interventions:

Palatoplasty.

Main Outcome Measures:

Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.

Results:

Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (<11 months, n = 28), standard (11-13 months, n = 158), or late (>13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( P < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.

Conclusions:

Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.

Maxillofacial Prosthetics

The treatment of head and neck cancers requires a team approach. Maxillofacial prosthetics and oncologic dentistry are involved in many phases of the treatment. After the cancer ablation surgery, if surgical reconstruction cannot not completely restore the surgical defect site, maxillofacial prostheses plays an important role to rehabilitate the patient's mastication, swallowing, and speech. For patients undergoing chemoradiation therapy, the outcome is enhanced by jaw positioning stent and fluoride carrier mouthpiece. This perioperative care by maxillofacial prosthetics improves the posttreatment outcomes and the patient's quality of life.

Cleft Lip and Palate

Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.

Effects of Surgical Intervention and Continuous Positive Airway Pressure Therapy on Velopharyngeal Structure and Function: A Case Report

Changes to the velum and velopharyngeal muscles following Furlow double-opposing Z-plasty in a 7-year-old female with submucous cleft palate and velopharyngeal dysfunction (VPD) were evaluated. Perceptual, instrumental (ie, nasometry and aerodynamic pressure flow), and research magnetic resonance imaging analyses were used during pre- and postsurgical time points at a university research clinic. Continuous positive airway pressure (CPAP) therapy was trialed following a failed surgery for residual VPD in the patient. Increases in velar length and thickness and decreases in levator veli palatini muscle angle of origin and contraction were observed following the Furlow double-opposing Z-plasty surgery. Variable improvements in residual hypernasality following the home-based CPAP therapy protocol were observed.

Speech and Language Issues in the Cleft Palate Population: The State of the Art

Objective

State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems.

Method

The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether.

Conclusion

Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.

The Relationship between the Characteristics of Speech and Velopharyngeal Gap Size

Objective

The purpose of this study was to examine the relationship between perceptual characteristics of hypernasality, nasal emission and nasal rustle, and size of the velopharyngeal gap.

Design

A retrospective medical chart review.

Setting

Cincinnati Children's Hospital Medical Center.

Subjects

Subjects were patients of the Craniofacial Anomaly Team. All were between ages 3 and 12 years and diagnosed with velopharyngeal dysfunction secondary to cleft palate ± cleft lip. A total of 173 charts were reviewed.

Outcome Measures

Speech characteristics were assessed perceptually by an experienced speech-language pathologist. Following that assessment, velopharyngeal closure was evaluated using videofluoroscopy, nasopharyngoscopy, or both.

Results

Based on the perceptual ratings alone, 21 subjects were diagnosed with nasal rustle only, 27 had hypernasality with nasal rustle, 89 had hypernasality with nasal emission without nasal rustle, and 36 had hypernasality with no audible nasal emission. An ordinal logit regression was conducted and showed that moderate and severe hypernasality contributed significantly to the prediction of a large gap size; nasal rustle contributed significantly to prediction of a small gap size. Perceptual characteristics of speech correctly predicted gap size for 121 of the 173 subjects (70%).

Conclusions

This investigation revealed that some information regarding velopharyngeal gap size may be predicted from the speech assessment alone. Confidence in the prediction is strongest if the patient has nasal rustle, suggesting a small gap, or if the patient has moderate to severe hypernasality, which is more commonly associated with a large opening.

Age-Related Changes Between the Level of Velopharyngeal Closure and the Cervical Spine

The primary focus of this study was to assess age-related changes in the vertical distance of the estimated level of velopharyngeal closure in relation to a prominent landmark of the cervical spine: the anterior tubercle of cervical vertebra 1 (C1). Midsagittal anatomic magnetic resonance images were examined across 51 participants with normal head and neck anatomy between 4 and 17 years of age. Results indicate that age is a strong predictor (P = 0.002) of the vertical distance between the level of velopharyngeal closure relative to C1. Specifically, as age increases, the vertical distance between the palatal plane and C1 becomes greater resulting in the level of velopharyngeal closure being located higher above C1 (range 4.88-10.55 mm). Results of this study provide insights into the clinical usefulness of using C1 as a surgical landmark for placement of pharyngoplasties in children with repaired cleft palate and persistent hypernasal speech. Clinical implications and future directions are discussed.

Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: A retrospective study of children referred to Isfahan Cleft Care Team between 2005 and 2009

OBJECTIVE

The purpose of this study is to determine the incidence of velopharyngeal insufficiency (VPI) and fistulae development in patients seen by the Isfahan Cleft Care Team and also determine the association of gender, age at repair, and cleft type with the incidence of each.

METHODS

This retrospective study was completed using records of patients referred to Isfahan Cleft Care Team between 2005 and 2009. One hundred thirty-one patients with a history of cleft palate (with or without cleft lip) who had undergone primary palate repair and were at least 4 years of age at the time of the speech evaluation were included in this review. The main outcome of this study was the incidence of fistulae and hypernasality following palatoplasty. A secondary outcome was the association of gender, age at the time of repair, and cleft type on the incidence of fistulae and hypernasality.

RESULTS

A post-surgical fistula was present in 23.7% of the patients studied. Fistula rates were significantly higher in patients who had undergone repair of bilateral clefts of the lip and palate (40.9%) than for those patients who had undergone repair of a unilateral cleft lip and palate (16.9%) (p=0.02). Presence of a fistula was not associated with gender (p=0.99) or age at time of primary surgical repair (p=0.71). Mild hypernasality was noted in 15.3% of patients. Moderate or severe hypernasality was present in 66.5% of the patients and the remaining cases presented with normal resonance. Severe hypernasality was significantly higher in patients with a Veau IV type cleft as compared to patients with Veau III cleft types (p=0.04). There was a significantly higher incidence of hypernasality in boys than in girls (p<0.001). The association of age at the time of palatal repair and incidence of hypernasality was not significant (r=0.13, p=0.07).

CONCLUSIONS

Overall, post-surgical complications were high in this cohort of patients who had undergone cleft palate repair by Isfahan Cleft Care Team during the study time frame. Therefore, there is a high priority need for increased training of best practices for the surgeons.

Speech and Resonance Disorders Related to Cleft Palate and Velopharyngeal Dysfunction: A Guide to Evaluation and Treatment

Children with speech and/or resonance disorders due to structural anomalies present challenges for speech-language pathologists in all settings. The purpose of this article is to provide current, practical information regarding the evaluation and treatment of children with speech/resonance disorders secondary to cleft palate and noncleft causes of velopharyngeal dysfunction. Simple “no-tech” procedures for assessment will be described so that the reader will be able to determine which children will benefit from therapy and which will require surgical intervention. Finally, specific speech therapy techniques will be given for changing placement from the pharynx to the oral cavity, thus eliminating phoneme-specific nasal emission.

Outcomes of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency

Objective

To compare surgical outcomes between pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty in the management of pediatric velopharyngeal insufficiency.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

After exclusion of children with velocardiofacial syndrome, 96 patients who underwent surgical intervention between 2008 and 2012 were identified. Surgical interventions were categorized as pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty. Main outcome measures included perceptual speech analyses, complications, and surgical revision rates.

Results

Of the 96 reviewed patients, 38 (39.6%) underwent pharyngeal flap, 20 (20.8%) sphincter pharyngoplasty, and 38 (39.6%) combined Furlow palatoplasty and sphincter pharyngoplasty. Choice of surgical intervention was based on patient characteristics, observed palatal length, and formal speech assessments. There were no differences in patient demographics or preoperative perceptual speech analysis scores among the 3 surgical groups. The mean speech improvement was significantly greater in both the pharyngeal flap ( P = .031) and combined procedure ( P = .013) compared with sphincter pharyngoplasty alone, but no differences were observed between the pharyngeal flap and combined procedure ( P = .797). There were no differences in complications among the 3 surgical interventions ( P = .220). The combined procedure required significantly less surgical revisions than the pharyngeal flap ( P = .019).

Conclusion

Combined Furlow palatoplasty and sphincter pharyngoplasty is an effective procedure for the management of pediatric velopharyngeal insufficiency and may result in superior speech outcomes and lower revision rates than sphincter pharyngoplasty and pharyngeal flap, respectively.

Autologous Fat Injection Combined with Palatoplasty and Pharyngoplasty for Velopharyngeal Insufficiency and Cleft Palate

Objective

The aim was to evaluate clinical application of autologous fat transplantation in the posterior pharynx to treat velopharyngeal incompetence and cleft palate.

Study Design

Case series with chart review.

Setting

Cleft Lip and Palate Center of Plastic Surgery Hospital, an academic medical center.

Subjects and Methods

We studied 11 patients (age, 5-26 years) with a cleft palate and velopharyngeal insufficiency who underwent autologous fat injection. Patients were followed for 9 to 40 months. Pronunciation evaluation, visual appearance of the palatopharyngeal area, nasopharyngeal fibroscopy (NPF), palatopharyngeal lateral radiography, and magnetic resonance imaging (MRI) were undertaken before and after the operation.

Results

Speech intelligibility was markedly increased in all patients. Pronunciation was good to excellent compared with the preoperative level ( P = .001). Mean velopharyngeal insufficiency rate was significantly reduced from 26.05% to 6.96% ( P = .028) by NPF and from 26.42% to 7.11% ( P = .017) by MRI (axial plane). Magnetic resonance imaging indicated significantly reduced mean minimum velopharyngeal distance, from 10.39 to 3.65 mm ( P = .012) in the sagittal plane, and markedly increased thickness of transplanted fat in the posterior pharyngeal wall (sagittal, 5.43 mm; axial, 4.74 mm). There were few complications (sleep apnea, nasopharyngeal regurgitation).

Conclusion

Autologous fat transplantation in the posterior pharyngeal wall was a good method for treating velopharyngeal incompetence. The safety profile was good in our sample, and we got a consistent result in the follow-up period. In addition, it also could be combined with routine surgery.

Management of velopharyngeal insufficiency using double opposing z-plasty in patients undergoing primary two-flap palatoplasty

BACKGROUND

Velopharyngeal insufficiency (VPI) may persist after primary repair of the cleft palate, and surgical correction is necessary in many cases. The purpose of this study is to evaluate the effect of double opposing Z-plasty (DOZ) in cleft palate patients suffering from VPI after primary two-flap palatoplasty.

METHODS

Between March 1999 and August 2005, we identified 82 patients who underwent two-flap palatoplasty for cleft palate repair. After excluding the patients with congenital syndrome and mental retardation, 13 patients were included in the final study group. The average age of the patients who underwent DOZ at was 5 years and 1 month. Resonance, nasal emission, and articulation were evaluated by a speech pathologist. The velopharyngeal gaps were measured before and after surgery.

RESULTS

Six patients attained normal speech capabilities after DOZ. The hypernasality grade was significantly improved after surgery in all of the patients (P=0.0015). Whereas nasal emission disappeared in 8 patients (61.5%), it was diminished but still persisted in the remaining 5 patients. Articulation was improved in all of the cases. In two cases, the velopharyngeal gap was measured using a ruler. The gap decreased from 11.5 to 7 mm in one case, and from 12.5 to 8 mm in the second case.

CONCLUSIONS

The use of DOZ as a surgical option to correct VPI has many advantages compared with other procedures. These include short surgery time, few troublesome complications, and no harmful effects on the dynamic physiological functioning of the pharynx. This study shows that DOZ can be another option for surgical treatment of patients with VPI after two-flap palatoplasty.

Videofluoroscopic and nasendoscopic correlates of speech in velopharyngeal dysfunction

OBJECTIVE

To compare videonasendoscopy, lateral videofluoroscopy, and perceptual speech examination in the assessment of velopharyngeal dysfunction.

DESIGN

Retrospective observational.

SETTING

Multidisciplinary cleft palate team at a tertiary academic institution.

PATIENTS, PARTICIPANTS

Patients who had undergone videonasendoscopy and lateral videofluoroscopy for suspected velopharyngeal dysfunction at our center were evaluated. Inclusion required that videonasendoscopy, lateral videofluoroscopy, and the perceptual speech exam were performed on the same day. A total of 88 patients were analyzed.

MAIN OUTCOME MEASURE(S)

Primary outcome measures included percent closure on videonasendoscopy, percent closure on lateral videofluoroscopy, and quantitative scores for hypernasal resonance, nasal emission, and facial grimace. Additional outcome measures included linear and angular anatomic measurements obtained from lateral videofluoroscopy.

RESULTS

Moderately strong correlation was found between closure estimates of videonasendoscopy and lateral videofluoroscopy (ρ = .583; p < .001). Lateral videofluoroscopy estimates of closure averaged 11.7% higher than videonasendoscopy. Closure correlated moderately with overall speech severity (ρ = .304; p = .005); whereas, a stronger correlation was seen with hypernasal resonance (ρ = -.479; p < .001). Patients exhibiting grimace had worse closure than those without (79.1% versus 70.7%; p = .035). Movement angle of the velum and change in genu angle correlated significantly with closure function (ρ = -.304; p = .034 and ρ = -.395; p < .001, respectively).

CONCLUSIONS

Videonasendoscopy and lateral videofluoroscopy closure estimates correlated moderately. Lateral videofluoroscopy tended to give smaller gap estimates. Hypernasal resonance and facial grimace are useful clinical indicators of large gap size. Velar movement angle and change in genu angle were identified as anatomical correlates of closure function.

Long-term effects of pharyngeal flaps on the upper airways of subjects with velopharyngeal insufficiency

OBJECTIVES

To investigate the long-term effects of pharyngeal flap surgery (PFS) on nasal and nasopharyngeal dimensions of patients with velopharyngeal insufficiency (VPI) and to correlate the findings with the onset of respiratory complaints after surgery.

DESIGN/PARTICIPANTS

Prospective study in 58 nonsyndromic patients with repaired cleft palate and VPI, evaluated 2 days before and 5 months (POST1) and 1 year (POST2) after PFS, on average. Patients were divided into two groups: one consisting of patients with postoperative respiratory complaints (RC group) and the other without complaints (NRC group).

INTERVENTIONS

Superiorly based PFS.

MAIN OUTCOME MEASURES

Respiratory complaints (self reports of mouth breathing, snoring, and other sleep obstructive events) assessed at POST1 and POST2, and minimum nasal (NCSA) and nasopharyngeal (NPA) cross-sectional areas assessed by rhinomanometry at POST2.

RESULTS

Respiratory complaints were reported by 55% and 36% of the patients evaluated at POST1 and POST2, respectively. Posterior rhinomanometry showed a significant postoperative reduction of mean NCSA in the RC and NRC groups (p < .05), to subnormal levels in some of them. The decrease was more pronounced in the RC group. No significant changes in NCSA were observed by anterior rhinomanometry. Similar results were obtained when NPA was assessed by modified anterior rhinomanometry.

CONCLUSION

In the long-term, PFS yielded a significant reduction in upper airways dimensions beyond what should be expected and associated with persistent respiratory complaints in some cases.

Lateral Pharyngeal Wall and Velar Movement and Tailoring Velopharyngeal Surgery: Determinants of Velopharyngeal Incompetence Resolution in Patients with Cleft Palate

BACKGROUND

After primary palatoplasty, patients with cleft palate may still require secondary surgical procedures to correct residual velopharyngeal incompetence. This study evaluated speech outcomes of patients who underwent differential velopharyngeal surgery based on degree of lateral pharyngeal wall movement and velar movement.

METHODS

In this retrospective cohort study, 31 patients with cleft palate from 1992 to 2003 underwent tailor-made velopharyngeal surgery with complete preoperative and postoperative speech assessments. All patients were evaluated postoperatively for velopharyngeal incompetence resolution, persistent velopharyngeal incompetence, and hyponasality.

RESULTS

Velopharyngeal incompetence was resolved in 90 percent of patients. Severe hyponasality occurred as a complication in 16 percent, requiring subsequent division of the pharyngeal flap. Patients with lateral pharyngeal wall movement greater than 25 percent had a significantly greater chance of incompetence resolution compared with those with lateral pharyngeal wall movement less than 25 percent (p < 0.001). Regarding combined lateral pharyngeal wall movement plus velar movement, all groups showed significantly lower velopharyngeal competence scores following surgery (p < 0.001). Patients with lateral pharyngeal wall movement less than 25 percent and velar movement greater than 50 percent had the least successful speech outcome. The data also showed that various types of surgical operations performed on patients with similar combined degrees of lateral pharyngeal wall movement and velar movement can result in equally successful speech outcomes. This finding indicated flexibility in following the treatment algorithm for tailoring velopharyngeal surgery.

CONCLUSION

The degree of lateral pharyngeal wall movement and velar movement, rather than type of surgical procedure chosen, is a more important determinant of velopharyngeal incompetence resolution in patients with cleft palate.

Diagnosis and Treatment of Velopharyngeal Insufficiency

INTRODUCTION

The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure.

PATIENTS AND METHODS

A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure.

RESULTS

All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04).

CONCLUSIONS

Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.

The Correction of Velopharyngeal Insufficiency by Furlow Palatoplasty in Patients Older than 3 Years Undergoing Veau-Wardill-Kilner Palatoplasty: A Prospective Clinical Study

BACKGROUND

Velopharyngeal insufficiency may persist after primary repair of the palate. This insufficiency causes a speech deficit. Although there are many treatment alternatives, the most effective treatment of velopharyngeal insufficiency remains controversial.

METHODS

The authors performed Furlow palatoplasty in patients older than 3 years who had undergone primary palatoplasty with the Veau-Wardill-Kilner technique. Speech was assessed by a speech therapist before and after the operation. Velopharyngeal closure and velum motion were recorded using a video nasendoscope before and also 12 months after the operation. Any increase in velum length was measured.

RESULTS

After Furlow palatoplasty, 10 of 27 patients (37 percent) made complete recovery and 12 (44 percent) made substantial recovery from hypernasal resonance, but five (18.5 percent) showed no improvement. Regarding nasal emission, 16 of 27 patients (59.3 percent) made complete and eight (29.6 percent) made substantial recovery, but there was no change in three (11 percent). Five of 27 patients (18.5 percent) achieved complete intelligibility and 18 of 27 (66.7 percent) improved intelligibility, but four (14.8 percent) did not show any improvement in intelligibility. Articulation improved considerably in 17 of 27 (63 percent). The overall rate of surgical success and near misses who benefited from the surgery was 18 of 27 (67 percent), and a positive correlation between surgical success and articulation and intelligibility was noticed. Video nasendoscopy showed complete velopharyngeal closure in 15 of 27 patients (56 percent). The mean velar length increased by 44 percent. After secondary Furlow palatoplasty, patients with small gaps benefited more.

CONCLUSIONS

The results suggest that Furlow palatoplasty performed in later years improves not only speech but also velopharyngeal closure by reorienting the levator veli palatini muscle and augmenting the velum.

Velopharyngeal Incompetence:

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.

A survey of cleft lip and palate management taught in training programs in Korea

OBJECTIVE

A national survey was conducted to obtain an overall view of the status, assess changes in trends of cleft management, and study new categories of interest.

METHOD

Questionnaires were sent to 90 chief residents of all Korean institutes with plastic surgery training programs.

RESULTS

Forty-eight respondents returned completed questionnaires. The results were: (1) the most common unilateral cleft lip repair method used is the rotation-advancement technique (100%); (2) 73% of respondents correct cleft lip nasal deformity at preschool age; (3) the Millard technique is the most common management in bilateral cleft lip repair (65%); (4) in the management of protruding premaxilla, 44% of the respondents choose presurgical orthopedics; (5) the usual cleft palate repairs are the pushback (64%) and double-opposing Z-plasty (43%) in complete cleft palates and the double-opposing Z-plasty (75%) and pushback (36%) comprised the common techniques in incomplete cases; (6) 86% of responding programs perform alveolar cleft repairs during the period of mixed dentition; the most common treatment of velopharyngeal incompetence is pharyngeal flap (71%); and (8) the interdisciplinary team approach is practiced by 64% of respondents.

CONCLUSIONS

Many changes were noted since a previous 1995 survey. We hope that this study provides the necessary information needed for the eventual establishment of standard cleft management in Korea.

Results with Furlow palatoplasty in management of velopharyngeal insufficiency

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

Furlow palatoplasty to restore velopharyngeal competence following tonsillectomy avulsion of a pharyngeal flap

OBJECTIVE

We report the successful use of a Furlow palatoplasty to salvage velopharyngeal competence following iatrogenic avulsion of a pharyngeal flap that had been previously established to treat velopharyngeal insufficiency associated with a submucous cleft palate.

INTERVENTION

A tonsillectomy, conducted by a surgeon unaffiliated with a cleft palate team, was used to remove enlarged tonsils that had developed after pharyngeal flap surgery and extended into the lateral ports causing nasal obstruction and hypernasality because of mechanical interference with port closure. A posttonsillectomy evaluation revealed avulsion of the pharyngeal flap, which was successfully treated using a Furlow palatoplasty.

CONCLUSIONS

To our knowledge, this is the first report of iatrogenic avulsion of a pharyngeal flap caused by tonsillectomy. Based on a review of the literature and this case experience, we would conclude that tonsillectomy should not be regarded as a routine procedure in patients previously treated with a pharyngeal flap. If required, it should be performed by a skilled otolaryngologist, preferably one affiliated with a multidisciplinary cleft palate team who is familiar with pharyngoplasty surgery. Finally, our experience would suggest that the Furlow palatoplasty is sufficiently robust to be used as a secondary salvage procedure to restore velopharyngeal sufficiency following iatrogenic avulsion of a pharyngeal flap.

Palatal distraction in a canine cleft palate model

The purpose of this study was to determine whether the canine hard palate can be lengthened by distraction osteogenesis in a cleft palate model using a mostly submucosal distractor. Five mongrel dogs were used. After raising mucoperiosteal flaps, a midline strip of bone was removed from the hard palate of each dog to simulate the bony defect seen in a cleft palate. A transverse osteotomy was then made to separate the posterior segment of the hard palate from the anterior segment. Posterior osteotomies were also made laterally parallel to the teeth so that the 2 posterior segments (one on either side of the bony cleft) were mobile. An intraoral distractor that was mostly submucosal was attached to the anterior hard palate and both segments of the mobilized posterior hard palate. Radiopaque bone markers were placed, and x-rays were obtained. After a 10-day latency period, the distractor was expanded 0.675 mm per day until it had been lengthened 10.125 mm. Distractors were left in place for an additional 8 weeks. After distractor removal, animals were observed for an additional 8 weeks before euthanization. Follow-up x-rays and histologic examinations were performed. New bone formation was found at the site of distraction in all dogs at the time of death. This new bone was seen on the follow-up x-rays and on histologic examination of the hard palates using both hematoxylin and eosin staining and Masson's trichrome stain. Distraction osteogenesis using a mostly submucosal device is an effective technique for lengthening the hard palate in a canine cleft palate model. The technique may eventually provide an alternative treatment for velopharyngeal incompetence in humans that is more precise and involves less morbidity than existing treatments.

Sphincter pharyngoplasty for the surgical management of speech dysfunction associated with velocardiofacial syndrome

There are no reports in the literature that document the effectiveness of sphincter pharyngoplasty as a surgical alternative to pharyngeal flap for management of velopharyngeal dysfunction in patients with velocardiofacial syndrome. A retrospective review of patients with velocardiofacial syndrome was undertaken at our tertiary cleft care centre. All patients were managed between 1984 and 1996 at the Cleft Palate and Craniofacial Deformities Institute, St Louis Children's Hospital. Subjects (n = 19) underwent velopharyngeal surgical management on the basis of perceptual speech evaluations and instrumental assessments of inadequate velopharyngeal closure. All patients had a molecular diagnosis of velocardiofacial syndrome based on fluorescent in situ hybridisation analysis of peripheral blood lymphocytes and independent evaluation by a medical geneticist. Surgical outcome was classified as successful if perceptual speech assessment indicated elimination of hypernasality, nasal emission and turbulence, and instrumental assessment indicated 100% velopharyngeal closure. Results showed that 18 of 19 patients were managed successfully with sphincter pharyngoplasty. Our data corroborate that sphincter pharyngoplasty is a reasonable alternative to pharyngeal flap in patients with velopharyngeal dysfunction secondary to velocardiofacial syndrome.

The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: is there a learning curve?

There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of "total procedures" and "procedure per year" were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of "total procedures" was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeon's improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high-volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low-volume surgeons. The influence of the surgeon's cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty.