Pharyngoplasty in patients with cleft lip and palate after maxillary advancement

Outcomes of Sphincter Pharyngoplasty in the Cleft Population

INTRODUCTION

Sphincter pharyngoplasty (SP) is becoming increasingly popular for correction of velopharyngeal insufficiency (VPI) after cleft palate repair because of high success rate, low incidence of postoperative obstructive sleep apnea (OSA), and ease of revision in case of failure. This study is a meta-analysis of SP outcomes, reasons for failure, and revision strategies.

METHODS

A comprehensive review of the literature on SP outcomes was conducted. Sphincter pharyngoplasty failure was defined as persistent hypernasality, incomplete velopharyngeal port (VP) closure on instrumental evaluation with concomitant VPI, or nonresolving hyponasality and/or OSA persisting >3 months after surgery. Two-tailed paired Student t test was used to compare outcomes between syndromic versus nonsyndromic patients and preoperative versus postoperative OSA rates.

RESULTS

Forty-four publications evaluating 2402 patients were included. Overall SP success rate was 78.4% (77.3% in nonsyndromic vs 84.8% in syndromic patients, P = 0.11). Overall primary revision rate was 17.8% (20% in nonsyndromic vs 15.4% in syndromic patients P = 0.97). Most failures (89.5%) manifested as persistent VPI with continued hypernasality requiring revision, whereas 10.5% of failures manifested as obstructive symptoms and/or severe hyponasality requiring revision. Causal factors of SP failure were the following: large central port (62.8%), dehiscence (15.5%), tight port (12.1%), and low-inset (9.7%). Primary revision success rate was 75.6%. Obstructive sleep apnea rates increased from 5.1% to 18.4% (P = 0.02).

CONCLUSIONS

This study suggests that SP can resolve VPI in 78.4% of patients, which can be increased to 94.7% after one revision. Most failures are technique-dependent; therefore, there could be significant ground for improvement of outcomes.

Cephalometric changes in nasopharyngeal area after anterior maxillary segmental distraction versus Le Fort I osteotomy in patients with cleft lip and palate

OBJECTIVE

The present study was designed to compare the effects of two surgical methods, anterior maxillary segmental distraction (AMSD) versus conventional Le Fort I osteotomy, on cephalometric changes of velopharyngeal area of patients with cleft lip and palate.

MATERIALS AND METHODS

This study was conducted on 20 CLP in two groups. The first group had classic Le Fort I maxillary advancement and the second group had AMSD with a modified hyrax as an intraoral tooth-borne distractor. In the second group, 1 week after the surgery, activation of hyrax screw was started with the rate of 2 times a day for about 10 days. Initial and final lateral cephalograms were traced and analyzed by OrthoSurgerX software.

RESULTS

The changes in variables evaluating velopharyngeal status showed a significant difference between the two groups. In Group A (conventional), the mean of nasopharyngeal area and Nasopharynx floor length showed a significant increase (P < 0.05) after the surgery, while in Group B (DO), the trend of changes was vice-versa. The changes in SNA, overjet, and soft-tissue convexity were similar in both groups.

CONCLUSION

AMSD can improve facial profile, almost similar to the conventional Le Fort I advancement, while there is a significant decrease in nasopharyngeal; hereby there is no increase in the velopharyngeal sphincter.

The Effect of Cranio-Maxillofacial Osteotomies and Distraction Osteogenesis on Speech and Velopharyngeal Status: A Critical Review

Objectives

To review the impact of maxillary advancement by orthognathic surgery and distraction osteogenesis on speech and velopharyngeal status based on the literature of the past 30+ years, to review the methods employed in previous studies to explain discrepancies in results, and to make recommendations for future studies.

Method

Thirty-nine published articles on the effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status were identified and were systematically analyzed. A total of 747 cases of cleft and noncleft patients were selected, including craniofacial deformities and syndromes mainly involving maxillary hypoplasia.

Results

Findings varied. Many studies found that surgery had no impact on speech and velopharyngeal status. Some reported worsening only in patients with preexisting velopharyngeal impairment or those with borderline velopharyngeal function before surgery. There was no clear difference in outcome between distraction and conventional osteotomy, although there have been few systematic comparisons. There was great variation among reviewed studies in the number of subjects, speech sample, number and type of listeners, speech outcome measures, and timing of postoperative assessment. Few studies employed reliability measures.

Conclusion

None of the 39 reviewed studies compared conventional osteotomy and distraction by including both groups in a single study. Randomized controlled trials with adequate number of subjects and follow-up duration are needed.

Velopharyngeal changes after maxillary distraction in cleft patients using a rigid external distraction device: A retrospective study

OBJECTIVE

 To evaluate early and late velopharyngeal changes in cleft lip and palate (CLP) patients after use of the Rigid External Distractor (RED) device and to correlate these changes to the amount of maxillary advancement.

MATERIALS AND METHODS

 Thirty Class III CLP patients were included in the study. Maxillary advancement was performed using the RED device in combination with titanium miniplates and screws for anchorage. Lateral cephalograms, nasometer, and nasopharyngoscope records were taken before distraction, immediately after distraction, and 1 year after distraction. A paired t-test was used to detect differences at P < .05.

RESULTS

 SNA angle and A point and ANS to Y axis were significantly increased after maxillary distraction (P  =  .0001). Statistically significant increases in nasopharyngeal and oropharyngeal depths, velar angle, and need ratio were also found (P  =  .0001). Nasalance scores showed a significant increase (P  =  .008 for nasal text and .044 for oral text). A significant positive correlation was observed between the amount of maxillary advancement and the increase in nasopharyngeal depth and hypernasality (P  =  .012 and .026, respectively).

CONCLUSIONS

 Nasopharyngeal function was deteriorated after maxillary advancement in CLP patients. There was a significant positive correlation between the amount of maxillary advancement and the increase in nasopharyngeal depth and hypernasality.

Non-cleft causes of velopharyngeal dysfunction: implications for treatment

Although a history of cleft palate is the most common cause of velopharyngeal dysfunction (VPD), there are other disorders that can also cause hypernasality and/or nasal emission. These include other structural anomalies of the velopharyngeal valve (velopharyngeal insufficiency), neurophysiological disorders that result in inadequate velopharyngeal movement (velopharyngeal incompetence), and even faulty articulation placement in the pharynx (velopharyngeal mislearning). Unfortunately, individuals with non-cleft causes of hypernasality and/or nasal emission do not typically present at a cleft palate/craniofacial center where there are professionals who specialize in the evaluation and treatment of these disorders. As a result, they are often misdiagnosed and do not receive appropriate treatment. In this review, we present various conditions that can cause hypernasality and/or nasal emission during speech. We discuss appropriate treatment based on the underlying cause of the condition. It is important that pediatric otolaryngologists are able to recognize these disorders so that affected patients are referred to specialists in velopharyngeal dysfunction for treatment.

Increase in Sagittal Depth of the Bony Nasopharynx following Maxillary Protraction in Patients with Unilateral Cleft Lip and Palate

Objective

To study the change in the sagittal depth of the bony nasopharynx in patients with unilateral cleft lip and palate (UCLP), following maxillary protraction using reverse headgear.

Methods

Nineteen patients (14 male, five female; aged 9.36 ± 2.89 years) with repaired complete UCLP underwent maxillary protraction with a Delaire type reverse headgear at a tertiary-care referral teaching hospital. Control data were taken from five patients (four male, one female; aged 8.25 ± 2.25 years) who did not receive any orthopedic/orthodontic treatment for a similar duration of time as the treated patients. Average treatment/observation period was 11.71 ± 3.39 months for the treated patients and 12.40 ± 2.60 months for the untreated subjects. Changes in the sagittal bony nasopharynx depth were measured by comparing pretreatment (T1) and posttreatment (T2) lateral cephalograms. Correlations between the changes in the bony nasopharynx depth and in other variables measured in the treated patients were analyzed. An exploratory analysis of differences in the changes from T1 to T2 between the treated patients and untreated subjects was also conducted.

Results

The favorable skeletal changes seen in SNA and ANB following maxillary protraction were accompanied by a significant increase in the sagittal depth of bony nasopharynx (1.74 ± 1.10 mm; P < .001). This change was significant when compared with the data from the untreated subjects ( P = .004). Correlations between the increase in bony nasopharynx depth and changes in other variables studied in the treated patients were weak and not statistically significant.

Conclusion

Sagittal depth of the bony nasopharynx in patients with repaired UCLP increased following maxillary protraction therapy using reverse headgear.

Influence of pharyngeal flap surgery on maxillary outgrowth in cleft patients

The aim of this study was to investigate the influence of the pharyngeal flap procedure on the frequency of Le Fort I osteotomies in full-grown nonsyndromic cleft patients. A retrospective review of 508 full-grown cleft patients born between 1 January 1983 and 31 December 1992 was performed. Following data analysis, 140 males older than 18 years and 111 females over the age of 16 years were included. 69 of the 251 included cleft patients required pharyngeal flap surgery (27.5%). Revision flap surgery was performed in 17.4% of the cases. A significantly lower age at time of the initial pharyngeal flap procedure was found in patients requiring revision surgery (5.6 years versus 6.8 years). The frequency of Le Fort I osteotomies was significantly higher in the patients with a pharyngeal flap (19%) compared to those without (8%) (p<0.05). The results of this study point towards the pharyngeal flap procedure being one of the possible limiting factors for maxillary antero-posterior growth in cleft patients.

A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis

This meta-analysis aims to provide evidence-based data to assist surgeons to make an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were 'cleft', 'distraction', 'maxilla', 'maxillary', 'advancement', 'osteotomy', and 'orthognathic surgery'. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intra-operative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. Both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics.

From Birth to Maturity: A Group of Patients Who Have Completed Their Protocol Management. Part I. Unilateral Cleft Lip and Palate

The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Because of the large volume of data and potential differences in outcomes, the authors' intention is to present this as part I of a four-part series beginning with unilateral cleft lip and palate. The results of isolated cleft palate, isolated cleft lip, and bilateral cleft lip and palate will be presented as parts II, III, and IV, respectively. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples are provided.