Surgical treatment of submucous cleft palate: a comparative trial of two modalities for palatal closure

The Relationship between Submucous Cleft Palate and a History of Nasal Regurgitation in Patients during Infancy

Objectives

Submucous cleft palate is a congenital disorder resulting in velopharyngeal insufficiency. Nasal regurgitation is one of the symptoms of submucous cleft palate. This study aims to investigate a relationship between submucous cleft palate and a history of nasal regurgitation in patients during infancy.

Methods

This retrospective study includes patients diagnosed with submucous cleft palate at our hospital for 20 years, from 1998 to 2017. Based on the clinical records of these patients, we investigated sex, age at referral to our facility, age at surgery, presence of nasal regurgitation, method of surgery, association of syndromes and mental retardation, and transition of velopharyngeal function.

Results

There were fifty-seven patients referred to our facility. Patients with episodes of nasal regurgitation were referred to clinics later than those without nasal regurgitation. The timing of surgery was also the same. The velopharyngeal function of patients with nasal regurgitation was worse than that of those without nasal regurgitation.

Conclusions

A history of nasal regurgitation cannot predict submucous cleft palate. However, patients with submucous cleft palate with nasal regurgitation had worse velopharyngeal function than those without nasal regurgitation. An increased understanding of the relationship between submucous cleft palate and nasal regurgitation and further study will predict submucous cleft palate and determine a good timing for surgical interventions.

Comparison of Speech Outcomes Between Speech Therapy Only and Double-Opposing Z-Plasty Combined With Speech Therapy in Patients With Submucous Cleft Palate

The purpose of this study was to compare speech outcomes in patients with submucous cleft palate (SMCP) between speech therapy alone and double-opposing Z-plasty (DOZ) combined with speech therapy. The subjects were 67 patients with SMCP (overt type, 45 males, 22 females), who were divided into the observation group (n=18), the speech therapy group (n=24; duration, 17.8 mo), and the DOZ and speech therapy (DOZ-speech therapy) group (n=25; median age at DOZ, 5.3 years, duration, 18.6 mo). The median age at initial and final speech assessments were 3 and 5 years. After age, sex, syndromic status, duration of speech therapy, surgery timing, and speech outcomes were investigated, statistical analysis was performed. After tailored interventions, both isolated and non-isolated SMCP patients experienced significant improvements in speech outcomes, including nasal emission, hypernasality, compensatory articulation, and unintelligible speech. Since comparable improvements were observed, there were no significant differences in the final assessments regardless of initial speech issues between the speech therapy group and the DOZ-speech therapy group (all P>0.05). In the DOZ-speech therapy group, the rate of achieving "socially acceptable" speech was 92.3% in isolated cases and 90% in non-isolated cases. Multivariate analysis revealed that DOZ showed a tendency to reduce hypernasality, compensatory articulation, and "unintelligible" speech; syndromic or developmental conditions influenced outcomes in nasal emission and hypernasality; and initial hypernasality and compensatory articulation were correlated with outcomes. Therefore, DOZ surgery could be recommended to resolve hypernasality and compensatory articulation in SMCP patients before speech issues worsen.

What Technique Results in the Lowest Rate of Velopharyngeal Insufficiency in Patients With Submucous Cleft Palate? A Systematic Review and Meta-Analysis

Objective: To determine which surgical technique offers the lowest rate of velopharyngeal insufficiency (VPI) without the need for further operative intervention, in pediatric patients with nonsyndromic submucous cleft palate (SMCP). Methods: This systematic review and meta-analysis included articles reporting on nonsyndromic pediatric patients treated surgically during childhood for SMCP, with data on postoperative speech outcomes and/or recommendations for secondary surgery. Main outcome measures included rates of unfavorable speech outcomes defined as persistent VPI requiring secondary surgery and speech outcome data. Results: 15 articles met our inclusion criteria, reporting on 383 children who underwent surgical treatment; 343 patients were included in studies reporting recommendations for secondary surgery. There was 1 randomized comparative trial, 4 comparative studies, and 10 single cohort studies. Eight articles used validated speech assessment tools. Our model showed the proportion of patients recommended for secondary surgery varied between techniques, ranging from 0.0% (CI 0.0, 1000) in pharyngeal flap to 17.8% (CI 8.9, 32.5) in straight line repair techniques, but there was no statistically significant difference between treatments (P = .33). Speech improvement ranged from 44.4% to 100%, with 9 studies recommending secondary surgery for some of their patient series. Conclusions: Although not of statistical significance, pharyngeal flap yields the lowest rate of reoperation as a primary technique for pediatric patients with nonsyndromic SMCP. Delayed repair age inherent to SMCP may render operations that rely on a functional levator muscle with less favorable outcomes. The absence of standardized surgical techniques, speech outcomes, speech therapy, and assessment make comparative analysis and recommendation difficult. We advocate for standardized speech assessment tools to improve future quantitative assessment of cleft surgery outcomes and a randomized controlled trial to better elucidate the preferred first-line technique.

Speech Outcomes and Velopharyngeal Function in Children Undergoing Submucous Cleft Palate Repair

OBJECTIVE

Describe and compare the results of speech and velopharyngeal function in children with classic and occult submucous cleft palate undergoing interdisciplinary treatment at the Gantz Foundation.

METHODS

The clinical history of all patients born between 2012 and 2017 with a diagnosis of classic or occult submucous cleft palate was retrospectively reviewed. Preoperative and postoperative medical, surgical, and speech and language history were collected.

RESULTS

Twenty-eight cases diagnosed at the age of 44.8±23.9 months were included. Of these, 71.4% presented classic submucous cleft, and 28.6% occult. Before primary surgery, 7.1% had a diagnosis of the syndrome, and 21.4% were under study. A total of 39.3% had hearing difficulties and 21.4% used tympanic ventilation tubes. A total of 60.7% had language problems, 39.3% had compensatory articulation, 17.9% had absent hypernasality, and 21.4% had absent nasal emission. The team indicated primary palate surgery in 71.4%, of which 85% performed the surgery at the mean age of 61.7±24.7 months. The surgical technique was Furlow in 88.2% of the cases and intravelar veloplasty in the remaining 11.8%. Then, 3 cases underwent velopharyngeal insufficiency surgery; 2 of them eliminated hypernasality and reduced nasal emission. The age of diagnosis ( P =0.021) and the performance of velopharyngeal insufficiency surgery ( P =0029) of the occult submucous cleft palate group was significatively later than the classic cleft palate group.

CONCLUSIONS

Language, hearing, compensatory articulation, hypernasality, and nasal emission problems were recorded. A high percentage required primary surgery. Of these, a low proportion also required a velopharyngeal insufficiency surgery, which improved the velopharyngeal function of the children but did not completely adapt it. In this regard, early diagnosis is essential, as well as an analysis of each center primary closure protocol.

Intravelar veloplasty in submucous cleft palate without lateral relaxing incision or nasal mucosal incision

BACKGROUND

Surgical treatment is recommended for patients with symptomatic submucous cleft palate once velopharyngeal insufficiency has been proven. This study describes the procedure and clinical outcomes of minimally invasive intravelar veloplasty.

METHODS

From August 2013 to March 2017, seven patients (median age, 36 months; range, 16-60 months, 5 females and 2 males) with submucous cleft palate underwent intravelar veloplasty. Neither a nasal mucosal incision nor a lateral relaxing incision was applied. Follow-up was performed at least twice: once at three weeks postoperatively and again between two and three years postoperatively (average, 31 months; range, 26-35 months). Speech was assessed by speech-language pathologists when the patients were at least 3 years old.

RESULTS

There were no cases of oronasal fistula or noticeable disturbance of facial development. All seven patients showed no or mild hypernasality and air emission and competent or at least borderline competent velopharyngeal function.

CONCLUSION

Intravelar veloplasty could serve as another option for managing submucous cleft palate with velopharyngeal insufficiency, resulting in satisfactory improvement in velopharyngeal function. Because neither a lateral nor a nasal incision was used, the burden of facial growth and risk of oronasal fistula can be minimized.

Treatment of VPI with Customized Pharyngeal Flaps: One Size Does Not Fit All

Failure of complete closure of the velopharyngeal sphincter results in velopharyngeal insufficiency (VPI), which may severely interfere with speech. The pharyngeal flap remains a common procedure for correcting VPI. We aimed to study whether customization of pharyngeal flaps using a dynamic preprocedural assessment can result in successful outcomes in the surgical treatment of VPI, despite variations in surgical technique.

A Comparative Study Evaluating Speech Outcomes in Classic versus Occult Submucous Cleft Palate Using a Primary Furlow Palatoplasty Technique

BACKGROUND

No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate-associated velopharyngeal insufficiency.

METHODS

Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate-associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome.

RESULTS

Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome.

CONCLUSION

The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Surgical Approaches and 30-Day Complications of Velopharyngeal Insufficiency Repair Using American College of Surgeons National Surgical Quality Improvement Program-Pediatric

BACKGROUND

This study aims to outline the 30-d complications of different velopharyngeal insufficiency (VPI) correction techniques using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric, VPI cases from 2012 to 2015 were identified. Patients were subdivided into two cohorts: (1) palatal procedures and (2) pharyngeal procedures, with the latter being subdivided into (1) pharyngeal flap and (2) sphincter pharyngoplasty. Patient characteristics and postoperative outcomes were compared using Pearson's chi-squared or Fischer's exact test for categorical variables and independent t-tests, Wilcoxon-Mann-Whitney, or analysis of variance for continuous variables.

RESULTS

A total of 767 VPI cases were identified: 191 (24.9%) treated with palatal procedures and 576 (75.1%) with pharyngeal procedures, of which 444 were pharyngeal flap and 132 were sphincter pharyngoplasty. Patients who underwent palatal procedure had longer anesthesia (152.41 min) and operating time (105.72 min), whereas patients who underwent pharyngeal procedure had longer length of stay (1.66 d). There were no significant differences in outcomes between the two groups, nor were there significant differences in outcomes between pharyngeal flap and sphincter pharyngoplasty subgroups. Patients who experienced complications were younger, shorter, inpatient, and having a shorter operation time, longer anesthesia time, or longer length of stay. Plastic surgeons performed the majority of palatal procedures (62.3%), whereas pharyngeal procedures were most often performed by otolaryngologists (48.8%).

CONCLUSIONS

As per national data, both palatal and pharyngeal procedures for repair can be performed with comparable 30-d complications. The chosen technique may be based on patient presentation and on the surgeon comfort level.

Occult subtotal cleft of the secondary palate with VPI associated to 8q22.2 deletion

BACKGROUND

Submucous cleft palate is a cleft of the secondary palate with low phenotypic gene expression. It can occur as an isolated malformation or associated with a syndrome that includes certain facial features and other vocal tract malformations. Velopharyngeal insufficiency (VPI) is rare in cases of non - syndromic occult clefts of the secondary palate (OSCSP). In contrast, syndromic OCSP has a high prevalence of VPI. VPI requires surgical treatment in the vast majority of cases.

OBJECTIVE

To present a case of OSCSP with VPI after partial tonsillectomy and adenoidectomy (T & A) associated with facial features and other vocal tract malformations. A chromosomal abnormality (8q22.2 deletion) was demonstrated by cytogenetic testing.

CASE PRESENTATION

Eight year old female with VPI following partial T & A. OSCSP was diagnosed. Complete T & A was performed in preparation for a pharyngeal flap. Pharyngeal flap surgery was customized according to findings of videonasopharyngoscopy (VNP) and multiplanar videofluoroscopy (MPVF). VPI was corrected without intraoperative or postoperative complications.

CONCLUSION

The presence of multiple vocal tract malformations should be a red flag for suspecting a syndromic OSCSP. Surgical treatment of VPI in cases of OSCSP should be performed after complete T & A, Imaging procedures for assessing neck blood vessels and it should be customized according to imaging (VNP and MPVF) findings.

Comparison of three different surgical techniques for designing pharyngeal flaps according to findings of videonasopharyngoscopy and multiplanar videofluoroscopy

BACKGROUND

Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter (VPS) is unable to completely seal anatomical closure between the nasal and oral cavities during speech. Palatal repair can restore VPS function but the prevalence of VPI after repair has been reported ranging from 20% to 40%. The combination of flexible videonasopharyngoscopy (FVNP) and multiplanar videofluoroscopy (MPVF) has been reported as the best approach for assessing the VPS mechanism and planning effective surgical procedures aimed to correct VPI.

OBJECTIVE

To study the outcome of three different techniques for performing pharyngeal flaps with the common denominator of individually designing the flap according to findings of VFNP and MPVF.

MATERIAL AND METHODS

A total of 140 cases of pharyngeal flap surgery were reviewed. Three surgeons performed 3 different surgical techniques. All cases underwent nasometry, VNP and MPVF preoperatively. All surgical procedures were carefully planned and designed according to findings of VNP and MPVF.

RESULTS

Nasal emission was completely eliminated in all cases. One-hundred-thirty-four patients (95%) demonstrated mean nasalance within normal limits after the surgical procedure whereas 6 patients persisted with mean nasalance scores above reference values postoperatively. There were no intraoperative or postoperative complications in any of the cases. No clinical data of sleep disordered breathing was detected in any of the cases after 2 months of postoperative follow-up. However, one case presented with clinical data of sleep disordered breathing 8 months postoperatively.

CONCLUSIONS

The results of this study suggest that as long as pharyngeal flaps are being designed according to the findings of imaging procedures, different surgical techniques can provide similar successful outcomes with minimal complications.

A Review of Randomized Controlled Trials in Cleft and Craniofacial Surgery

This study presents a systematic review of randomized controlled trials (RCTs) in cleft and craniofacial surgery. All studies reporting on RCTs in cleft and craniofacial surgery were identified on PubMed using the search terms "cleft," "velopharyngeal insufficiency," "velopharyngeal dysfunction," "nasoalveolar molding," "gingivoperiosteoplasty," "Pierre Robin sequence," "craniofacial," "craniosynostosis," "craniofacial microsomia," "hemifacial microsomia," "hypertelorism," "Le Fort," "monobloc," "distraction osteogenesis," "Treacher Collins," and "Goldenhar." Studies were excluded if they were not randomized, did not focus primarily on topics related to cleft or craniofacial surgery, included repeat publications of data, or were unavailable in English. Studies were evaluated on demographic and bibliometric data, study size, specific area of focus, and findings reported. Four hundred forty-seven unique studies were identified. One hundred eighty-three papers met inclusion criteria (115 cleft lip and palate, 65 craniofacial, and 3 spanning both disciplines). Sixty-six (36%) were dedicated to topics related to surgical techniques. There were no studies comparing current cleft lip or soft palate repair techniques and no studies on cleft rhinoplasty. The most frequently reported surgical topic was cleft palate. There were several studies on orthognathic techniques which compared distraction osteogenesis to traditional advancement. Most craniofacial operations, such as cranial vault remodeling and frontofacial advancement/distraction, were not represented. Several standard operations in cleft and craniofacial surgery are not supported by Level I evidence from randomized controlled trials. Our community should consider methods by which more RCTs can be performed, or redefine the acceptable standards of evidence to guide our clinical decisions.

Surgical indication of Furlow palatoplasty to treat submucous cleft palate

This study investigated the effects of Furlow palatoplasty on children with submucous cleft palate (SMCP) and identified surgical indications by comparing SMCP and control patients. Twenty-three SMCP children (average age 28.9 months) who were nonsyndromic and underwent surgery between April 2010 and December 2016 were included. Facial computed tomography (CT) was performed preoperatively and at least 1 year postoperatively after a language test. Facial CT measurements were taken for 140 children aged 0-6 years without deformities (control group). Later surgery was associated with more severe nasality. In the coronal view, the difference in the maxillary tuberosity before and after surgery was 3.8 mm (p < 0.05). The height and width of the palatal arch (HNP and WNP) were well maintained (p > 0.05), whereas the angle of the levator veli palatini muscle (ALM) increased (p < 0.05). The nasopharynx was close to normal postoperatively. The distance between the medial pterygoid plates, the HNP, and the WNP were larger in SMCP patients preoperatively (p < 0.05), but these differences disappeared after surgery (p > 0.05). The ALM in SMCP patients was narrower preoperatively, but became flatter postoperatively (p < 0.05), indicating the repositioning of the levator muscle, with improvement of the velopharyngeal function. Furlow palatoplasty is indicated if the HNP and WNP values are larger, and the ALM value is less, in patients with SMCP than in those without.

Timing of Furlow Palatoplasty for Patients With Submucous Cleft Palate

Background:

Submucous cleft palate (SMCP) is the most common form of cleft involving the posterior palate, resulting in variable degrees of velar dysfunction and speech disturbance. Although early surgical intervention is indicated for patients with true cleft palate, the indications for palatoplasty and timing of surgical intervention for patients with SMCP remain controversial.

Methods:

Twenty-nine patients with SMCP were retrospectively reviewed. Patients treated with Furlow palatoplasty were dichotomized based on patient age at the time of surgical correction into early speech development and late speech development. Primary outcome measures included standardized assessments of hypernasal resonance and quantitative pre- and postoperative nasometry scores. Patients managed nonoperatively were included for comparison of early and late speech outcomes.

Results:

Both early and late groups demonstrated improvement in qualitative assessment of hypernasal resonance following Furlow palatoplasty. Early and late groups also had significant improvement in pre- to postoperative nasometry scores from 7.4 to 2.3 SD from norm ( P = .01) and 6.0 to 3.6 SD from norm ( P = .02), respectively. There was no difference in postoperative nasometry scores between early and late groups, 2.3 and 3.6 SD ( P = .12).

Conclusion:

Furlow palatoplasty significantly improves the degree of hypernasality in patients with SMCP based on pre- and postoperative nasometry scores and on qualitative assessment of hypernasality. There were no differences in speech outcomes based on early compared with late operative intervention. Therefore, early palatal repair is not obligatory for optimal speech outcomes in children with SMCP and palatoplasty should be deferred until the emergence of overt velopharyngeal insufficiency.

Velopharyngeal videofluoroscopy: Providing useful clinical information in the era of reduced dose radiation and safety

BACKGROUND

The state of the art for correcting velopharyngeal insufficiency (VPI) is a surgical procedure which is customized according to findings on imaging procedures: multiplanar videofluoroscopy (MPVF) and flexible videonasopharyngoscopy (FVNP). Recently, the use of MPVF has been challenged because of the potential risk of using ionizing radiation, especially in children.

OBJECTIVE

To study whether using a protocol for performing MPVF can effectively decrease radiation dose in patients with VPI while providing useful information for planning surgical correction of VPI in combination with FVNP. The methodology used for performing the imaging procedures is described as well as the effectiveness of the surgical procedure.

MATERIAL AND METHODS

Eighty - nine patients (Age range = 3-17 years; median = 5.5 years) with VPI resulting from multiple etiologies were studied. All patients underwent MPVF and FVNP for planning surgical correction of VPI. Radiation dosage data in each case was recorded. Forty of the 89 patients also completed a postoperative evaluation. Eleven out of the remaining 49 patients have not completed a postoperative evaluation and 38 patients are still pending surgical correction.

RESULTS

Radiation dosage ranged from 1.00 to 8.75 miliSieverts (mSv); Mean = 2.88 mSv; SD = 1.575 mSv. Preoperative nasometry demonstrated mean nasalance ranging from 41%-95%; Mean = 72.30; SD = 4.54. Postoperatively mean nasalance was within normal limits in 36 (90%) out of 40 cases, ranging from 21% to 35%; Mean = 28.10; SD = 5.40. Nasal emission was eliminated postoperatively in all cases.

CONCLUSION

MPVF provides useful information for planning the surgical procedure aimed at correcting VPI. The combination of MPVF and FVNP is a reliable procedure for assessing velopharyngeal closure and to surgically correcting VPI with a highly successful outcome.

Submucous cleft palate: outcomes after primary repair with repositioning of the levator muscle in 51 consecutive patients

I report the incidence of hypernasal resonance, nasal emission, and fistula after intravelar surgery with retropositioning of the levator muscle by a single surgeon in a consecutive series of 51 patients who presented with symptomatic submucous cleft palate. Intravelar veloplasty with repositioning of the levator muscle was highly effective in that 37/51 patients (73%) achieved either normal or mild and inconsistent resonance (p<0.0001), and 39 (77%) normal or mild and inconsistent nasal emissions (p<0.0001). The fistula rate was 6% (n=3). Both the clinical grade of submucous cleft palate and the presence of a syndrome correlated directly with changes in hypernasality, whereas the age of the patient and the degree of hypernasality at presentation did not. Non-syndromic patients with clinical grade III and II submucous cleft palates responded well to intravelar surgery with repositioning of the levator muscle, and routine preoperative videofluoroscopy is not recommended. I recommend intravelar surgery with repositioning of the levator muscle routinely for all non-syndromic patients who present with grade III or II submucous cleft palate and velopharyngeal insufficiency.

WITHDRAWN: Interventions for the management of submucous cleft palate

The Cochrane Oral Health Group withdrew this review as of Issue 1, 2016. The review is out of date and does not meet current Cochrane methodological standards.

The editorial group responsible for this previously published document have withdrawn it from publication.

Submucous cleft palate: an often-missed diagnosis

This study aimed to investigate the age at diagnosis, palatal characteristics, and symptoms of submucous cleft palate (SMCP) and to compare the speech outcomes between 3 operative techniques for primary repair of SMCP.It was a retrospective review of 92 patients diagnosed with SMCP between 1994 and 2008, where patients were treated with 1 of 3 surgical procedures: double opposing z-palatoplasty, radical intravelar veloplasty, or pharyngeal flap.The need for a second procedure was considered a primary outcome measure, with operative failure defined by the need for a secondary operation. Postoperative speech was evaluated perceptually using the Great Ormond Street Speech Assessment.We found that SMCP was diagnosed at a mean age of 3.6 years. At diagnosis, 8% were asymptomatic, 67% had abnormal speech, 49% had recurrent otitis media with effusions, and 47% had hearing loss. Ear, nose, and throat surgery was performed on 37% without the diagnosis of SMCP being made. Subjective impression of a short palate was a predictor for secondary surgery (P < 0.02). Age at repair did not affect velopharyngeal insufficiency outcome; however, repair after 18 months of age led to a higher likelihood of developing articulatory speech errors resulting in the need for more speech therapy.In conclusion, the triad of features of SMCP is well recognized, but our study reveals that a high percentage is seen by physicians who have failed to make the diagnosis despite signs and symptoms being evident. Surgical correction is successful regardless of technique and age, but earlier recognition to prevent speech impairment should be sought.

Submucous Cleft Palate: A Systematic Review of Surgical Management Based on Perceptual and Instrumental Analysis

Objective

Submucous cleft palate (SMCP) is a congenital condition associated with abnormal development of the soft palate musculature. In a proportion of cases, this results in velopharyngeal insufficiency (VPI), the treatment for which includes pharyngeal flap surgery, pharyngoplasty, and palate reconstruction. The aim of this paper is to determine whether there is superiority of one or more types of surgical procedure over the others in improving speech in patients with VPI secondary to SMCP.

Methodology

Nine databases, including MEDLINE and EMBASE, were searched between inception and January 2013 to identify articles published relating to the surgical management of SMCP. Only studies that reported outcome measures for postoperative speech were included in the systematic review.

Results

Twenty-six studies analyzing the outcomes of surgery for VPI in patients with SMCP met the inclusion criteria. In these studies, speech outcomes were measured either in a binary fashion (i.e., normal speech or evidence of VPI) or using scales of VPI severity. Of the 26 studies, only two utilized blinded speech assessment, and 12 included both preoperative and postoperative speech assessment.

Conclusions

The review found little evidence to support any specific surgical intervention. This is in large part due to the inclusion of mixed etiologies within study populations and the lack of unbiased validated preoperative and postoperative speech assessment. Further methodologically rigorous studies need to be conducted to provide a secure evidence base for the surgical management of SMCP.

Transillumination of the occult submucous cleft palate

Occult submucous cleft palate is a congenital deformity characterized by deficient union of the muscles that normally cross the velum and aid in elevation of the soft palate. Despite this insufficient muscle coverage, occult submucous cleft palate by definition lacks clear external anatomic landmarks. This absence of anatomic signs makes diagnosis of occult submucous cleft less obvious, more dependent on ancillary tests, and potentially missed entirely. Current diagnostic methodologies are limited and often are unrevealing in the presurgical patient; however, a missed diagnosis of occult submucous cleft palate can result in velopharyngeal insufficiency and major functional impairment in patients after surgery on the oropharynx. By accurately and easily diagnosing occult submucous cleft palate, it is possible to defer or modify pharyngeal surgical intervention that may further impair velopharyngeal function in susceptible patients. In this report, we introduce transillumination of the soft palate using a transnasal or transoral flexible endoscope as an inexpensive and simple technique for identification of submucous cleft palate. The use of transillumination of an occult submucous cleft palate is illustrated in a patient case and is compared to other current diagnostic methodologies.

22q11.2 deletion detected by endoscopic observation of pharyngeal pulsations in a child with submucous cleft palate and persistent velopharyngeal insufficiency

22q11.2 microdeletion syndrome (22q11.2DS) is the most common syndrome associated with cleft palate and velopharyngeal insufficiency (VPI). Over 180 clinical features have been described. Most common features include: cardiac malformations, cleft palate, velopharyngeal insufficiency, characteristic facial features, hypotonia, behavioral disorders, and musculoskeletal disorders among several other fenotipical features. A case of 22q11.2DS confirmed by cytogenomic analysis is presented with review of the literature. Main clinical features were a submucous cleft palate (SMCP) with persistent VPI after palatoplasty, an ectopic left internal carotid artery and a prominent aortic root. VPI was corrected with a pharyngeal flap, tailored according to findings of videonasopharyngoscopy, videofluoroscopy and neck CT scan with contrast.

Evolution in minimal-incision palatoplasty: surgical technique and outcomes in 67 consecutive cases

BACKGROUND

Conventional palatoplasty relies on extensive mucosal incisions and isolation of flaps on the palatine vessels to facilitate midline closure and velar reconstruction. This introduces substantial scarring, which has adverse effects on vascularity and growth. The authors have developed a minimally invasive palatoplasty technique that may have advantages over traditional techniques. The authors present their operative experience and outcomes when using the minimally invasive method paired with a novel cranial base maneuver for nasal mucosa closure.

METHODS

Based on cadaveric dissections, the authors developed a modified minimal-incision approach that permits anatomical reconstruction from a midline approach. From 2003 to 2010, a retrospective review was performed on 67 consecutive minimal-incision palatoplasties. Cases requiring relaxing incision and/or conversion to other palatoplasty techniques were compared with minimal incision alone.

RESULTS

Minimally invasive palatoplasty alone was able to be performed in 78 percent (n=52) of all cases. Fistula rates were 7.6 percent (n=4) in the minimally invasive palatoplasty group and 20 percent (n=3) in the relaxing/conversion group (p=0.04). Of patients requiring relaxing incisions/conversion, a higher percentage were syndromic (73 percent; p=0.01). Eighty-nine percent of all Veau class I defects were able to be successfully closed with the minimally invasive palatoplasty approach (p=0.01).

CONCLUSIONS

Minimal-incision palatoplasty paired with a cranial base maneuver for nasal mucosa elevation results in adequate soft-tissue mobility and length to arrive at a tension-free closure. Fistula and velopharyngeal insufficiency rates are comparable to that of other techniques, and theoretical advantages of this technique will be borne out by longer term follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A revised classification of the cleft lip and palate

BACKGROUND

Submucous cleft palate is characterized by muscular diastasis of the velum in the presence of intact mucosa with variable combinations of bifid uvula and hard palatal defect. Submucous cleft palate is indicated as a separate entity in most previous classifications but it has never been properly classified on an anatomical basis.

OBJECTIVES

To revise the Smith-modified Kernahan 'Y' classification of cleft lip and palate deformities, and to describe the different anatomical subtypes of submucous cleft palate.

METHODS

The present study was conducted in Hayatabad Medical Complex, Abasin Hospital and Aman Hospital Peshawar, Pakistan, from November 2010 to December 2011. All patients who presented to the outpatient departments with cleft lip and palate, with the exception of previously operated cases, were included. All cases were described according to the Smith-modified Kernahan 'Y' classification and the authors' revised Smith-modified Kernahan 'Y' classification. All of the data were organized and analyzed using SPSS version 17 (IBM Corporation, USA).

RESULTS

A total of 163 cases of cleft lip and palate deformities were studied, of which 59.5% were male and 40.5% were female. Smith modification of the Kernahan 'Y' classification completely described the cleft deformities in 93.9% of patients. However, while the Kernahan 'Y' classification represented the submucous cleft palate, it did not describe its different anatomical subtypes in 6.13% of patients. The revised Smith-modified Kernahan 'Y' classification completely described the cleft deformities of the entire study population, including the different submucous cleft palate patients.

DISCUSSION

The Smith alphanumeric modification of the Kernahan 'Y' classification of cleft lip and palate came into existence after a long search and a series of modifications over the past century. This classification system describes the cleft region, site of the cleft, degree of the cleft, rare and asymmetrical clefts, and are computer database friendly. However, this classification did not describe the different anatomical subtypes of submucous cleft palate that have variable relationships with velopharyngeal insufficiency.

CONCLUSION

The revised Smith-modified Kernahan 'Y' classification described in the present study can describe all types of cleft lip and palate deformities in addition to the different types of submucous cleft palate deformities.

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.

Velopharyngeal insufficiency, submucous cleft palate and a phonological disorder as the associated clinical features which led to the diagnosis of Jacobsen syndrome. Case report and review of the literature

Jacobsen syndrome is an uncommon but well-known contiguous gene syndrome caused by partial deletion involving the long arm of chromosome 11. Most common features include: psychomotor impairment, facial dysmorphism, and thrombocytopenia. Cleft palate has been rarely reported. A case of Jacobsen syndrome confirmed by cytogenomic analysis is presented with review of the literature. Main clinical features were phonological disorder, submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI). VPI was corrected surgically according to findings of videonasopharyngoscopy and videofluoroscopy. It is concluded that clinicians should consider that VPI associated with SMCP may be the main manifestations of a chromosomal syndrome.

Age of diagnosis and evaluation of consequences of submucous cleft palate

OBJECTIVES

To evaluate the frequency of submucous cleft palate (SMCP) in a group of children with clefts. The reason for suspecting submucous cleft, age of diagnosis, effect of age on speech development, problems in speech, hearing and swallowing were compared with previous literature.

METHODS

Retrospective chart review: Out of 33 patients with SMCP, registered by the Groninger cleft team over approximately 20 years (1990 until July 2012), 28 non-syndromic patients with a proven diagnosis of SMCP were included: 17 males and 11 females. Speech and hearing were examined and the number of patients with SMCP and age at time of diagnosis were evaluated. The percentages of problems in resonance, articulation and hearing, present at time of diagnosis, were compared with the percentages of problems found after surgery.

RESULTS

Out of 800 patients with clefts, 28 patients (3,5%) were diagnosed with SMCP at a mean age of 3;9 years. All patients presented one or more symptomatic complaints at time of diagnosis: hypernasality (65%), problems in articulation (46%), conductive hearing loss (39%) and/or swallowing problems (32%). A bifid uvula was found in 92%. Following surgery, hypernasal speech and swallowing problems were no longer observed. The articulation problems remained after surgery. Age of diagnosis seems no predictor of articulation problems. An improvement in hearing was observed but normal hearing was not achieved. Pharyngoplasty appeared to be a successful and save treatment of hypernasality.

CONCLUSIONS

SMCP is a rare cleft palate which is, despite the presence of a bifid uvula and symptoms of velopharyngeal insufficiency, often diagnosed late. In children with a bifid uvula and mild problems in speech, hearing and swallowing, it is important to be alert to SMCP because SMCP may account for these persistent mild complaints. Therefore, early detecting of SMCP can yield profits.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.

Velopharyngeal valving during speech, in patients with velocardiofacial syndrome and patients with non-syndromic palatal clefts after surgical and speech pathology management

BACKGROUND

Velocardiofacial syndrome (VCFS) is the most common genetic syndrome associated with cleft palate. There are reports describing several anomalies associated with the palatal cleft in patients with VCFS, which can affect the characteristics of the velopharyngeal insufficiency (VPI) in these cases.

OBJECTIVE

The purpose of this study is to assess velopharyngeal sphincter function during speech, using videonasopharyngoscopy (VNP) and videofluoroscopy (VF), in patients with VCFS, as compared with patients with non-syndromic palatal clefts (NSCP).

MATERIAL AND METHOD

Twenty patients with VCFS corroborated by a FISH test were studied. All patients showed a palatal cleft. All patients had received previous management including speech therapy and palatal repair. These patients underwent a thorough clinical speech evaluation, including VNP and VF. Twenty patients with NSCP matched by sex, type of cleft and within the age range of the patients with VCFS were studied as controls.

RESULTS

From the patients with VCFS, seventeen patients showed a submucous cleft palate. Three patients showed sub-total cleft of the secondary palate. Fourteen patients (70%) showed a coronal velopharyngeal closure pattern. Six patients (30%) showed a circular pattern. In contrast, 10 patients (50%) from the NSCP group showed a circular pattern, two of them showed a Passavant's ridge. Seven patients (35%) showed a coronal pattern and 3 patients (15%) showed a saggital pattern. Mean velum (V) and lateral pharyngeal wall (LPW) motion were significantly decreased in patients with VCFS (V=46% vs 71%; LPW=14% vs 30%; P<0.001). Size of the defect during speech was significantly increased in patients with VCFS (34.57% vs 67.37%; P<0.001).

CONCLUSION

Velopharyngeal valving during speech is significantly different in patients with VCFS as compared with patients with NSCP. Several anomalies associated with the palatal cleft in patients with VCFS can explain these differences. Thus, the surgical approach for repairing a palatal cleft should consider these differences. Moreover, surgical planning should be performed according to the specific findings of the velopharyngeal sphincter in order to improve speech outcome.

Submucous Cleft Palate and Velopharyngeal Insufficiency: Comparison of Speech Outcomes Using Three Operative Techniques by One Surgeon

Objective

Our purpose was to compare speech outcomes among three primary procedures for symptomatic submucous cleft palate (SMCP): two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap.

Design

Retrospective review.

Setting

Tertiary hospital.

Patients, Participants

All children with SMCP treated by the senior author between 1984 and 2008.

Interventions

One of three primary procedures: two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap.

Main outcome Measures

Speech outcome and need for a secondary operation were analyzed among procedures. Success was defined as normal or borderline competent velopharyngeal function. Failure was defined as persistent borderline insufficiency or velopharyngeal insufficiency with recommendation for a secondary operation.

Results

We identified 58 patients with SMCP who were treated for velopharyngeal insufficiency. We found significant differences in median age at operation among the procedures ( p < .001). Two-flap palatoplasty with muscular retropositioning (n = 24), double-opposing Z-palatoplasty (n = 19), and pharyngeal flap (n = 15) were performed at a median of 2.5, 3.6, and 9.5 years, respectively. There were significant differences in success among procedures (p = .018). Normal or borderline competent function was achieved in 6/20 (30%) patients who underwent two-flap palatoplasty, 10/15 (67%) following double-opposing Z-palatoplasty, and 11/12 (92%) following pharyngeal flap. Among patients treated with palatoplasty, success was independent of age at operation (p = .16).

Conclusions

Double-opposing Z-palatoplasty is more effective than two-flap palatoplasty with muscular retropositioning. For children older than 4 years, primary pharyngeal flap is also highly successful but equally so as a secondary operation and can be reserved, if necessary, following double-opposing Z-palatoplasty.

Speech outcomes following pharyngeal flap in patients with velocardiofacial syndrome

BACKGROUND

Velocardiofacial syndrome is the most common defined disorder associated with palatal insufficiency. The authors' purpose is to evaluate one surgeon's experience with correction of velopharyngeal insufficiency in velocardiofacial syndrome using a tailored pharyngeal flap.

METHODS

The authors reviewed the records of all children with velocardiofacial syndrome and velopharyngeal insufficiency who were managed with a pharyngeal flap between 1983 and 2009. Data collected included age at operation, preoperative videofluoroscopic findings, speech outcomes, complications, and need for a secondary operation.

RESULTS

The authors identified 33 patients with velocardiofacial syndrome and velopharyngeal insufficiency who had postoperative speech evaluations. Velopharyngeal insufficiency was diagnosed at a median age of 5 years. Palatal findings were: Veau type I (n = 4), overt submucous (n = 6), or occult submucous (n = 23). Median preoperative lateral pharyngeal wall movement was 22 percent (range, 0 to 90 percent). Successful correction of velopharyngeal insufficiency was achieved in 29 of 33 patients (88 percent). One patient had a medially displaced right internal carotid artery, and evidenced intraoperative bleeding and required a blood transfusion. One patient developed obstructive sleep apnea.

CONCLUSION

A tailored pharyngeal flap is highly effective for correction of velopharyngeal insufficiency in velocardiofacial syndrome with few complications.

Surgical planning for restoring velopharyngeal function in velocardiofacial syndrome

BACKGROUND

Velocardiofacial syndrome (VCFS) is one of the most common multiple anomaly syndromes in humans. Around 70% of the cases show velopharyngeal insufficiency (VPI), as a consequence of cleft palate. VPI is much more frequent due to special abnormal conditions inherent to VCFS including: platybasia, hypotrophy of adenoid, enlarged tonsils, hypotonia and abnormal pharyngeal muscles.

OBJECTIVE

To evaluate the surgical treatment of VPI in VCFS patients.

MATERIALS AND METHODS

In the Hospital Gea Gonzalez at Mexico City, all cases of VCFS from January 2000 to July December 2007 were studied. All patients subjected to velopharyngeal surgery for correcting VPI were selected. Twenty-nine patients underwent velopharyngeal surgery. All operations were planned according to findings of videonasopharyngoscopy (VNP) and multiview video fluoroscopy (MVF).

RESULTS

Twenty patients underwent pharyngeal flap operations, and 9 patients were operated on with a sphincter pharyngoplasty. After a pharyngeal flap, 17 cases (85%) improved to normal nasal resonance or mild hypernasality. Three flaps showed moderate hypernasality postoperatively. From the 9 sphincter pharyngoplasties, 6 cases (66%) improved to moderate hypernasality. Four patients (33%) persisted with severe hypernasality postoperatively. There were no complications.

CONCLUSIONS

Tailor-made pharyngeal flaps seem to be the best option for restoring velopharyngeal function in cases of VPI in VCFS patients. The use of VNP and MVF is useful for planning the operations for VPI, and they are also useful for indicating the removal of tonsils in cases with high risk of obstruction. Moreover, VNP is also useful for preventing damage to the internal carotids which are usually displaced in VCFS patients.

Interventions for the management of submucous cleft palate

BACKGROUND

Submucous cleft palate (SMCP) is a common congenital malformation of the soft palate which may present as velopharyngeal insufficiency (VPI), which can affect the quality and intelligibility of speech. Surgical techniques, which can be used to reconstruct these structural or anatomical defects and to correct velopharyngeal insufficiency, include palatal repair and procedures that rearrange the muscle attachments of the soft palate.

OBJECTIVES

To provide reliable evidence regarding the effectiveness of surgical interventions to treat velopharyngeal insufficiency and improve speech in patients with submucous cleft palate.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register (to 21st December 2006); Cochrane Developmental, Psychosocial and Learning Problems Group Trials Register (on 12th March 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (from 1966 to 21st December 2006); EMBASE (from 1980 to 21st December 2006); and CINAHL, ERIC, PsycINFO (on 7th March 2007).

SELECTION CRITERIA

Randomised controlled trials comparing surgical interventions to correct velopharyngeal insufficiency in submucous cleft palate.

DATA COLLECTION AND ANALYSIS

Limited data from one included trial precluded pooling of data, and only a descriptive summary is presented.

MAIN RESULTS

This review included one trial, involving 72 participants aged 4 to 7 years with submucous cleft palate associated velopharyngeal insufficiency, which compared minimal incision palatopharyngoplasty (MIPP) to MIPP with additional velopharyngeal surgery, either pharyngeal flap (32) or sphincter pharyngoplasty (3). The trial provided no information about post-operative speech assessment, very limited data on any instrumental assessments and there were no reports of obstructive sleep apnoea or other adverse effects after the interventions. Complete closure occurred in 32 (86%) of the participants in the MIPP group and in 31 (89%) in the additional treatment group, P > 0.05. After eliminating the nine patients with residual velopharyngeal insufficiency, the post-operative gap size during closure was 7.4 +/-3.2% in the MIPP group and 8 +/-4.1% in the additional intervention group (P > 0.5).

AUTHORS' CONCLUSIONS

The trial provided some weak and unreliable evidence that there was no significant difference in the effectiveness of minimal incision palatopharyngoplasty versus the same procedure performed simultaneously with an individually tailored pharyngeal flap or sphincter pharyngoplasty for correcting velopharyngeal insufficiency associated with submucous cleft palate.

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.

Speech in 6 Year Old Children With Sub-Mucous Cleft Palate

Speech in 83 children (in total) with sub-mucous cleft palate was evaluated at the age of 6 years. Velopharyngeal insufficiency was graded on the basis of perceptual assessment, taking into account the co-existence of various velopharyngeal insufficiency characteristics in speech. Out of 56 patients operated with a velopharyngeal flap to eliminate velo-pharyngeal insufficiency, 42 of them (75%) achieved normal velopharyngeal function in speech. Dento-alveolar misarticulations were found in 35% of the children. Misar-ticulations occurred independently of velopharyngeal insufficiency.

Does palatal muscle reconstruction affect the functional outcome of cleft palate surgery?

BACKGROUND

This study was designed to compare two-layer palatoplasty (Wardill-Kilner V-Y pushback technique) without intravelar veloplasty versus three-layer palatoplasty (Kriens technique) with intravelar veloplasty with regard to postoperative functional outcome of eustachian tube and velopharyngeal competence.

METHODS

A prospective cohort study was conducted enrolling 70 patients with nonsyndromic cleft palate (except submucous type of cleft) over a period of 2 years. They were divided into two main groups according to the type of cleft palate: group A (Veau class II) included 32 patients and group B (Veau class I) included 38 patients. In each group, Wardill-Kilner palatoplasty (two-layer repair without intravelar veloplasty) versus Kriens palatoplasty (three-layer repair with intravelar veloplasty) was randomly selected for patients.

RESULTS

For the three-layer palatoplasty in both groups, there was a greater tendency for resolution of secretory otitis media in the early postoperative period, less time required for extrusion of the grommet tube, and a lower incidence of recurrent secretory otitis media. The incidence of postoperative velopharyngeal incompetence was greater with two-layer palatoplasty group. The incidence of palatal fistula was greater with three-layer palatoplasty.

CONCLUSIONS

Palatal muscle reconstruction in cleft palate patients confers better functional results regarding velopharyngeal competence and eustachian tube function. Although the overall incidence of postoperative palatal fistula is within the accepted range, the incidence of fistula is higher in the palatal muscle reconstruction subgroup. Future studies are required that include a larger number of patients.

Avaliação perceptiva e instrumental da função velofaríngea na fissura de palato submucosa assintomática

TEMA: a fissura de palato submucosa (FPSM) pode estar associada, ou não, a sintomas de disfunção velofaríngea (DVF). OBJETIVO: o presente estudo teve por propósito verificar se pacientes com FPSM diagnosticados como assintomáticos em uma avaliação perceptiva da fala apresentam ausência de hipernasalidade e fechamento velofaríngeo adequado em exame instrumental. MÉTODO: vinte pacientes com FPSM e sem sintomas de DVF, de ambos os gêneros, com idade entre 6 e 46 anos, foram submetidos à avaliação acústica da fala (nasometria), para a determinação da nasalância, o correlato acústico da nasalidade, e, à avaliação aerodinâmica da fala (técnica fluxo-pressão), para a determinação do fechamento velofaríngeo. A total concordância entre os resultados aferidos na avaliação perceptiva e nas avaliações instrumentais foi a hipótese de nulidade testada. RESULTADOS: a avaliação aerodinâmica confirmou integralmente as observações da avaliação perceptiva, ou seja, todos os 20 pacientes foram diagnosticados como tendo fechamento velofaríngeo adequado em ambas as modalidades de avaliação. Os resultados da nasometria, por sua vez, concordaram com os da avaliação perceptiva em apenas 15 dos 20 pacientes analisados (75% dos casos). Os 5 pacientes restantes (25%) apresentaram escores de nasalância sugestivos de hipernasalidade na nasometria, não constatada na avaliação perceptiva, levando, neste caso, à rejeição da hipótese de nulidade. CONCLUSÃO: os resultados mostram a importância do uso combinado de avaliação perceptiva e instrumental para o diagnóstico da DVF em casos de FPSM. Com base nos achados recomenda-se o acompanhamento periódico dos casos considerados assintomáticos em avaliação perceptiva da fala e que apresentem evidências de DVF em uma avaliação instrumental, como a nasometria, particularmente em se tratando de crianças, mais sujeitas ao desenvolvimento de sintomas com o avanço da idade.

Surgery for speech in cleft palate patients

INTRODUCTION

Superiorly based pharyngeal flaps and sphincter pharyngoplasties are the two main possibilities for the surgical treatment of hypernasality in velopharyngeal dysfunction. Videonaspharyngoscopy and multi-view videofluoroscopy can provide anatomical and physiological data for planning these surgical procedures for correcting hypernasality.

AIM

This study was undertaken to assess the planning and outcome of pharyngeal flaps and sphincter pharyngoplasties for correcting velopharyngeal insufficiency. The surgical techniques were customized according to the findings of videonasopharyngoscopy and multiview videofluoroscopy.

MATERIALS AND METHODS

Seventy patients with repaired palate clefts and residual velopharyngeal dysfunction were studied. The patients were randomly divided into two groups. The first group received a pharyngeal flap. The second group received a sphincter pharyngoplasty. Both procedures were individually customized according to the findings of videonasopharyngoscopy and multi-view videofluoroscopy.

RESULTS

There was a non-significant difference (P >0.05) between the mean size of preoperative velopharyngeal closure gap between the two groups of patients (mean=27.5%; S.D.=7.7% versus mean=28.3%; S.D.=5.9%). Postoperatively, velopharyngeal dysfunction was completely corrected in 89% of the cases from group 1, and in 85% of the cases from group 2. There was a non-significant difference (P >0.05) between the success rate for correcting VPI in both groups of patients.

CONCLUSIONS

Pharyngeal flap and sphincter pharyngoplasty seem to be safe and reliable procedures for treating residual velopharyngeal dysfunction. Although not all the patients studied for this paper achieved complete closure after the surgical procedures, all of them showed a reduction of the size of the velopharyngeal closure defect. The planning of the surgical procedure, in order to match the postoperative structure to the preoperative velopharyngeal dimensions and movements visualized through Videonasopharyngoscopy and videofluoroscopy, seems to be the most important aspect of the surgery for correcting residual velopharyngeal dysfunction.

Cleft palate repair: art and issues

Caring for the child with cleft palate requires a multidisciplinary approach that begins with evaluation for other possible congenital anomalies, decisions about timing of repair, and choice of techniques. Postoperative follow-up similarly requires a team approach and should include an otolaryngologist, an orthodontist, and a speech therapist. The art of cleft palate repair has enjoyed a decade rich in new developments. New techniques have been developed, and standard techniques have been refined. Most importantly, the need for prospective, randomized trials to objectively compare surgical techniques has been recognized. Initiation and completion of these trials will improve outcomes for patients with cleft palate repairs.

Videonasopharyngoscopy in patients with 22q11.2 deletion syndrome (Shprintzen syndrome)

INTRODUCTION

Velo-cardio-facial syndrome (VCFS) (also known as DiGeorge sequence, conotruncal anomaly face syndrome, 22q11.2 deletion syndrome among other labels) is now recognized as the most common syndrome associated with cleft palate and velopharyngeal insufficiency. VCFS has been associated with medially positioned internal carotid arteries. This anomaly has been associated with obvious posterior pharyngeal pulsations seen on videonasopharyngoscopy. The purpose of this paper is to study the role of videonasopharyngoscopy for the evaluation of patients with VCFS and submucous cleft palate.

MATERIALS AND METHODS

Twenty patients with submucous cleft palate, velopharyngeal insufficiency, and 22q11.2 deletion as demonstrated by fluorescence in situ hybridization (FISH) were studied. Also, 20 patients with submucous cleft palate, and without abnormalities in the FISH procedure, were studied as controls. All patients from both groups underwent videonasopharyngoscopy. A double-blind procedure was utilized whereby all videonasopharyngoscopies were independently revised by the two examiners.

RESULTS

Both examiners coincided that 17 patients with VCFS demonstrated obvious posterior pharyngeal pulsations seen on videonasopharyngoscopy. In contrast, both examiners agreed that none of the patients from the control group showed posterior pharyngeal pulsations.

CONCLUSIONS

Videonasopharyngoscopy seems to be a safe and reliable procedure for evaluating patients with VCFS. The observations of posterior pharyngeal wall pulsations on videonasopharyngoscopy should alert clinicians to the diagnosis of VCFS. Also, the findings of videonasopharyngoscopy can be useful for preventing the risk of damage to the carotid arteries during velopharyngeal surgery. This indicates another important role of videonasopharyngoscopy in the preoperative assessment of children for palatopharyngoplasty.