Diagnosis and Treatment of Velopharyngeal Insufficiency

Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients

OBJECTIVE

Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients.

SETTING

An academic tertiary pediatric care center.

METHODS

Retrospective cohort study.

PATIENTS

Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL).

OUTCOME MEASURES

The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS).

RESULTS

97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05).

CONCLUSION

Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.

Models for Predicting Velopharyngeal Competence Based on Speech and Resonance Errors and Velopharyngeal Area Estimation

OBJECTIVE

To develop tools for predicting velopharyngeal competence (VPC) based on auditory-perceptual assessment and its correlation with objective measures of velopharyngeal orifice area.

DESIGN

Methodological study.

PARTICIPANTS AND METHODS

Sixty-two patients with repaired cleft palate, aged 6 to 45 years, underwent aerodynamic evaluation by means of the pressure-flow technique and audiovisual recording of speech samples. Three experienced speech-language pathologists analysed the speech samples by rating the following resonance, visual, and speech variables: hypernasality, audible nasal air emission, nasal turbulence, weak pressure consonants, facial grimacing, active nonoral errors, and overall velopharyngeal competence. The correlation between the perceptual speech variables and velopharyngeal orifice area estimates was analysed with Spearman's correlation coefficient. Two statistical models (discriminant and exploratory) were used to predict VPC based on the orifice area estimates. Sensitivity and specificity analyses were performed to verify the clinical applicability of the models.

RESULTS

There was a strong correlation between VPC (based on the orifice area estimates) and each speech variable. Both models showed 88.7% accuracy in predicting VPC. The sensitivity and specificity for the discriminant model were 92.3% and 97.2%, respectively, and 96.2% and 94.4% for the exploratory model.

CONCLUSION

Two predictor models based on ratings of resonance, visual, and speech variables and a simple calculation of a composite variable, SOMA (Eng. "sum"), were developed and found to be efficient in predicting VPC defined by orifice estimates categories based on aerodynamic measurements. Both tools may contribute to the diagnosis of velopharyngeal dysfunction in clinical practice.

Incidence of Velopharyngeal Insufficiency after Primary Cleft Palate Repair: A 27-Year Assessment of One Surgeon's Experience

Background  Velopharyngeal insufficiency (VPI) is a major complication of cleft palate repair. The purpose of this study was to evaluate the incidence and predictive factors of VPI after cleft palate repair based on 27 years of one surgeon's experience. Methods  Medical records were retrospectively reviewed for 652 patients who underwent cleft palate repair between 1995 and 2021. After exclusion of those with other syndromes or developmental disorders, the study included 374 patients with sufficient follow-up until the age of 4 years, when language evaluation was possible. VPI status was categorized through subjective and objective tests into normal, VPI, and borderline. We analyzed potential differences in VPI incidence by multiple factors. Factors with significance were analyzed to confirm the relationships between subvariables. Results  Of the 374 patients, 311 (83.2%) exhibited normal pronunciation, 51 (13.6%) had VPI, and 12 (3.2%) were borderline. Primary cleft palate repair performed after 18 months was associated with a higher incidence of VPI than repair conducted before 18 months ( p  = 0.005). The incidence of VPI was higher in cases of submucous cleft palate than in the other types based on the Veau classification ( p  = 0.011). However, in the multivariable analysis, only the submucous type showed statistically significant results ( p  = 0.026). Conclusion  A total of 374 people underwent primary cleft palate repair, and 13.6% of those with VPI required secondary therapy. The incidence of VPI was relatively high among patients with primary cleft palate repair after 18 months and patients with submucous cleft palate.

Exploration of the Utility of the Generic ICHOM Standard Set Measures in Evaluating the Speech of Patients with Cleft Lip/Palate

Background

The International Consortium of Health Outcome Measurements (ICHOM) standard set for cleft care appraisal recommends clinicians assess articulation with percentage consonants correct (PCC) and velopharyngeal function with velopharyngeal competency rating (VPC-R). This study explores the utility and limitations of these generic measures in detecting cleft speech sound disorders by comparing them with two cleft-specific speech-rating systems, cleft audit protocol of speech-augmented Americleft modification (CAPS-A-AM) and Pittsburgh weighted speech scale (PWSS).

Methods

Consecutive children with repaired, nonsyndromic cleft lip/palate, aged 5 years or older (n = 27) underwent prospective speech evaluations conducted at a single academic institution. These evaluations were conducted, recorded, and evaluated by blinded speech-language pathologists experienced with all tools.

Results

When comparing measures of articulation, PCC scores correlated better with scores for relevant subcomponents of CAPS-A-AM than PWSS. When comparing measures of velopharyngeal function, VPC-R scores correlated well with relevant components of both scales. Using a "screening test versus diagnostic test" analogy, VPC-R ratings were 87.5% sensitive and 73.7% specific for detecting velopharyngeal dysfunction according to subcomponents of CAPS-A-AM, and 70.6% sensitive and 100% specific according to subcomponents of PWSS.

Conclusions

This exploratory study demonstrates that PCC and VPC-R perform moderately well in detecting articulatory and velopharyngeal dysfunction in patients with cleft lip/palate; however, these tools cannot describe nuances of cleft speech sound disorder. Thus, although PCC and VPC-R adequately track basic minimum outcomes, we encourage teams to consider extending the standard set by adopting a cleft-specific measurement system for further evaluation of the tools.

Velopharyngeal insufficiency, speech, and language impairment in craniofacial microsomia: a scoping review

This review provides a comprehensive overview of the literature on velopharyngeal insufficiency, associated anomalies, and speech/language impairment in patients with craniofacial microsomia (CFM). A systematic search of the literature was conducted to identify records on VPI and speech impairment in CFM from their inception until September 2022 within the databases Embase, PubMed, MEDLINE, Ovid, CINAHL EBSCO, Web of Science, Cochrane, and Google Scholar. Seventeen articles were included, analysing 1,253 patients. Velopharyngeal insufficiency results in hypernasality can lead to speech impairment. The reported prevalence of both velopharyngeal insufficiency and hypernasality ranged between 12.5% and 55%, while the reported prevalence of speech impairment in patients with CFM varied between 35.4% and 74%. Language problems were reported in 37% to 50% of patients. Speech therapy was documented in 45.5% to 59.6% of patients, while surgical treatment for velopharyngeal insufficiency consisted of pharyngeal flap surgery or pharyngoplasty and was reported in 31.6% to 100%. Cleft lip and/or palate was reported in 10% to 100% of patients with CFM; these patients were found to have worse speech results than those without cleft lip and/or palate. No consensus was found on patient characteristics associated with an increased risk of velopharyngeal insufficiency and speech/language impairment. Although velopharyngeal insufficiency is a less commonly reported characteristic of CFM than other malformations, it can cause speech impairment, which may contribute to delayed language development in patients with CFM. Therefore, timely recognition and treatment of speech impairment is essential.

Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates

Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.

Endoscopic evaluation of velopharyngeal function in cleft lip palate patients - A correlation with speech analysis

BACKGROUND

Speech abnormalities due to velopharyngeal insufficiency (VPI) significantly affect communication skills, self-esteem, and scholastic performance. It leads to a poor social, emotional, educational, and behavioral development and a poor quality of life overall in cleft lip palate (CLP) patients. Its early diagnosis and severity assessment using video-nasoendoscopy and speech assessment can significantly contribute to management. The present study evaluated VPI in CLP patients using both tools.

METHODS

A total of 48 patients with repaired cleft palate were subjected to speech and video-nasoendoscopic assessment. Speech assessment measured severity of hypernasality, speech intelligibility, and voice quality. Video-nasoendoscopy evaluated velopharyngeal port closure to grade the severity of VPI. The speech assessment and video-nasoendoscopy findings were analyzed and correlated.

RESULTS

There was a moderately strong statistically significant negative correlation between the grade of VPI and hypernasality (r = -0.542, p = 0.000). There was a stronger statistically significant negative correlation of grade of velopharyngeal port insufficiency with speech intelligibility (r = -0.634, p = 0.000). About 72% of the patients had abnormal voice quality.

CONCLUSION

This study is the first attempt at diagnosing and grading VPI on a quantitative scoring based on a ratio scale for the motion of soft palate and pharyngeal walls. The strong correlation between endoscopic grading and speech analysis findings warrants further evaluation of nasoendoscopic grading of VPI in more studies.

Revision Pharyngoplasty in Cleft Palate and Velopharyngeal Insufficiency: Management and Outcomes

INTRODUCTION

Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty.

METHODS

A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant.

RESULTS

Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3.

CONCLUSION

Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.

Speech diagnosis and intervention in children with a repaired cleft palate: A qualitative study of Flemish private community speech-language pathologists' practices

Purpose: This study investigated the practice patterns of private community speech-language pathologists (SLPs) when treating children with a repaired cleft of the palate with or without a cleft of the lip (CP ± L). Practices were explored in terms of diagnostics and treatment focus, treatment dosage and experienced difficulties when treating children with a CP ± L.Method: Eleven female private community SLPs, who lived in Flanders (i.e. the northern part of Belgium) and were aged between 23 and 62 years participated in this study. Data were collected from semi-structured face-to-face interviews. The qualitative software program NVivo 12 was used for data analysis. The interviews were analysed using an inductive thematic approach.Result: SLPs reported a lack of available information on speech-related cleft care. SLPs expressed the need to receive a referral letter from the hospital in order to make an adequate speech diagnosis. Most therapists reported that they performed an articulatory assessment combined with a language assessment. Most SLPs used a hybrid treatment model including a variety of intervention techniques. These techniques were not always in line with available scientific evidence. SLPs reported the desire to receive practical step-by-step guidelines on how to provide speech intervention to children with a CP ± L. In contrast, there was a strong consensus among the therapists that an individualised treatment plan is necessary.Conclusion: The results of this study have revealed gaps in the dissemination and implementation of scientific evidence relevant to speech services for children with a CP ± L (i.e. a research-practice gap) in Flanders. Research evidence needs to be adequately translated into clinical practice by providing concrete and practical guidelines.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients

PURPOSE

Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPI in these patients. The purpose of this paper is to assess cleft-orthognathic patients under the lens of persistent or newly-developed VPI, to understand outcomes and generate a targeted management algorithm.

METHODS

A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPI development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPI outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test.

RESULTS

Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients (P < 0.001).

CONCLUSIONS

Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

Characteristics and surgical outcomes of cleft palate in kabuki syndrome: a case series of 11 patients

Objective

A significant number of patients with KS have cleft palate (CP) or submucous cleft palate (SMCP) and show delayed speech development. However, few reports have discussed the characteristics of CP in KS and the outcomes of postoperative speech development. The purpose of this study was to investigate the characteristics and surgical outcomes of CP in patients with KS, and to discuss the importance of the diagnosis of CP or SMCP.

Methods

We conducted a retrospective study on patients with clinically diagnosed KS who underwent palatoplasty. Clinical and surgical data were collected from patients’ medical records, and velopharyngeal function was evaluated using nasopharyngoscopy and speech analysis.

Results

In 11 cases, 5 patients had CP (45.5%) and 6 had SMCP (54.5%). Four patients who were genetically tested had a pathogenic variant of KMT2D. Seven of nine patients (77.8%) who underwent conventional palatoplasty showed velopharyngeal insufficiency and hypernasality. All patients who underwent pharyngeal flap surgery achieved velopharyngeal competency. Statistical analysis revealed a statistically significant difference in postoperative results between non-syndromic and KS patients.

Conclusion

Patients with SMCP may be more common than previously reported. The results showed that it is difficult to produce optimal results with conventional palatoplasty; therefore, pharyngeal flap surgery should be considered as a treatment to obtain favorable results. Pharyngeal flap surgery in patients with KS should be carefully designed based on speech evaluation and nasopharyngoscopic findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02852-4.

Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair

OBJECTIVE

Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population.

DESIGN

A single-institution, retrospective review.

SETTING

Multidisciplinary clinic in a tertiary academic institution.

PATIENTS

A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded.

MAIN OUTCOME MEASURES

Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology.

RESULTS

Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2).

CONCLUSIONS

Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.

Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function

ABSTRACT

Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

Outcomes of Furlow Double-Opposing Z-Plasty Palatoplasty for the Treatment of Symptomatic Overt and Occult Submucous Cleft Palate: A Comparison Study

BACKGROUND

The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure.

METHODS

This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score.

RESULTS

A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score <7 without recommendation for secondary speech surgery) in 291 patients (82.1 percent). Apart from those requiring secondary surgery, there were no documented complications. Occult-type patients were 7.5 years old at palatoplasty with a speech score of 14.1; overt-type patients were 6.5 years old with a score of 15.7. Postoperative speech scores were similar for both groups. Secondary speech surgery patients had a higher preoperative score (16.9 versus 14.2). Age at time of palatoplasty and submucous cleft palate type were not predictive of the need for secondary surgery. Syndromic patients had higher preoperative and postoperative speech scores (15.6 and 7.5, respectively) than nonsyndromic patients (14.3 and 4.3) and needed secondary surgery more often (24.4 percent versus 9.2 percent). V-shaped velar vaulting on preoperative assessment was present in 92 percent of occult-type patients.

CONCLUSIONS

Furlow palatoplasty is a safe and effective means of repairing submucous cleft palate. Patients with the occult type presented later with a lower Pittsburgh Weighted Speech Score. High preoperative speech score and syndromic status were associated with the need for secondary speech surgery. V-shaped velar vaulting is a reliable sign of occult submucous cleft palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Velar Closing Ratio As a Predictor for the Verlopharyngeal Function After Double Opposing Z-Plasty for Postpalatoplasty Velopharyngeal Insufficiency in Patients With Cleft Palate

BACKGROUND

This study was designed to identify the potential predictors of postoperative velopharyngeal function after double opposing Z-plasty (DOZP) for the treatment of velopharyngeal insufficiency (VPI) in patients who had prior palatoplasty for cleft palate.

METHODS

This retrospective study reviewed the medical records of consecutive patients who received DOZP for VPI after receiving a prior palatoplasty treating cleft palate between 2004 and 2017. The speech outcome of patient was measured using the Pittsburgh Weighted Speech Scale (PWSS) at 6 months following surgery and determined the outcome suggests velopharyngeal competence (PWSS ≤2) or incompetence (PWSS >2). Stepwise logistic regression was used to identify the variables for the prediction of competent surgical outcome. The specific receiver operating characteristic curves with an area under the curve (AUC) was used to evaluate the predictor related to the surgical outcome as competence.

RESULTS

The study included 93 patients. Age, relative velar length, velar lengthening, and closure pattern were not significantly associated with postoperative competence status of the patient. The only variable that predicted a successful surgical outcome was preoperative velar closing ratio. However, the accuracy of velar closing ratio in predicting a competent surgical outcome is only moderate (AUC = 70.37).

CONCLUSION

The results of this study showed that preoperative velar closing ratio may predict, with moderate accuracy, a successful surgical outcome in patients with postpalatoplasty VPI who undergo DOZP. Therefore, in patients with a low preoperative velar closing ratio, some alternative surgical methods other than DOZP may be considered to avoid unsatisfactory surgical outcome.

Comparing Quality of Life and Perceptual Speech Ratings in Children With Cleft Palate

OBJECTIVE

To delineate the relationship between patient and parent-reported quality of life (QOL) ratings and perceptual characteristics of speech assigned by a speech-language pathologist (SLP) in children with repaired cleft palate.

DESIGN

Prospective.

SETTING

Academic Children's Hospital.

PARTICIPANTS

This population-based sample included children, aged 3 to 18 with a history of repaired cleft palate, and their parents.

INTERVENTION

Participants completed the Velopharyngeal Insufficiency Effects on Life Outcomes Questionnaire (VELO). Children's speech was judged perceptually by an expert SLP using the Pittsburgh Weighted Speech Scale (PWSS).

MAIN OUTCOME MEASURE(S)

Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire assessed participant and parent perceptions of impact of velopharyngeal function on QOL. Pittsburgh Weighted Speech Scale assessed nasal emissions, facial grimacing, nasality, quality of phonation, and articulation.

RESULTS

Enrollment included 48 participant parent dyads. Overall, participants reported high QOL scores within the 95% CI with children reporting slightly better yet not significantly different QOL (86.27 ± 8.96) compared to their parents (81.81 ± 15.2). Children received an average score of 1.38 ± 1.96 on the PWSS corresponding to borderline velopharyngeal competence. A significant moderate negative correlation was found between PWSS total score and parent VELO total score (r = -0.51103, P = .0002). Mild-moderate significant negative correlations were measured between PWSS total and the 5 subscales of the VELO. No significant correlations were measured between PWSS and child VELO total responses or between total scores and subscales.

CONCLUSIONS

Results suggest that as perceptual analysis of speech improves, overall QOL improves moderately.

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.

Assessing speech at three years of age in the cleft palate population: a scoping review of assessment practices

BACKGROUND

There is no consensus in the UK regarding the types of speech samples or parameters of speech that should be assessed at 3 years of age in children with cleft palate ± cleft lip (CP±L), despite cleft units routinely assessing speech at this age. The standardization of assessment practices would facilitate comparisons of outcomes across UK cleft units; earlier identification of speech impairments-which could support more timely treatments; and more reliable recording of therapy impacts and surgical interventions.

AIMS

To explore assessment practices used to assess speech in 3-year-old children with CP±L, including speech parameters, methods of assessment and the nature of the speech sample used.

METHODS & PROCEDURES

A broad examination of the literature was undertaken through the use of a scoping review conducted in accordance with Joanna Briggs Institute guidelines. Search terms were generated from a preliminary search and then used in the main search (Medline, CINAHL, Embase, AMED and PsycINFO).

MAIN CONTRIBUTION

A combination of approaches (medical, linguistic, developmental and functional) is required to assess CP±L speech at age 3. A developmental approach is recommended at this age, considering the complexity of speech profiles at age 3, in which typically developing speech processes may occur alongside cleft speech characteristics. A combined measure for both nasal emission and turbulence, and an overall measure for velopharyngeal function for speech, show potential for assessment at this age. Categorical ordinal scales are frequently used; the use of continuous scales has yet to be fully explored at age 3. Although single-word assessments, including a subset of words developed for cross-linguistic comparisons, are frequently used, more than one type of speech sample may be needed to assess speech at this age validly. The lack of consensus regarding speech samples highlights a need for further research into the types of speech samples 3-year-olds can complete; the impact of incomplete speech samples on outcome measures (particularly relevant at this age when children may be less able to complete a full sample); the impact of different speech samples on the validity of assessments; and the reliability of listener judgements.

CONCLUSIONS & IMPLICATIONS

Whilst a medical model and linguistic approaches are often central in assessments of age-3 cleft speech, this review highlights the importance of developmental and functional approaches to assessment. Cross-linguistic single-word assessments show potential, and would facilitate the comparison of UK speech outcomes with other countries. Further research should explore the impact of different speech samples and rating scales on assessment validity and listener reliability.

Buccinator Re-Repair (Bs + Re: IVVP): A Combined Procedure to Maximize the Palate Form and Function in Difficult VPI Cases

Objectives:

To assess the outcome of a modified buccinator flaps’ palatal lengthening combined with radical intravelar veloplasty (Bs + Re: IVVP) for the management of postpalatoplasty velopharyngeal incompetence and report the functional and structural changes occurring in the palate.

Design:

Prospective cohort study of consecutive cleft patients presenting with velopharyngeal incompetence and managed by buccinator re-repair procedure. Blind assessment of randomized recordings of speech and evaluation of velar form and function with nasoendoscopy and lateral videofluoroscopy were done. Patients’ demographic data were also collected.

Patients:

Among 30 consecutive cases who had Bs + Re: IVVP, 24 had adequate pre- and postoperative records of speech outcome data.

Setting:

Multidisciplinary cleft team in a tertiary referral center.

Results:

There were significant improvements in hypernasality, nasal emission, facial grimace and weak consonants, and overall intelligibility of speech. Endoscopy and lateral videofluoroscopy showed significant improvement in total and functional velar length, closure ratio, velopharyngeal gap at closure, palatal thickness, palatal convexity, and mobility. Regarding the procedure complications, no flap ischemia, fistula, or obstructive sleep apnea reported, but there were one cheek hematoma and two minor oral mucosal dehiscence which healed spontaneously.

Conclusions:

Buccinator re-repair (Bs + Re: IVVP) has been shown to be an effective and safe procedure in treating difficult postpalatoplasty velopharyngeal incompetence. It was also shown that it is still a physiological nonobstructive procedure with low morbidity.

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.

Relationship of Velopharyngeal Insufficiency With Face Mask Therapy in Patients With Cleft Lip and Palate

OBJECTIVE

To determine whether orthodontic/dentofacial orthopedic maxillary protraction face mask therapy induces changes in velopharyngeal functioning in a cohort of pediatric patients having cleft palate with or without cleft lip.

DESIGN

Retrospective chart review.

SETTING

A children's hospital in the United States.

PARTICIPANTS

Forty-three pediatric patients with cleft palate, with or without cleft lip, syndromic or with isolated clefts, who received face mask therapy from January 2009 to April 2016.

INTERVENTION

Clinical data were extracted for review and analysis from medical records obtained from the Cleft Database/Research Registry (CDB-RR).

MAIN OUTCOME MEASURES

Pittsburgh Weighted Speech Scores (PWSS) before and after therapy.

RESULTS

There was a significant increase in PWSS after face mask therapy for patients with a PWSS score of 0 prior to treatment. Patients with PWSS >0 before treatment remained largely stable after face mask therapy. Maxillary advancement was not significantly associated with change in PWSS or fistula presence/absence.

CONCLUSIONS

There is an increased risk of velopharyngeal insufficiency with maxillary protraction face mask treatment in patients with cleft palate. Patient counseling and obtaining consent regarding speech changes during treatment are recommended.

Outcome of Palate Re-repair with Radical Repositioning of the Levator Muscle Sling as a First-Line Strategy in Postpalatoplasty Velopharyngeal Incompetence Management Protocol

BACKGROUND

Palatal re-repair aims to improve velar function by retropositioning the levator muscles. Although it has become a popular procedure, very few studies document its efficacy. To date, this is the largest series reported to clarify its indications and efficacy.

METHODS

One hundred eighty-three consecutive cleft patients presenting with velopharyngeal incompetence and evidence of abnormally oriented levator muscles underwent palate re-repair (regardless of the gap size) performed by a single surgeon from 2000 to 2015. Perceptual speech assessment was performed using the Pittsburgh Weighted Speech Score. Other patients' demographic data were collected.

RESULTS

Complete records of 111 patients were available. Eighteen cases were syndromic (18.9 percent). Postoperatively, there was highly significant improvement (p < 0.001) in nasal emission (from 2.24 to 0.64), nasality (from 3.44 to 1.27), articulation (from 5.32 to 2.01), and total score (from 11.29 to 4.11). Speech became normal/borderline normal, improved or did not improve in 66.7, 24.3, and 9 percent of patients, respectively. An initial diagnosis of isolated cleft palate, Caucasians, intravelar veloplasty in the primary repair, older patients, and nonsyndromic cases were associated with better outcome. There were no reported cases of postoperative fistula or new obstructive sleep apnea.

CONCLUSIONS

This large series study provides confirmatory evidence of the effectiveness and safety of the re-repair procedure. It is recommended as a first-line procedure in all velopharyngeal incompetence cases with abnormally oriented levator muscles regardless of gap size, even if the primary operation included prior muscle dissection. The pharyngoplasty rate could be significantly reduced with the current protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Time course of improvement after re-repair procedure for VPI management

OBJECTIVES

Palatal re-repair aims to improve velar function by retro-positioning the levator veli palatini muscles. The surgery includes extensive dissection, leading to tissue edema and scar formation which may need time to remodel. Together with the change of muscle orientation and tension, it is expected that a period of time is needed to reach the final functional performance. This study attempts to determine how much time is required to reach the optimum performance of the palate after re-repair.

METHODS

A retrospective chart review identified consecutive cleft patients with VPI who underwent palate re-repair procedure by a single surgeon from 2000 to 2015 and achieved normal or borderline normal VP function. Only patients who had regular postoperative follow-up visits for speech assessments until resolution of speech abnormalities were included. The percent of patients cured at each time point following surgery was recorded.

RESULTS

Forty-five patients met the inclusion criteria. The mean age at surgery was 6.6 ± 3.2 years. Speech abnormalities had resolved in 44.5% of patients within the first 6 months after surgery, 62.2% after up to 1 year, 75.6% after up to 2 years and 88.9% after up to 3 years post re-repair palatoplasty. The remaining 11.1% continued to improve after 3 years up to 6 years.

CONCLUSIONS

Re-repair procedures may take a longer time than previously thought for the final outcome to manifest. Close monitoring of improvement with continued speech therapy is recommended before deciding to move to the next surgical step in management.

A Treatment Protocol for Velopharyngeal Insufficiency and the Outcome

BACKGROUND

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications.

METHODS

The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed.

RESULTS

Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea.

CONCLUSION

The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Role of the Velopharyngeal Sphincter in the Speech of Patients with Cleft Palate or Cleft Lip and Palate Using Perceptual Methods

BACKGROUND:

The velopharyngeal sphincter (VPS) plays the main role in speech formation. The cleft palate, due to the damage of the soft palate, leads to dysfunction of the velopharyngeal sphincter thus causing speech disorder.

AIM:

To establish a link between the nasal air escape and the perceptual symptoms in the speech of patients with cleft palate or cleft lip and palate using auditory-visual perceptual procedures for determining the influence the velopharyngeal dysfunction has on speech.

MATERIAL AND METHODS:

Twenty patients with speech disorders, out of which 10 have cleft palate or cleft lip and palate (experimental group), participated in the perceptual assessment by means of Czermak mirror fogging test for assessing the nasal air escape and Pittsburgh Weighted Speech Scale (PWSS) for assessing the probable nature of the velopharyngeal sphincter.

RESULTS:

The respondents with a considerable nasal air escape have a higher velopharyngeal inability, that is, probably incompetent nature of the velopharyngeal sphincter. There is a strong correlation between the nasal air escape and the probable nature of the velopharyngeal sphincter (the coefficient of linear correlation r = 0.9756). The calculated p-value is p = 0.000002.

CONCLUSION:

The perceptual speech symptoms and the nasal air escape provide unique insight into the state and role the velopharyngeal sphincter has in speech.

Double-Opposing Z-Palatoplasty for Secondary Surgical Management of Velopharyngeal Incompetence in the Absence of a Primary Furlow Palatoplasty

Objective

The present study was performed to identify factors that lead to a favorable outcome of postpalatoplasty velopharyngeal incompetence using the double-opposing Z-palatoplasty.

Design

A retrospective analysis was performed on 23 consecutive nonsyndromic patients who underwent secondary surgical management of velopharyngeal incompetence using a double-opposing Z-palatoplasty technique following primary, non-Furlow palatoplasty for overt cleft palate.

Main Outcome Measures

All subjects were evaluated preoperatively using a perceptual speech assessment scale, nasendoscopy, and videofluoroscopy. Inclusion criteria consisted of a velopharyngeal gap of 9 mm or less on phonation. Patients were followed with perceptual speech assessment for at least 1 year following secondary surgery.

Results

The perceptual speech assessment score for all patients decreased from 6.48 ± 2.26 (mean ± standard deviation; range, 3 to 11) to 1.90 ± 1.51 (range, 0 to 6) at 6 months or more postoperatively ( P < .0001). Of the 21 patients with follow-up data 1 year or more post–op, 16 (76%) achieved velopharyngeal competence and five (24%) had borderline competence. Preoperative assessment factors associated with compromised outcome included a large velopharyngeal gap of 7 to 9 mm, poor lateral wall motion of 40% or less, and an elevated perceptual speech assessment score.

Conclusion

Double-opposing Z-palatoplasty is a surgical technique that can be used successfully to correct velopharyngeal incompetence in selected secondary palatoplasty patients. This technique permits correction of velopharyngeal incompetence and restoration of the velopharyngeal mechanism irrespective of prior intravelar veloplasty and without accompanying loss in the nasal airway. Preoperative assessment can better identify those patients who are less likely to achieve velopharyngeal competence following double-opposing Z-palatoplasty alone.

Ear Infection in Isolated Cleft Lip: Etiological Implications

BACKGROUND AND HYPOTHESIS

Chronic ear infections are a common occurrence in children with orofacial clefts involving the secondary palate. Less is known about the middle ear status of individuals with isolated clefts of the lip, although several studies have reported elevated rates of ear infection in this group. The purpose of this retrospective study was to test the hypothesis that chronic ear infections occur more frequently in isolated cleft lip cases (n = 94) compared with controls (n = 183).

METHODS

A questionnaire was used to obtain information on history of chronic ear infection. The association between ear infection status (present/absent) and cleft lip status (cleft lip case/control) was tested using both chi-square and logistic regression.

RESULTS AND CONCLUSIONS

The reported occurrence of chronic ear infection was significantly greater in cleft lip cases (31%) compared with unaffected controls (11%). After adjusting for age and sex, having a cleft lip increased the odds of being positive for ear infection by a factor greater than 3 (odds ratio = 3.698; 95% confidence interval = 1.91 to 7.14). Within cleft lip cases, there was no difference in the occurrence of ear infection by defect laterality or by the type of clefting present in the family history. Although velopharyngeal insufficiency was present in 18.4% of our cleft lip sample, there was no statistical association between ear infection and abnormal speech patterns. These results may have potential implications both for the clinical management of isolated cleft lip cases and for understanding the etiology of orofacial clefting.

Vomopalatoplasty: a novel procedure to reduce velopharyngeal distance in cleft palate repair

Despite numerous improvements in the palatoplasty procedure, speech dysfunction tends to develop in many patients, requiring another surgery. In addition, vomer flaps have been used in palatoplasty in various shapes and on purposes. Nonetheless, they have been used mostly to cover the defect in wide and complete type of cleft palate. We introduce the vomopalatoplasty procedure that uses a vomer flap to reduce the nasopharyngeal space in incomplete or submucous type of cleft palate patients.The mucoperiosteal flaps on the nasal and oral sides were elevated by the conventional palatoplasty procedure, which subsequently elevated the bilateral vomer flaps to the posterior edge of vomer. Then, the vomer flap was sutured with the mucoperiosteal flap of the nasal side to the anterior half of the soft palate, and thus, the soft palate was fixed in more posterosuperior direction than in conventional palatoplasty. For patients whose junction of vomer and hard palate had to be exposed, a part of the bone at the bifid posterior nasal spine of the hard palate may be removed sometimes.Ostectomy of the bifid posterior nasal spine or the posterior end of the hard palate was performed in 11 patients. Another 12 patients did not need ostectomy. After the surgery, the surgical wounds healed well in all patients without any major complications such as dehiscence or loss of flap.Our vomopalatoplasty is easy to perform, and the procedure could be combined to the conventional palatoplasty procedure. Thus, we consider vomopalatoplasty as a useful procedure that could reduce the nasopharyngeal space in patients with incomplete or submucous type of cleft palate.

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.