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Pitkanen VV, Geneid A, Saarikko AM, Hakli S, Alaluusua SA. Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty. J Craniofac Surg 2023:00001665-990000000-01192. [PMID: 37955448 DOI: 10.1097/scs.0000000000009822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/06/2023] [Indexed: 11/14/2023] Open
Abstract
Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.
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Affiliation(s)
- Veera V Pitkanen
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Ahmed Geneid
- Department of Otolaryngology and Phoniatrics-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki
| | - Anne M Saarikko
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Sanna Hakli
- Department of Otolaryngology and Phoniatrics, Oulu University Hospital and PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Suvi A Alaluusua
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
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Pitkänen V, Szwedyc A, Alaluusua S, Geneid A, Vuola P, Saarikko A. Outcomes of Primary Furlow Double-Opposing Z-plasty for the Treatment of Symptomatic Submucous Cleft Palate. J Craniofac Surg 2023; 34:2066-2070. [PMID: 37221637 PMCID: PMC10521778 DOI: 10.1097/scs.0000000000009385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/25/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Submucous cleft palate (SMCP) requires surgical repair if symptomatic. The Furlow double-opposing Z-plasty is the preferred method in Helsinki cleft center. AIMS To assess the efficacy and complications of Furlow Z-plasty in the treatment of symptomatic SMCP. METHODS This retrospective study reviewed documentation of 40 consecutive patients with symptomatic SMCP who underwent primary Furlow Z-plasty by 2 high-volume cleft surgeons at a single center between 2008 and 2017. Patients underwent perceptual and instrumental evaluation of velopharyngeal function (VPF) by speech pathologists preoperatively and postoperatively. RESULTS The median age at Furlow Z-plasty was 4.8 years (SD 2.6, range 3.1-13.6). The overall success rate, including postoperative competent or borderline competent VPF, was 83%, and 10% required secondary surgery for residual velopharyngeal insufficiency. The success rate was 85% in nonsyndromic, and 67% in syndromic patients with no significant difference ( P =0.279). Complications arose in only 2 (5%) patients. No children were found to have obstructive sleep apnea postoperatively. CONCLUSION Furlow primary Z-plasty is a safe and effective operation for symptomatic SMCP with a success rate of 83% with only 5% rate of complications.
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Affiliation(s)
- Veera Pitkänen
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Anika Szwedyc
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Suvi Alaluusua
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Ahmed Geneid
- Department of Otolaryngology and Phoniatrics - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Pia Vuola
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Anne Saarikko
- Department of Plastic Surgery, Cleft and Craniofacial Center
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Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3777. [PMID: 34667705 PMCID: PMC8517311 DOI: 10.1097/gox.0000000000003777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR). Methods A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender. Results Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, P = 0.0159], speech delay/deficits (OR 7.7, P < 0.001), NAE (OR 9.7, P < 0.001), articulation errors (OR 10.2, P < 0.001), or need for secondary speech surgery (OR 13.2, P < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; P = 0.0043) and good VP function (84.78% versus 56.25%, respectively; P = 0.0094). Conclusions This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.
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Zhao N, Liu ZG, Xu YX, Yue J, Xue LF, Xiao WL. Clinical study on obstructive sleep apnea following pharyngeal flap surgery. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2021; 39:566-569. [PMID: 34636205 DOI: 10.7518/hxkq.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study aims to investigate the incidence and severity of obstructive sleep apnea (OSA) in cleft patients with velopharyngeal insufficiency (VPI) after pharyngeal flap surgery (PFS) and explore the influence of operation age. METHODS A retrospective study was conducted in 82 cleft patients after PFS. The patients were divided into two groups according to their age at the time of surgery. The incidence and severity of OSA were assessed at least 1.2 years (mean 6.0 years) postoperatively by polysomnography (PSG). RESULTS The incidence rates of OSA were 20% in the adult group and 31% in the child group. No significant difference was found between the two groups (P=0.289). Patients with OSA in the adult and child groups were classified into different levels of severity (mild, moderate, severe) according to the apnea hypoventilation index (AHI). No statistically significant difference in the severity of OSA was found between the two groups (P=0.079). CONCLUSIONS Some patients still have OSA average of 6.0 years after PFS, and operation ageis unrelated to the incidence and severity of OSA.
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Affiliation(s)
- Ning Zhao
- School of of Stomatology, Qingdao University, Qingdao 266555, China
| | - Zhen-Guo Liu
- Dept. of Otolaryngology, Head and Neck Surgery, West Coast Hospital, the Affiliated Hospital of Qingdao University, Qingdao 266555, China
| | - Yao-Xiang Xu
- School of of Stomatology, Qingdao University, Qingdao 266555, China.,Dept. of Stomatology, West Coast Hospital, the Affiliated Hospital of Qingdao University, Qingdao 266555, China
| | - Jin Yue
- School of of Stomatology, Qingdao University, Qingdao 266555, China.,Dept. of Stomatology, West Coast Hospital, the Affiliated Hospital of Qingdao University, Qingdao 266555, China
| | - Ling-Fa Xue
- School of of Stomatology, Qingdao University, Qingdao 266555, China.,Dept. of Stomatology, West Coast Hospital, the Affiliated Hospital of Qingdao University, Qingdao 266555, China
| | - Wen-Lin Xiao
- School of of Stomatology, Qingdao University, Qingdao 266555, China.,Dept. of Stomatology, West Coast Hospital, the Affiliated Hospital of Qingdao University, Qingdao 266555, China
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Haque S, Khamis MF, Alam MK, Wan Ahmad AWM. The Assessment of 3D Digital Models Using GOSLON Yardstick Index: Exploring Confounding Factors Responsible for Unfavourable Treatment Outcome in Multi-Population Children With UCLP. Front Pediatr 2021; 9:646830. [PMID: 34262887 PMCID: PMC8273310 DOI: 10.3389/fped.2021.646830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/28/2021] [Indexed: 11/13/2022] Open
Abstract
To evaluate dental arch relationship (DAR) using GOSLON Yardstick and also to explore the association between multiple factors (age, gender, UCLP types, UCLP side, Family history of cleft, family history of Class III malocclusion, techniques of cheiloplasty, techniques of palatoplasty) and DAR in children unilateral cleft lip and palate (UCLP) in different populations. Two hundred fifty-five laser scanned 3D digital models (LS3DM) of UCLP children (5-12 years) from Malaysia, Bangladesh, and Pakistan were included. The intra- and inter-examiner agreements were evaluated by kappa statistics, to compare the GOSLON mean score between the populations and to explore the responsible factors that affect DAR, one way ANOVA, and crude logistic regression analysis was used, respectively. The mean GOSLON score was 2.97; 3.40 and 3.09 in Malaysia, Bangladesh, and Pakistan, respectively. Twenty seven, 40, and 30 subjects were in unfavourable (category rating 4 and 5) groups in Malaysia, Bangladesh, and Pakistan, respectively. A significant association was found between techniques of palatoplasty (p = 0.03; p = 0.04 and p = 0.04 in Malaysia, Bangladesh, and Pakistan, respectively) and unfavourable DAR. Different cheiloplasty techniques (p = 0.04) and gender (p = 0.03) also exhibited noteworthy associations with unfavourable DAR in the Bangladeshi population. Bardach techniques of palatoplasty were significantly associated with unfavourable DAR in all three populations. Moreover, male UCLP and modified Millard techniques of cheiloplasty were also associated with unfavourable DAR in the Bangladeshi population.
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Affiliation(s)
- Sanjida Haque
- Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Mohd Fadhli Khamis
- Oral Biology and Forensic Odontology Unit, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Forensic Odontology Unit, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
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Palatal Re-Repair With Double-Opposing Z-Plasty in Treatment of Velopharyngeal Insufficiency of Patients With Unilateral Cleft Lip and Palate. J Craniofac Surg 2020; 31:2235-2239. [DOI: 10.1097/scs.0000000000006681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Liao YF, Noordhoff MS, Huang CS, Chen PKT, Chen NH, Yun C, Chuang ML. Comparison of Obstructive Sleep Apnea Syndrome in Children with Cleft Palate following Furlow Palatoplasty or Pharyngeal Flap for Velopharyngeal Insufficiency. Cleft Palate Craniofac J 2017; 41:152-6. [PMID: 14989690 DOI: 10.1597/02-162] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI). Patients A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI. Interventions An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively. Main Outcome Measures Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured. Results In the P group, the mean percentage of stage 2 sleep was lower than the F group (p < .05). The mean RDI and DI were larger in the P group, compared with the F group (p < .001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p < .001 and p = 0.05, respectively). Conclusions A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.
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Affiliation(s)
- Yu-Fang Liao
- Division of Orthodontics, the Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan
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Myung Y, Ahn T, Kim BK, Jeong JH, Baek RM. Clinical Significance of the Levator Veli Palatini Muscle in Velocardiofacial Syndrome Patients. Cleft Palate Craniofac J 2017; 55:521-527. [DOI: 10.1177/1055665617732786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Anatomical variation and deficits of velocardiofacial syndrome patients are related to unsatisfactory treatment results in surgical correction of speech abnormalities. The main purpose of the article is to investigate the clinical significance of thinned levator veli palatini muscle in VCFS patients. Methods: The authors reviewed medical records of all children with velocardiofacial syndrome who received pharyngeal flap surgery between March 2007 and September 2015. Data including thickness of levator veli palatini in magnetic resonance examination; preoperative velopharyngeal gap size from nasoendoscopy; and preoperative and postoperative speech outcomes were collected. Results: Total of 36 velocardiofacial syndrome patients with preoperative objective data and postoperative speech outcomes were identified. Preoperative velopharyngeal gap showed significant correlation with thickness of levator veli palatini (correlation coefficient: 0.297/0.397, P = .02/.03) and gap size showed correlation with postoperative speech improvement (0.347/0.413, P = .04/.02). However, muscle thickness showed no correlation with speech outcomes (0.046/0.037, P = .77/.86). Conclusion: Thinned levator veli palatini muscle in velocardiofacial syndrome patients are related to widened velopharyngeal gap and production of hypernasal speech, and can give negative impact on postoperative surgical outcome of pharyngeal flap surgery.
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Affiliation(s)
- Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Taeseon Ahn
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Baek-kyu Kim
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Jae Hoon Jeong
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Rong-Min Baek
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
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Arshad AI, Alam MK, Khamis MF. Assessment of complete unilateral cleft lip and palate patients: Determination of factors effecting dental arch relationships. Int J Pediatr Otorhinolaryngol 2017; 92:70-74. [PMID: 28012538 DOI: 10.1016/j.ijporl.2016.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The purpose of the current study was to assess the treatment outcome of non-syndromic patients having complete unilateral cleft lip and palate (CUCLP) by using GOSLON index and to determine any association of pre and/or postnatal factors with the treatment outcome. MATERIALS AND METHODS One hundred and one sets of dental models of patients having CUCLP were assessed in this retrospective study. Five examiners that were blinded to case-specific information scored the dental models at two instances with an interval of two weeks to ensure memory bias elimination (5 × 101 × 2 = 1010 observations). Calibration courses were conducted prior to scoring and each examiner was provided with scoring sheets, pictures of GOSLON reference models and flowcharts explaining the scoring method. RESULTS According to GOSLON index, a mean (SD) GOSLON score of 3.04 (1.25) was determined. Based on treatment outcome groups, 62 patients had favorable (grade 1, 2, and 3) and 39 cases had unfavorable (grade 4 and 5) treatment outcome. Chi-square tests revealed a significant association of gender (P = 0.002), cheiloplasty (P = 0.001) and palatoplasty (P < 0.001) with the treatment outcome. These associations were further explored by entering five independent variables in the logistic regression models. CONCLUSIONS The current study found an intermediate treatment outcome of CUCLP cases using GOSLON index. Final logistic model showed that gender, cheiloplasty, and palatoplasty had significantly higher odds of influencing outcomes. Identification of these factors provides us an evidence of traditional and outdated surgical methods and encourages clinicians to adopt current techniques to improve treatment outcomes. This implementation will facilitate comparison between the traditional and current techniques of primary surgical repair.
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Affiliation(s)
- Anas Imran Arshad
- School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
| | | | - Mohd Fadhli Khamis
- Forensic Dentistry Unit, School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
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An Outcome Study of a 2-Flap Pushback Palatoplasty Used in the Treatment of Wide Cleft Palates. J Craniofac Surg 2015; 26:620-4. [DOI: 10.1097/scs.0000000000001355] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Conley SF. CPCJ 50th Anniversary Editorial Board Commentary: Otolaryngology--then and now. Cleft Palate Craniofac J 2014; 51:378-80. [PMID: 24983490 DOI: 10.1597/14-134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This review continues the series of articles by the Editorial Board reflecting upon the first volume of the journal published in 1964 and celebrating the 50th anniversary of The Cleft Palate-Craniofacial Journal. This editorial examines the contributions of Otolaryngology-Head and Neck Surgery to interdisciplinary cleft care. The aerodigestive tract has many functions that are impacted by the cleft anomaly. Progress in the development of selected therapies will be reviewed.
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Moraleda-Cibrián M, Edwards SP, Kasten SJ, Berger M, Buchman SR, O'Brien LM. Symptoms of sleep disordered breathing in children with craniofacial malformations. J Clin Sleep Med 2014; 10:307-12. [PMID: 24634629 DOI: 10.5664/jcsm.3536] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to investigate the frequency of sleep disordered breathing (SDB) symptoms in a clinical sample of children with congenital craniofacial malformations (CFM) followed at a tertiary medical center and non-selected for sleep problems. METHODS Cross-sectional study of 575 children aged 2-18 years followed at the Craniofacial Anomalies Program between March 2007 and May 2011. The Sleep-Related Breathing Disturbance scale of the Pediatric Sleep Questionnaire was used to screen for SDB, snoring, and sleepiness. A cutoff value ≥ 0.33 of the total answered questions identified children with positive screening for SDB symptoms. RESULTS Overall, 25% of children screened positive for SDB, 28% for snoring, and 20% for sleepiness. In children with non-syndromic CFM, those with Robin sequence had the highest frequency of SDB, snoring, and sleepiness (43%, 44%, and 38%, respectively). In children with syndromic CFM, velocardiofacial/ DiGeorge syndrome had the highest frequency of SDB and sleepiness (48% and 43%, respectively). Children with Treacher Collins had the highest frequency of snoring (83%). The presence of cleft palate was not associated with an increased frequency of SDB symptoms. Nevertheless, children with syndromic CFM, compared to those with non-syndromic CFM, had a higher SDB score (0.27 ± 0.21 vs.0.21 ± 0.19, p = 0.003) and were more likely to have sleepiness (26% vs. 18%, p = 0.05). CONCLUSIONS Congenital craniofacial malformations in children are associated with high risk for SDB symptoms. Our findings should encourage a high index of suspicion for SDB in children with CFM, with a low threshold for further testing and close follow-up. CITATION Moraleda-Cibrián M; Edwards SP; Kasten SJ; Berger M; Buchman SR; O'Brien LM. Symptoms of sleep disordered breathing in children with craniofacial malformations.
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Affiliation(s)
- Marta Moraleda-Cibrián
- Sleep Disorders Center, Department of Neurology ; Department of Oral & Maxillofacial Surgery
| | | | - Steven J Kasten
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Mary Berger
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Steven R Buchman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Louise M O'Brien
- Sleep Disorders Center, Department of Neurology ; Department of Oral & Maxillofacial Surgery
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Spruijt NE, ReijmanHinze J, Hens G, Vander Poorten V, Mink van der Molen AB. In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review. PLoS One 2012; 7:e34332. [PMID: 22470558 PMCID: PMC3314640 DOI: 10.1371/journal.pone.0034332] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 02/26/2012] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Nicole E. Spruijt
- Department of Plastic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Judith ReijmanHinze
- Department of Otorhinolaryngology, Head and Neck Surgery, Free University Medical Center, Amsterdam, The Netherlands
| | - Greet Hens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Leuven, Belgium
| | - Vincent Vander Poorten
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Leuven, Belgium
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Kummer AW, Clark SL, Redle EE, Thomsen LL, Billmire DA. Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals. Cleft Palate Craniofac J 2012; 49:146-52. [DOI: 10.1597/10-285] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.
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Affiliation(s)
- Ann W. Kummer
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati, Cincinnati, Ohio
| | - Stacey L. Clark
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin E. Redle
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leisa L. Thomsen
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A. Billmire
- University of Cincinnati, Cincinnati, Ohio
- Division of Pediatric Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Prospective Clinical Trial Comparing Outcome Measures Between Furlow and von Langenbeck Palatoplasties for UCLP. Ann Plast Surg 2011; 66:154-63. [DOI: 10.1097/sap.0b013e3181d60763] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The effect of cleft palate repair on contractile properties of single permeabilized muscle fibers from congenitally cleft goat palates. Ann Plast Surg 2008; 60:188-93. [PMID: 18216514 DOI: 10.1097/sap.0b013e318052c6f2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inherent differences in the levator veli palatini (LVP) muscle of cleft palates before palatoplasty may play a role in persistent postrepair velopharyngeal insufficiency (VPI). Contractile properties of LVP muscle fibers were analyzed from young (2-month) normal (YNP), young congenitally cleft (YCP) and again on the same YCP subjects 6 months after palatoplasty, mature repaired palate (MRP). The cross-sectional area and rate of force development (ktr) were measured. Specific force (sF(0)) and normalized power (nP(max)) were calculated. Using k(tr) to determine fiber type composition, YNP was 44% type 1 and 56% type 2, while YCP was 100% type 2. Two MRP subjects shifted to 100% type 1; 1 demonstrated increased resistance to fatigue. No differences in sF(0) were observed. nP(max) increased with presence of type 2 fibers. The persistent state of type 2 fibers following palatoplasty leads to increased fatigue in the LVP of MRP subjects and may cause VPI symptoms.
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Liao YF, Chuang ML, Chen PKT, Chen NH, Yun C, Huang CS. Incidence and severity of obstructive sleep apnea following pharyngeal flap surgery in patients with cleft palate. Cleft Palate Craniofac J 2002; 39:312-6. [PMID: 12019007 DOI: 10.1597/1545-1569_2002_039_0312_iasoos_2.0.co_2] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate the incidence and severity of obstructive sleep apnea (OSA) associated with pharyngeal flap surgery in patients with cleft palate at least 6 months postoperatively and to determine whether age or the flap width had an effect on them. The hypothesis tested in this study was that the severity of OSA associated with pharyngeal flap surgery is greater in children than in adults. SUBJECTS Ten adults, six men and four women, with a mean age of 28.0 years at pharyngeal flap (adult group). Twenty-eight children, 13 boys and 15 girls, with a mean age of 6.3 years at pharyngeal flap (child group). DESIGN A prospective analysis. MAIN OUTCOME MEASURES An overnight polysomnographic study was used to determine the incidence and severity of OSA 6 months after pharyngeal flap. RESULTS The incidence of OSA following pharyngeal flap was high but not significantly different between these two groups (90% in adults and 93% in children, p = 1.000). When OSA was stratified into different levels of severity according to the values of respiratory disturbance index, there were noticeable differences between these two groups (p =.022). In the adult group, eight patients (89%) had mild OSA and 1 patient (11%) had moderate to severe OSA. In the child group, 11 patients (42%) were found to have mild OSA, and 15 patients (58%) had moderate to severe OSA. No relation was found between the flap width and the incidence (p =.435 in adults and.640 in children) or the severity (p =.325 in adults and.310 in children) of OSA in each group. CONCLUSIONS Six months following pharyngeal flap surgery, more than 90% of the patients with cleft palate still had OSA. The severity of OSA associated with pharyngeal flap surgery tended to be greater in children than in adults. The flap width was unrelated to the incidence and severity of OSA, no matter in adults or in children.
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Affiliation(s)
- Yu-Fang Liao
- Department of Orthodontics, Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan
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Sell D, Grunwell P, Mildinhall S, Murphy T, Cornish TA, Bearn D, Shaw WC, Murray JJ, Williams AC, Sandy JR. Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes. Cleft Palate Craniofac J 2001; 38:30-7. [PMID: 11204679 DOI: 10.1597/1545-1569_2001_038_0030_clapci_2.0.co_2] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN Prospective descriptive study on a cross-sectional sample of children. PATIENTS/PARTICIPANTS Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP. MAIN OUTCOMES Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention. CONCLUSIONS Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.
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Affiliation(s)
- D Sell
- Department of Speech and Language Therapy at the Great Ormond Street Hospital for Children, London, England.
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Eichenberg B, Punjabi AP, D'Antonio L. Long term outcome analysis of two treatment methods for cleft palate: combined levator retropositioning and pharyngeal flap versus double-opposing Z-plasty. Cleft Palate Craniofac J 2000; 37:326. [PMID: 10830813 DOI: 10.1597/1545-1569_2000_037_0326_ltte_2.3.co_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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