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Kimia R, Solot CB, McCormack SM, Cohen M, Blum JD, Villavisanis DF, Vora N, Valenzuela Z, Taylor JA, Low DW, Jackson OA. Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients. Cleft Palate Craniofac J 2024; 61:1007-1017. [PMID: 36749038 DOI: 10.1177/10556656231154808] [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] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Rotem Kimia
- Division of Plastic and Reconstructive Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Cynthia B Solot
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marilyn Cohen
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica D Blum
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dillan F Villavisanis
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nisha Vora
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary Valenzuela
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Lentskevich MA, Yau A, Figueroa AE, Termanini KM, Gosain AK. Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis. Cleft Palate Craniofac J 2023:10556656231216834. [PMID: 37993983 DOI: 10.1177/10556656231216834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE Buccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening. DESIGN Three databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed. SETTING Long-term follow up of patients. PATIENTS With history of cleft palate presenting with VPI. INTERVENTION BMF palatal lengthening. MAIN OUTCOME MEASURE Random-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment. RESULTS From the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias. CONCLUSIONS BMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.
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Affiliation(s)
- Marina A Lentskevich
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Alice Yau
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Ariel E Figueroa
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Kareem M Termanini
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Arun K Gosain
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Yang C, Li J, Li H, Chen N, Yin X, Shi B, Li J, Huang H. Inspiration After Posterior Pharyngeal Flap Palatoplasty: A Preliminary Study Using Computational Fluid Dynamic Analysis. Front Pediatr 2022; 10:823777. [PMID: 35592839 PMCID: PMC9111012 DOI: 10.3389/fped.2022.823777] [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: 11/28/2021] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Posterior pharyngeal flap palatoplasty (PPF) is one of the most commonly used surgical procedures to correct speech, especially for patients suffering from velopharyngeal insufficiency (VPI). During PPF, surgeons use the catheter to control the lateral velopharyngeal port on each side. Airway obstruction and sleep apnea are common after PPF. To understand the air dynamics of the upper airway after PPF, we used computational fluid dynamics (CFD) to demonstrate the airflow. In our previous study, we have revealed the expiration process of the upper airway after PPF and shown the features of how PPF successfully restores the oral pressure for speech. In this study, we focus on examining the inspiration process. Normal airway structures were included. For the normal velopharyngeal structure, one cylinder was applied to each model. For recapitulating the velopharyngeal structure after PPF, two cylinders were used in each model. The ports for borderline/inadequate closure, which can help the oral cavity get the required pressure, were chosen for this study. A real-time CFD simulation was used to capture the airflow through the ports. We found that the airflow dynamics of the upper airway's inspiration were dependent on the velopharyngeal structure. Although the airflow patterns were similar, the velocities between one-port and two-port structures were different, which explained why patients after PPF breathed harder than before and suggested that the one-port structure might be a better choice for secondary VPI reconstruction based on the CFD analyses.
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Affiliation(s)
- Chao Yang
- Department of Oral Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jiang Li
- The Third People's Hospital of Chengdu, Clinical College of Southwest Jiaotong University, The Second Affiliated Chengdu Hospital, Chongqing Medical University, Chengdu, China
| | - Huo Li
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory, Sichuan Province Sichuan Academy, Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Nan Chen
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xing Yin
- Department of Orthodontics, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- Department of Oral Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jingtao Li
- Department of Oral Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanyao Huang
- Department of Oral Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Bonanthaya K, Jalil J, Sasikumar AV, Shetty PN. Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes. Cleft Palate Craniofac J 2021; 59:1097-1106. [PMID: 34402312 DOI: 10.1177/10556656211035914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The Furlow palatoplasty is a proven procedure in the management of secondary velopharyngeal dysfunction in patients with cleft palate. But the selection of cases, the degree of clinical success, and the preoperative predictors of the same are less established. This study is an effort to retrospectively look at outcomes, in a large series of velopharyngeal dysfunction cases treated with the Furlow palatoplasty alone. DESIGN Retrospective analysis of preoperative and postoperative speech and videofluoroscopic data. SETTING Tertiary care center. PATIENTS/PARTICIPANTS Ninety-two patients who were diagnosed with velopharyngeal dysfunction post primary cleft palate repair. INTERVENTIONS Furlow palatoplasty for velopharyngeal dysfunction post primary cleft palate repair. MAIN OUTCOME MEASURES Variables analyzed were perceptual speech parameters and, closure ratios obtained from lateral video-fluoroscopic images. RESULTS Overall, 81.5% had postoperative improvements in their lateral video-fluoroscopic parameters, 63% improved their nasality scores, and 65.2% had improved speech intelligibility. A simple linear regression was done to predict the postoperative closure ratio. Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative closure ratio. CONCLUSIONS The Furlow palatoplasty alone led to complete resolution, or significant improvement of velopharyngeal dysfunction in a majority of patients, despite the cohort having a wide range of severity in terms of degree of dysfunction. The predictive formula will be validated in a further study.
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Affiliation(s)
| | - Jazna Jalil
- Bhagwan Mahaveer Jain Hospital, Bengaluru, India
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5
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Carr M, Skarlicki M, Palm S, Bucevska M, Bone J, Gosain AK, Arneja JS. Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence. Cleft Palate Craniofac J 2021; 59:785-793. [PMID: 34137284 PMCID: PMC9121530 DOI: 10.1177/10556656211021738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication. DESIGN Retrospective review. SETTING Tertiary care center. PATIENTS Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded. INTERVENTION Modified pharyngeal flap with through-and-through dissection of the soft palate. MAIN OUTCOME MEASURE(S) Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale. RESULTS The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours. CONCLUSIONS This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.
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Affiliation(s)
- Michael Carr
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Sheryl Palm
- Department of Audiology & Speech, University of British Columbia, Cleft Palate-Craniofacial Clinic, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Marija Bucevska
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Arun K Gosain
- Division of Pediatric Plastic Surgery, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jugpal S Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.,Sauder School of Business, University of British Columbia, Vancouver, BC, Canada
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Airflow of the Two-Port Velopharyngeal Closure: Study Using Computational Fluid Dynamics. J Craniofac Surg 2021; 31:2188-2192. [PMID: 33136852 DOI: 10.1097/scs.0000000000006772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Posterior pharyngeal flap palatoplasty is used to restore the function of velopharyngeal (VP) closure, after which 2 ports remain between the nasal and oral cavity. The authors hypothesized that the airflow dynamics of the upper airway is different in PPF patients compared to health subjects, who only has 1 movable port. Twenty adults who have multislice spiral computed tomography scan were included in this study. Two cylinders (radius, 2.00 mm; height, 4.5 mm) were used to recapitulate the 2-port VP structure after PPF palatoplasty. The areas of ports were modified by changing the radius of 2 cylinders. Real-time computational fluid dynamics simulation was used to capture the airflow velocity and pressures through the 2 ports. The airflow velocity and pressure of upper airway were recorded as the total areas of 2 VP ports increased. The total orifice areas of the 2-port VP closure for 4 VP conditions, including adequate closure, adequate/borderline closure, borderline/inadequate closure, and inadequate closure, were demonstrated. Significant differences between the 2-port VP function for demonstrating PPF reconstruction and the 1-port VP function were found. Airflow dynamics is dependent on the VP structure. The 2-port airflow model for mimicking VP closure after PPF palatoplasty demonstrated airflow characteristics that were significantly different from the 1-port model in normal VP closure.
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Complications and the Need for Long-Term Follow-Up after Secondary Speech Surgery: A National and Longitudinal Claims Analysis. Plast Reconstr Surg 2021; 146:1340-1346. [PMID: 33234965 DOI: 10.1097/prs.0000000000007339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although most patients attain normal speech after cleft palate repair, up to 20 percent require secondary speech surgery. Despite the frequency of these procedures, complications and rates of subsequent revisions of secondary speech surgery after all procedure types have never been reviewed using national, longitudinal data. METHODS The authors examined insurance claims from Clinformatics Data Mart between 2001 and 2017. Cases were categorized as palatalprocedures (i.e., palatoplasty, revision palatoplasty, secondary lengthening, palatal island flap) or pharyngeal procedures (i.e., pharyngeal flap, dynamic sphincter pharyngoplasty) (n = 846). Continuous enrollment from 180 days before to 30 days after surgery was required. Patients were excluded if they underwent palatoplasty, or any surgery at less than 3 years of age, without a speech diagnosis. Outcomes included 30-day complications and rates of subsequent revision secondary speech surgery. Multivariable logistic regression was used to evaluate the relationship between procedure type and complications. RESULTS In this cohort, 52.5 percent underwent pharyngeal procedures, and 47.5 percent underwent palatal procedures. Complications occurred in 10.9 percent of patients and included respiratory complications (4.0 percent), bleeding (1.2 percent), dehiscence (3.6 percent), and critical care episodes (3.0 percent). There was no difference in complications between procedure types (OR, 0.87; 95 percent CI, 0.56 to 1.37; p = 0.56). The subsequent revision rate was 12.7 percent, but was 21.7 percent in patients with 3 years of postoperative enrollment. CONCLUSIONS Although complication rates were comparable to those in recent literature, rates of subsequent revisions of secondary speech procedures were high in patients with longer postoperative enrollment. Thus, these patients merit prolonged follow-up, as velopharyngeal dysfunction may recur over time. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Abstract
PURPOSE OF REVIEW Submucous cleft palate (SMCP) represents an uncommon congenital palatal anomaly with a variable rate of velopharyngeal dysfunction or resulting speech abnormality. Classic teaching regarding management of this entity involves delayed repair until a perceptual speech assessment by a skilled speech-language pathologist can be performed, typically at age 3-5 years. An assessment of timing of intervention, surgical techniques, and patient comorbidities is critical for optimized outcomes. RECENT FINDINGS Early diagnosis and surgical intervention for SMCP are associated with improved speech outcomes. Expanding indications for surgery are being actively investigated. Timing of intervention and surgical technique may be influenced by a syndromic diagnosis, specifically 22q11.2 deletion syndrome. SUMMARY Diagnosis of classic SMCP and occult SMCP may be difficult based on provider experience. Variable surgical techniques may be used with good outcomes; patient comorbidities including syndromic diagnoses may determine best surgical technique. Expanding indications for surgery and timing of repair continue to evolve and warrant additional study.
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de Blacam C, Baylis AL, Kirschner RE, Smith SM, Sell D, Sie KCY, Harris HE, Orr DJA. Protocol for the development of a core outcome set for reporting outcomes of management of velopharyngeal dysfunction. BMJ Open 2020; 10:e036824. [PMID: 32792441 PMCID: PMC7430341 DOI: 10.1136/bmjopen-2020-036824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Velopharyngeal dysfunction (VPD) is present in up to 40% of patients following cleft palate repair. Children with VPD display hypernasal speech, nasal air emission and are at a high risk for developing articulation disorders. The overall result is decreased intelligibility and acceptability of speech, as well as significant functional and social impairments. Although there are several surgical approaches for the management of children with VPD, standard treatment protocols have not been well defined. There is a need for a core outcome set (COS) to reduce outcome reporting bias and heterogeneity across studies of VPD. The COS-VPD Initiative is an international effort to establish a COS for the reporting of studies of the management of VPD. METHODS AND ANALYSIS The study has been developed according to the Core Outcome Set-STAandards for Development standards for the design of a COS study and will be carried out according to the guidance of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. A long list of clinical and patient-reported outcomes will be identified from a systematic review of the literature. A two-stage Delphi consensus process will be used to refine this list into a COS. An international panel of key stakeholders including patients, parents and multidisciplinary clinical and academic experts will be invited to participate in this process. Consensus criteria will be specified a priori and the steering group will ratify the final COS. ETHICS AND DISSEMINATION The study has ethical approval through Children's Health Ireland at Crumlin Research and Ethics Committee, Ref: GEN/683/18. The study is registered with the COMET Initiative (http://www.cometinitiative.org/studies/details/1146?result=true). The COS will be disseminated by publication in the peer-reviewed literature, presentation at international research meetings and distribution to patient-representative organisations. This will facilitate the application of the COS in future studies of the management of VPD.
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Affiliation(s)
- Catherine de Blacam
- Department of Plastic Surgery, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Adriane L Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
- Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Richard E Kirschner
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
- Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Susan M Smith
- Department of General Practice, RCSI, Dublin, Ireland
| | - Debbie Sell
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kathleen C Y Sie
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | | | - David J A Orr
- Department of Plastic Surgery, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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10
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Management of velopharyngeal insufficiency by modified Furlow palatoplasty with pharyngeal flap: a retrospective outcome review. Int J Oral Maxillofac Surg 2019; 48:703-707. [DOI: 10.1016/j.ijom.2019.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 11/25/2018] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
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Jackson O, Crowley TB, Sharkus R, Smith R, Jeong S, Solot C, McDonald-Mcginn D. Palatal evaluation and treatment in 22q11.2 deletion syndrome. Am J Med Genet A 2019; 179:1184-1195. [PMID: 31038278 DOI: 10.1002/ajmg.a.61152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/21/2018] [Accepted: 02/27/2019] [Indexed: 01/23/2023]
Abstract
Palatal involvement occurs commonly in patients with 22q11.2 Deletion Syndrome (22qDS), and includes palatal clefting and velopharyngeal dysfunction in the absence of overt or submucous clefts. The reported incidence and distribution of palatal abnormalities vary in the literature. The aim of this article is to revisit the incidence and presenting features of palatal abnormalities in a large cohort of patients with 22qDS, summarize the surgical treatments performed in this cohort, and provide an overview of surgical treatment protocols and management guidelines for palatal abnormalities in this syndrome. Charts of 1,121 patients seen through the 22q and You Center at the Children's Hospital of Philadelphia were reviewed for palatal status, demographic factors, deletion size, and corrective surgical procedures. Statistical analysis was performed using Pearson's chi-squared test to identify differences between gender, deletion size, and palatal abnormality. Of the patients with complete evaluations, 67% were found to have a palatal abnormality. The most common finding was velopharyngeal dysfunction in 55.2% of patients, and in 33.3% of patients, this occurred in the absence of palatal clefting. There was no significant difference in the incidence of palatal abnormalities by gender; however, a difference was noted among race (p < 0.01) and deletion sizes (p < 0.01). For example, Caucasian and Asian patients presented with a much higher prevalence of palatal abnormalities, and conversely those with nested deletions presented with a much lower rate of palatal defects. Overall, 26.9% of patients underwent palatal surgery, and the most common indication was velopharyngeal dysfunction. Palatal abnormalities are a hallmark feature of 22q11.2 Deletion Syndrome; understanding the incidence, presenting features, and treatment protocols are essential for practitioners counseling and treating families affected with this disorder.
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Affiliation(s)
- Oksana Jackson
- Division of Plastic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Sharkus
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Smith
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Jeong
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Solot
- Department of Speech Language Pathology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna McDonald-Mcginn
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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12
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Huang H, Cheng X, Wang Y, Huang D, Wei Y, Yin H, Shi B, Li J. Analysis of Velopharyngeal Functions Using Computational Fluid Dynamics Simulations. Ann Otol Rhinol Laryngol 2019; 128:742-748. [PMID: 30957524 DOI: 10.1177/0003489419842217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives: Competent velopharyngeal (VP) function is the basis for normal speech. Understanding how VP structure influences the airflow during speech details is essential to the surgical improvement of pharyngoplasty. In this study, we aimed to illuminate the airflow features corresponding to various VP closure states using computed dynamic simulations. Methods: Three-dimensional models of the upper airways were established based on computed tomography of 8 volunteers. The velopharyngeal port was simulated by a cylinder. Computational fluid dynamics simulations were applied to illustrate the correlation between the VP port size and the airflow parameters, including the flow velocity, pressure in the velopharyngeal port, as well as the pressure in oral and nasal cavity. Results: The airflow dynamics at the velopharynx were maintained in the same velopharyngeal pattern as the area of the velopharyngeal port increased from 0 to 25 mm2. A total of 5 airflow patterns with distinct features were captured, corresponding to adequate closure, adequate/borderline closure (Class I and II), borderline/inadequate closure, and inadequate closure. The maximal orifice area that could be tolerated for adequate VP closure was determined to be 2.01 mm2. Conclusion: Different VP functions are of characteristic airflow dynamic features. Computational fluid dynamic simulation is of application potential in individualized VP surgery planning.
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Affiliation(s)
- Hanyao Huang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xu Cheng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yang Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Radiology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Dantong Huang
- Department of Biomedical Engineering, Columbia University, New York, USA
| | - Yuhao Wei
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Heng Yin
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Abstract
Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.
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Mason KN, Riski JE, Perry JL. Changes in the Height of Velopharyngeal Closure Relative to the Cervical Spine From Infancy Through Adolescence in Patients With Cleft Palate. Cleft Palate Craniofac J 2018; 55:508-516. [PMID: 29554448 DOI: 10.1177/1055665617732784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Palpation is often used to identify C1, an intraoperative landmark, for placement of the pharyngoplasty. However, little is known about the relationship between the palatal plane (PP) and this cervical spine landmark across select variables. This study seeks to analyze variations in the height of velopharyngeal closure relative to C1 across differing cleft types and age groups. DESIGN Retrospective, cross-sectional analysis. SETTING Large, multidisciplinary center for craniofacial disorders. METHODS Clinical lateral cephalograms were analyzed in nonsyndromic patients who underwent primary palatoplasty. Regression analysis and analysis of covariance were completed to determine how age and cleft type impact underlying cervical and velopharyngeal measures. RESULTS Age ( P < .001) and cleft type ( P = .036) were significant predictors of the distance between the height of velopharyngeal closure and C1. Those with greater severity of clefting demonstrated larger distances between the height of velopharyngeal closure and C1. Compared to normative data, children with cleft palate have significantly larger distances between the PP and C1. The height of velopharyngeal closure above C1 was observed to range from 3.6 to 12.6 mm across cleft populations. CONCLUSIONS This study demonstrates the variability in C1 as a landmark across variables including cleft type and age. Because of differences in the height of velopharyngeal closure across cleft types relative to C1, it is necessary to preoperatively quantify the vertical distance between the PP and palpable intraoperative landmark, C1, to determine the appropriate height of pharyngoplasty insertion.
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Affiliation(s)
- Kazlin N Mason
- 1 Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA.,2 Center for Craniofacial Disorders, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - John E Riski
- 2 Center for Craniofacial Disorders, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jamie L Perry
- 1 Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
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Humanitarian Activities of Interplast Turkiye: 6 Years of Experience in Uzbekistan for Surgical Treatment of Cleft Patients and Related Secondary Deformities. Ann Plast Surg 2018; 77:494-498. [PMID: 27070687 DOI: 10.1097/sap.0000000000000821] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cleft lip and palate (CL/P) is one of the leading congenital deformities among the world. Children born with CL/P experience problems with feeding, speech, hearing, and dentition. In developed countries, CL/P patients are receiving optimal health care involving multidisciplinary team approach and staged surgical operations, whereas in developing countries, there is severe shortage of both medical and financial sources. To overcome these limitations, humanitarian surgical missions are essential. The aim of this article is to share our experience of humanitarian surgical mission in Uzbekistan consisting of 6 consecutive visits between 2009 and 2014. The series of these humanitarian activities consisting of 6 consecutive visits was organized by the cooperation of Interplast Turkiye and governmental Turkish Coordination and Cooperation Agency. After initial evaluation, triage at the initial setting and prompt anesthesia evaluation among many more of them, 529 patients mostly with cleft, craniofacial, or congenital deformities were operated. The success of this type of mission is not solely based on the expertise of the team members, but also meticulous planning, patient selection, good coordination with the local colleagues and communication. At this point, caregivers attending from a culturally close and similar language-spoken countries will certainly have more advantages in achieving a mission. Volunteer surgical missions for congenital deformities can be an important relief for this burden in developing countries. Nevertheless, training the native surgeons and supporting the plastic surgery foundations in these countries are as important as providing the necessary health care by such humanitarian missions.
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Hill C, Hayden C, Riaz M, Leonard AG. Buccinator Sandwich Pushback: A New Technique for Treatment of Secondary Velopharyngeal Incompetence. Cleft Palate Craniofac J 2017; 41:230-7. [PMID: 15151445 DOI: 10.1597/02-146.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. Patients In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. Design The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. Results Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. Conclusion The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.
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Affiliation(s)
- C Hill
- Northern Ireland Plastic and Maxillofacial Service, The Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland.
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17
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Abyholm F, D'Antonio L, Davidson Ward SL, Kjøll L, Saeed M, Shaw W, Sloan G, Whitby D, Worhington H, Wyatt R. Pharyngeal Flap and Sphincterplasty for Velopharyngeal Insufficiency Have Equal Outcome at 1 Year Postoperatively: Results of a Randomized Trial. Cleft Palate Craniofac J 2017; 42:501-11. [PMID: 16149831 DOI: 10.1597/03-148.1] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of this trial was to compare the relative effectiveness (efficacy and morbidity) of two surgical procedures for correcting velopharyngeal insufficiency (VPI). Design This was an international multicenter randomized trial to study the outcome of two surgical procedures (flap and sphincter pharyngoplasty) for speech, incidence of sleep apnea, and surgical complications. Method Ninety-seven patients 3 to 25 years old with repaired cleft palate and previously identified VPI were enrolled from five centers in the United States, Norway, and the U.K. Data were collected at presurgery, 3 months postsurgery, and 12 months postsurgery for subsequent analysis blind to the procedure. Main outcome measures included perceptual speech parameters, sleep apnea, nasalance measures, endoscopic features, and surgical complications. Results Groups for both surgical procedures achieved a high level of clinical improvement. At 3 months postsurgery, elimination of hypernasal resonance was achieved in twice as many patients after the flap procedure. This reached significance. However, at 12 months postsurgery, no statistically significant difference in outcomes remained between the two procedures for resonance, nasalance, endoscopic outcomes, or surgical complications. Flap and sphincter pharyngoplasty rarely resulted in clinically significant sleep apnea, and no difference was detected between the two procedures in the long-term incidence of sleep apnea. Conclusions Despite strongly held views in the literature concerning the relative effectiveness and safety of flap and sphincter pharyngoplasty, no significant differences were detected 1 year postoperatively.
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Nakamura N, Ogata Y, Kunimitsu K, Suzuki A, Sasaguri M, Ohishi M. Velopharyngeal Morphology of Patients with Persistent Velopharyngeal Incompetence following Repushback Surgery for Cleft Palate. Cleft Palate Craniofac J 2017; 40:612-7. [PMID: 14577815 DOI: 10.1597/1545-1569_2003_040_0612_vmopwp_2.0.co_2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To characterize the velopharyngeal morphology of patients with persistent velopharyngeal incompetence (VPI) following repushback surgery for cleft palate. Participants Seven patients with moderate to severe VPI following repushback surgery for secondary correction of cleft palate, and 14 patients who had already obtained complete velopharyngeal closure function (VPF) were enrolled. Control data were obtained from the longitudinal files of 20 normal children in Kyushu University Dental Hospital. Main Outcome Measures Skeletal landmarks and measurements were derived from tracing of lateral roentgenographic cephalograms. The measurements included velar length, pharyngeal depth, and pharyngeal height and the ratio of velar length to pharyngeal depth. Additionally, the configuration of the upper pharynx (pharyngeal triangle) involving the cranial base, cervical vertebrae, and the posterior maxilla and also the position of posterior pharyngeal wall (PPW) in the pharyngeal triangle were analyzed. Results The VPI group had a significantly shorter velar length and greater pharyngeal depth, resulting in a smaller length/depth ratio than the controls. The points of PPW and cervical vertebrae of the VPI group were located more posteriorly and inferiorly than those in the group with complete VPF after the primary operation and the controls. The positions of cranial base and maxilla were not significantly different. Additionally, the position of PPW in the pharyngeal triangle was located significantly posteriorly and superiorly in the VPI group, compared with the controls. Conclusions The craniopharyngeal morphology of patients with persistent VPI was characterized by a short palate, wide-based and counterclockwise-rotated pharyngeal triangle, and posteriorly and superiorly positioned PPW. These might be contributory factors for the prediction of VPF before repushback surgery for cleft palate.
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Affiliation(s)
- Norifumi Nakamura
- Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Higashi-ku, Fukuoka, Japan.
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19
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de Blacam C, Smith S, Orr D. Surgery for Velopharyngeal Dysfunction. Cleft Palate Craniofac J 2017; 55:405-422. [DOI: 10.1177/1055665617735102] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: This systematic review sought to evaluate the consensus in the literature regarding the surgical management of VPD and to determine whether a particular procedure results in superior speech outcome or less morbidity Design: A systematic review was carried out according to PRISMA-P guidelines. Systematic review software was used to facilitate 3-stage screening and data extraction by 2 reviewers. Setting: University teaching hospital. Patients, Participants: Studies that reported perceptual speech assessment or obstructive sleep apnea (OSA) in patients who had undergone surgery for VPD were included in the review. Interventions: Four categories of surgery for VPD were examined—pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior pharyngeal wall augmentation. Main outcome measures: Perceptual speech assessment, need for further surgery, and occurrence of OSA were the outcomes of interest. Results: Eighty-three relevant studies were identified, comprising data on 4011 patients. Pharyngeal flap was the most common procedure (64% of patients). Overall, 70.7% of patients attained normal resonance and 65.3% attained normal nasal emission. There was no notable difference in speech outcomes, need for further surgery, or occurrence of OSA across the 4 categories of surgery examined. Heterogeneous groups of patients were reported upon and a variety of perceptual speech assessment scales were used. Conclusions: There is a lack of consensus in the literature to guide procedure selection for patients with VPD. The development of a standardized minimum data set to record postoperative speech, OSA, and patient-reported outcomes is required.
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Affiliation(s)
- Catherine de Blacam
- Department of Plastic and Reconstructive Surgery, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland
| | - Susan Smith
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Orr
- Departments of Surgery and Paediatrics, Trinity College Dublin, Dublin, Ireland
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Rogers C, Konofaos P, Wallace RD. Superiorly Based Pharyngeal Flap for the Surgical Treatment of Velopharyngeal Insufficiency and Speech Outcomes. J Craniofac Surg 2017; 27:1746-1749. [PMID: 27763974 DOI: 10.1097/scs.0000000000003050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A retrospective chart review comparing pre and postoperative speech in 19 patients who underwent pharyngeal flap surgery for the diagnosis of velopharyngeal insufficiency. Eighteen of the patients had a history of cleft palate. Patients were assigned a speech grade between 1 and 5 based on the objective and subjective quality of their speech. Comparison of pre and postoperative speech showed significant improvement in speech quality from a mean grade of 3.37 to 2.00 (P < 0.001). This study demonstrates that a wide, superiorly based pharyngeal flap did lead to significant improvement in speech outcomes in this group of patients independent of gender or age.
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Affiliation(s)
- Cori Rogers
- Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, TN
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21
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Modified Superior-Based Pharyngeal Flap Is Effective in Treatment of Velopharyngeal Insufficiency Regardless of the Preoperative Closure Pattern. J Craniofac Surg 2017; 28:413-417. [DOI: 10.1097/scs.0000000000003328] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Repeat Double-Opposing Z-Plasty for the Management of Persistent Velopharyngeal Insufficiency. Ann Plast Surg 2016; 77:626-629. [DOI: 10.1097/sap.0000000000000744] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Sweeney WM, Lanier ST, Purnell CA, Gosain AK. Genetics of Cleft Palate and Velopharyngeal Insufficiency. J Pediatr Genet 2016; 4:9-16. [PMID: 27617110 DOI: 10.1055/s-0035-1554978] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Velopharyngeal insufficiency (VPI) can occur in the setting of an unrepaired or repaired cleft lip and palate. The rate of VPI has been documented as high as 33% in some studies with higher rates of recurrences following surgery associated with genetic syndromes such as 22q11.2 deletions. The primary cause of VPI in these groups is still identified as the anatomic abnormalities of the velum. In this review, the anatomy and physiology of the velum are discussed along with genetic mutations associated with VPI.
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Affiliation(s)
- Walter M Sweeney
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Northwestern University, Chicago, Illinois, United States
| | - Steve T Lanier
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Northwestern University, Chicago, Illinois, United States
| | - Chad A Purnell
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Northwestern University, Chicago, Illinois, United States
| | - Arun K Gosain
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Northwestern University, Chicago, Illinois, United States
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25
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Campos LD, Trindade-Suedam IK, Martins Sampaio-Teixeira AC, Yamashita RP, Pereira Lauris JR, Lorenzi-Filho G, Kiemle Trindade IE. Obstructive Sleep Apnea following Pharyngeal Flap Surgery for Velopharyngeal Insufficiency: A Prospective Polysomnographic and Aerodynamic Study in Middle-Aged Adults. Cleft Palate Craniofac J 2016; 53:e53-9. [DOI: 10.1597/14-152] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To compare the frequency and severity of obstructive sleep apnea (OSA) in middle-aged adults who underwent pharyngeal flap surgery for velopharyngeal insufficiency (VPI) with matched subjects who did not undergo pharyngeal flap surgery and to verify the relationship between OSA severity and internal pharyngeal dimensions. Setting National referral care center for cleft lip and palate. Method Prospective study on 42 nonsyndromic subjects with repaired cleft palate with flap (F group, n = 22) and without flap (NF group, n = 20), aged 40 to 58 years. The main outcome measure was the apnea-hypopnea index (AHI), measured by in-lab nocturnal polysomnography (PSG). The OSA-related symptoms were investigated by Pittsburgh, Epworth, and Berlin questionnaires. The nasopharyngeal or velopharyngeal (NP/VP) cross-sectional area was measured by modified anterior rhinomanometry in subgroups of the F (n = 14) and NF (n = 10) groups at rest and during speech. Differences were considered significant at P < .05. Results Questionnaire scores and frequency of self-reported symptoms of snoring, nasal obstruction, and breathing interruptions during sleep did not differ between groups. OSA was diagnosed by PSG in 60% and 77% of the NF and F subjects, respectively. The difference was not significant. No cases of severe OSA were observed. There was no correlation between AHI and NP/VP area. Conclusion A significant number of middle-aged adults with repaired cleft palate had OSA and related symptoms, regardless of the presence of a pharyngeal flap. Results suggest that VPI treatment with a flap may not cause sleep-disordered breathing in the cleft population. Besides advancing age, congenital upper airway abnormalities may be involved.
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Affiliation(s)
| | - Ivy Kiemle Trindade-Suedam
- Department of Biological Sciences, Bauru School of Dentistry and Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo
| | | | - Renata Paciello Yamashita
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo
| | - José Roberto Pereira Lauris
- Department of Dental Pediatrics, Orthodontics, and Collective Health, Bauru School of Dentistry, University of Sao Paulo
| | - Geraldo Lorenzi-Filho
- Pulmonary Division, Heart Institute (InCor), School of Medicine, University of Sao Paulo
| | - Inge Elly Kiemle Trindade
- Department of Biological Sciences, Bauru School of Dentistry and Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo
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Mason KN, Perry JL, Riski JE, Fang X. Age-Related Changes Between the Level of Velopharyngeal Closure and the Cervical Spine. J Craniofac Surg 2016; 27:498-503. [PMID: 26963301 PMCID: PMC4788047 DOI: 10.1097/scs.0000000000002403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The primary focus of this study was to assess age-related changes in the vertical distance of the estimated level of velopharyngeal closure in relation to a prominent landmark of the cervical spine: the anterior tubercle of cervical vertebra 1 (C1). Midsagittal anatomic magnetic resonance images were examined across 51 participants with normal head and neck anatomy between 4 and 17 years of age. Results indicate that age is a strong predictor (P = 0.002) of the vertical distance between the level of velopharyngeal closure relative to C1. Specifically, as age increases, the vertical distance between the palatal plane and C1 becomes greater resulting in the level of velopharyngeal closure being located higher above C1 (range 4.88-10.55 mm). Results of this study provide insights into the clinical usefulness of using C1 as a surgical landmark for placement of pharyngoplasties in children with repaired cleft palate and persistent hypernasal speech. Clinical implications and future directions are discussed.
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Affiliation(s)
- Kazlin N Mason
- *East Carolina University, Greenville, NC; Children's Healthcare of Atlanta, Atlanta, GA †East Carolina University ‡Children's Healthcare of Atlanta, Atlanta, GA
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27
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Bennett KG, Robinson AB, Kasten SJ, Buchman SR, Vercler CJ. Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns. Cleft Palate Craniofac J 2016; 54:13-18. [PMID: 26752134 DOI: 10.1597/15-250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD). DESIGN A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice. MAIN OUTCOME MEASURES We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD. RESULTS A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038). CONCLUSIONS Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.
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Lateralization of the Pharyngeal Flap for Treatment of Lateral Velopharyngeal Gap. J Craniofac Surg 2016; 27:101-4. [PMID: 26745192 DOI: 10.1097/scs.0000000000002274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pharyngeal flap is usually used for treatment of velopharyngeal insufficiency (VPI); it is bridged between the posterior pharyngeal wall and the soft palate traversing the central part of the velopharyngeal port. The aim of this study was to assess the efficacy of lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap. Fifteen patients with VPI due to lateral velopharyngeal gap were subjected to closure of the gap by pharyngeal flap that was lateralized to fill the gap. Preoperative and postoperative assessment of velopharyngeal functions including flexible nasopharyngoscopy, auditory perceptual assessment (APA), and nasometric assessment were performed. Postoperatively, flexible nasopharyngoscopy showed complete velopharyngeal closure in all the patients, with significant improvement of speech parameters as measured by APA. Also, nasalance score showed significant improvement for oral and nasal sentences that was measured by nasometry. Lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap is an effective method; it improves the velopharyngeal closure and the speech of the patients.
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Chim H, Eshraghi Y, Iamphongsai S, Gosain AK. Double-Opposing Z-Palatoplasty for Secondary Surgical Management of Velopharyngeal Incompetence in the Absence of a Primary Furlow Palatoplasty. Cleft Palate Craniofac J 2015; 52:517-24. [DOI: 10.1597/13-187] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Harvey Chim
- Department of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Yashar Eshraghi
- Department of Surgery, University Hospitals Case School of Medicine, Cleveland, Ohio
| | - Seree Iamphongsai
- Division of Plastic and Reconstructive Surgery, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Arun K. Gosain
- Division of Pediatric Plastic Surgery, Lurie Children's Hospital of Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ezzat AEM, Khalifa RA, Akel MM, El-Shenawy HM. Functional and speech outcomes of superiorly based flap pharyngoplasty combined with radical intravelar veloplasty. JOURNAL OF CLEFT LIP PALATE AND CRANIOFACIAL ANOMALIES 2015; 2:41-48. [PMID: 26005709 DOI: 10.4103/2348-2125.150746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate functional and speech outcomes of superiorly based pharyngeal flap (SBF) pharyngoplasty combined with radical intravelar veloplasty (RIVVP) for the management of velopharyngeal insufficiency (VPI) following surgically repaired cleft palate. DESIGN A case series with chart review. The study was conducted in academic tertiary care medical centre. PATIENTS AND METHODS Fifteen patients with VPIs following surgically repaired cleft palate were managed between May 2011 and August 2014, with SBF pharyngoplasty combined with RIVVP. RESULTS We found that the speech defects improved by a success rate of 93.4%; the VP function became normal (circular pattern of closure) in 80% of patients and the postoperative overall success rate of VP competence grades was 93.4%. Moreover, we found that the overall incidence of complications were 33.3%. CONCLUSION By doing SBF pharyngoplasty combined with RIVVP the surgical procedure was satisfactory in both functional and speech outcomes.
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Affiliation(s)
- Abdelrahman E M Ezzat
- Department of ENT, Phonatric unite of ENT department, Faculty of Medicine, Al-Azhar University, Cairo
| | - Rana A Khalifa
- Department of ENT, Phonatric unite of ENT department, Faculty of Medicine, Al-Azhar University, Cairo
| | - Mabrouk M Akel
- Department of Pediatric Surgery, Faculty of Medicine, Al-Azhar University, Cairo
| | - Hanna M El-Shenawy
- Department of Oral Surgery and Medicine, National Research Center, Dokki, Giza, Egypt
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31
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El-Anwar MW, Amer HS, Elnashar I, Khazbak AO, Khater A. Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function. Laryngoscope 2014; 125:1729-32. [PMID: 25545913 DOI: 10.1002/lary.25106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/03/2014] [Accepted: 12/01/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function. METHODS This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation. RESULTS All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001). CONCLUSION ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.
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Affiliation(s)
- Mohammad Waheed El-Anwar
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hazem Saeed Amer
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ismail Elnashar
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Alaa Omar Khazbak
- Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Khater
- Audiology Unit, Otolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Madrid JRP, Ortega VG, Echeverri P, Velasquez NL. Prevalence of Obstructive Sleep Apnea After Orticochea Pharyngoplasty for Velopharyngeal Insufficiency Management. Cleft Palate Craniofac J 2013; 52:682-7. [PMID: 23952561 DOI: 10.1597/12-049] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study is to describe the prevalence of obstructive sleep apnea (OSA) and its level of severity associated with Orticochea pharyngoplasty in patients with velopharyngeal insufficiency after at least 1 year of the surgical procedure. DESIGN Case series prospective descriptive study. MAIN OUTCOME MEASURES At FISULAB, a rehabilitation center for patients with cleft palate, we studied 37 patients who were treated elsewhere with Orticochea pharyngoplasty for velopharyngeal insufficiency; these patients may or may not have had clinical symptoms related to OSA. All participants underwent a polysomnography sleep study, which was also done in different institutions. We applied the Epworth Sleepiness Scales during the clinical investigation because it is an effective instrument used to measure average daytime sleepiness. Another questionnaire to identify cases of OSA was used. Among other variables studied, the apnea/hypopnea index was the main outcome, while age and type of cleft were secondary variables. RESULTS From 37 patients who were studied (100%), we obtained the following results: normal apnea/hypopnea index: seven patients (18.9%); mild apnea/hypopnea index: 14 patients (37.8%); moderate apnea/hypopnea index: eight patients (21.6%); and severe apnea/hypopnea index: eight patients (21.6%). CONCLUSIONS In this study, we found that more than three quarters (81%) of the patients who were treated for velopharyngeal insufficiency with Orticochea pharyngoplasty presented obstructive sleep apnea when analyzing the apnea/hypopnea index in the polysomnography sleep study.
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Management of velopharyngeal insufficiency using double opposing z-plasty in patients undergoing primary two-flap palatoplasty. Arch Plast Surg 2013; 40:97-103. [PMID: 23533153 PMCID: PMC3605568 DOI: 10.5999/aps.2013.40.2.97] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/09/2013] [Accepted: 01/15/2013] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) may persist after primary repair of the cleft palate, and surgical correction is necessary in many cases. The purpose of this study is to evaluate the effect of double opposing Z-plasty (DOZ) in cleft palate patients suffering from VPI after primary two-flap palatoplasty. METHODS Between March 1999 and August 2005, we identified 82 patients who underwent two-flap palatoplasty for cleft palate repair. After excluding the patients with congenital syndrome and mental retardation, 13 patients were included in the final study group. The average age of the patients who underwent DOZ at was 5 years and 1 month. Resonance, nasal emission, and articulation were evaluated by a speech pathologist. The velopharyngeal gaps were measured before and after surgery. RESULTS Six patients attained normal speech capabilities after DOZ. The hypernasality grade was significantly improved after surgery in all of the patients (P=0.0015). Whereas nasal emission disappeared in 8 patients (61.5%), it was diminished but still persisted in the remaining 5 patients. Articulation was improved in all of the cases. In two cases, the velopharyngeal gap was measured using a ruler. The gap decreased from 11.5 to 7 mm in one case, and from 12.5 to 8 mm in the second case. CONCLUSIONS The use of DOZ as a surgical option to correct VPI has many advantages compared with other procedures. These include short surgery time, few troublesome complications, and no harmful effects on the dynamic physiological functioning of the pharynx. This study shows that DOZ can be another option for surgical treatment of patients with VPI after two-flap palatoplasty.
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Mehendale FV, Lane R, Laverty A, Dinwiddie R, Sommerlad BC. Effect of palate re-repairs and hynes pharyngoplasties on pediatric airways: an analysis of preoperative and postoperative cardiorespiratory sleep studies. Cleft Palate Craniofac J 2012; 50:257-67. [PMID: 22551554 DOI: 10.1597/11-198] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES : To determine whether Sommerlad palate re-repairs and Hynes pharyngoplasties cause obstructive sleep apnea/hypopnea or increased upper airway resistance. DESIGN : Prospective before-and-after study. SETTING : Tertiary cleft unit. PATIENTS : A total of 44 patients undergoing a Sommerlad palate re-repair or a Hynes pharyngoplasty. Interventions : Preoperative and postoperative multichannel cardiorespiratory sleep studies. MAIN OUTCOME MEASURES : The main outcome measures were mean arterial oxygen saturation, desaturation index, percentage of time spent with arterial oxygen saturation <90%, mean pulse rate, number of pulse rate rises (arousals) per hour, inspiratory effort derived from pulse transit time, pulse transit time arousals, and snoring. RESULTS : No patient in either group required intervention for airway obstruction or obstructive sleep apnea/hypopnea. Re-repairs caused no significant change in any parameter. Hynes caused an increase in inspiratory effort (P = .04) and obstructive sleep apnea/hypopnea grading (P = .002). All other parameters showed no significant deterioration. No patient developed more than mild/moderate obstructive sleep apnea/hypopnea. Snoring and arterial oxygen saturation levels were not reliable indicators of increased inspiratory effort. CONCLUSIONS : A palate re-repair had no significant adverse effect on the airway. A Hynes, in patients with optimized velar function, caused a significant increase in inspiratory effort and obstructive sleep apnea/hypopnea grade. However, compared with studies on midline flaps and on sphincter pharyngoplasties, a Hynes appears to be less obstructive. Failure to study changes in inspiratory effort in patients undergoing velopharyngeal incompetence surgery may underestimate the obstructive effect of pharyngoplasties.
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Affiliation(s)
- Felicity V Mehendale
- Cleft Lip and Palate Service, East of Scotland, Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK.
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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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Sullivan SR, Vasudavan S, Marrinan EM, Mulliken JB. Submucous Cleft Palate and Velopharyngeal Insufficiency: Comparison of Speech Outcomes Using Three Operative Techniques by One Surgeon. Cleft Palate Craniofac J 2011; 48:561-70. [DOI: 10.1597/09-127] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Our purpose was to compare speech outcomes among three primary procedures for symptomatic submucous cleft palate (SMCP): two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. Design Retrospective review. Setting Tertiary hospital. Patients, Participants All children with SMCP treated by the senior author between 1984 and 2008. Interventions One of three primary procedures: two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. Main outcome Measures Speech outcome and need for a secondary operation were analyzed among procedures. Success was defined as normal or borderline competent velopharyngeal function. Failure was defined as persistent borderline insufficiency or velopharyngeal insufficiency with recommendation for a secondary operation. Results We identified 58 patients with SMCP who were treated for velopharyngeal insufficiency. We found significant differences in median age at operation among the procedures ( p < .001). Two-flap palatoplasty with muscular retropositioning (n = 24), double-opposing Z-palatoplasty (n = 19), and pharyngeal flap (n = 15) were performed at a median of 2.5, 3.6, and 9.5 years, respectively. There were significant differences in success among procedures (p = .018). Normal or borderline competent function was achieved in 6/20 (30%) patients who underwent two-flap palatoplasty, 10/15 (67%) following double-opposing Z-palatoplasty, and 11/12 (92%) following pharyngeal flap. Among patients treated with palatoplasty, success was independent of age at operation (p = .16). Conclusions Double-opposing Z-palatoplasty is more effective than two-flap palatoplasty with muscular retropositioning. For children older than 4 years, primary pharyngeal flap is also highly successful but equally so as a secondary operation and can be reserved, if necessary, following double-opposing Z-palatoplasty.
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Affiliation(s)
- Stephen R. Sullivan
- Pediatric and Craniomaxillofacial Surgery, Harvard Medical School, Department of Plastic and Oral Surgery, Children's Hospital, Boston, Massachusetts, Warren Alpert Medical School of Brown University and Rhode Island and Hasbro Children's Hospital, Providence, Rhode Island
| | - Sivabalan Vasudavan
- Craniofacial and Cleft Lip/Palate Orthodontics, Department of Dentistry, Children's Hospital Boston, Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Eileen M. Marrinan
- Central New York Cleft and Craniofacial Center, State University of New York, Upstate Medical University Hospital, Syracuse, New York
| | - John B. Mulliken
- Harvard Medical School, Department of Plastic and Oral Surgery, Children's Hospital, Boston, Massachusetts
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Teixeira RP, Reid JA, Greensmith A. Fatty Hypertrophy Cause Obstructive Sleep Apnea after Fat Injection for Velopharyngeal Incompetence. Cleft Palate Craniofac J 2011; 48:473-7. [DOI: 10.1597/09-024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Intervention Soft tissue augmentation of the posterior pharyngeal wall and the soft palate is reported to reduce velopharyngeal incompetence, and fat grafting in selected patients has shown effective and lasting results for restoring normal resonance. Potential complications of soft tissue augmentation for velopharyngeal incompetence include obstructive sleep apnea. Patient An 8-year-old boy with velopharyngeal incompetence and a small velopharyngeal gap underwent a fat injection procedure and subsequently developed obstructive sleep apnea concomitant with a significant weight gain. Videofluoroscopy and nasendoscopy showed a remarkable enlargement of the grafted fat areas that required a soft palate debulking procedure, significantly improving obstructive sleep apnea. Conclusion This is an unusual case where alteration in volume of grafted fat at the recipient site is suspected of causing obstructive sleep apnea. It is also an example of long-term fat graft survival and fat graft overgrowth.
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Affiliation(s)
- Rodrigo P. Teixeira
- Department of Plastic and Maxillofacial Surgery The Royal Children's Hospital, Melbourne, Australia
| | - Julie A. Reid
- Department The Royal Children's Hospital, Melbourne, Australia
| | - Andrew Greensmith
- Department of Plastic and Maxillofacial Surgery The Royal Children's Hospital, Melbourne, Australia
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Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern. J Craniofac Surg 2011; 22:813-7. [PMID: 21558943 DOI: 10.1097/scs.0b013e31820f3691] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern.This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed.There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea.Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.
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An Algorithm for Application of Furlow Palatoplasty to the Treatment of Velocardiofacial Syndrome–Associated Velopharyngeal Insufficiency. Ann Plast Surg 2011; 66:479-84. [DOI: 10.1097/sap.0b013e3182185ccb] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Atrophy among mucosa-only versus muscular mucosa superiorly based pharyngeal flaps: a pilot animal study. Plast Reconstr Surg 2010; 125:1679-1684. [PMID: 20517091 DOI: 10.1097/prs.0b013e3181d4fdff] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Velopharyngeal insufficiency is frequently managed surgically via the superiorly based pharyngeal flap procedure. The flap used in this procedure traditionally consists of both mucosa and muscle. Although muscle is included to potentially increase survival and tissue bulk, its inclusion may result in postoperative dysfunction of pharyngeal sidewall motion. Although the benefits of pharyngeal flap surgery are established, the denervated muscular portion of the flap appears to atrophy. The purpose of this study was to evaluate whether a flap consisting entirely of mucosa provides the same tissue bulk as a conventional pharyngeal flap 12 weeks postoperatively. METHODS Ten laboratory-grade cats served as direct patient surrogates. Cats were randomized to undergo a superiorly based pharyngeal flap procedure with flaps composed of either both muscle and mucosa (n = 5) or mucosa only (n = 5). Blinded volumetric analysis was performed by three board-certified neuroradiologists using magnetic resonance imaging of the pharynx immediately after surgery and at 4, 8, and 12 weeks. RESULTS At 12 weeks postoperatively, pharyngeal flaps composed of both mucosa and muscle atrophied to reach volumetric equivalence with mucosa-only flaps. Evaluation of final pharyngeal flap volume demonstrated no statistical differences between the two groups. CONCLUSIONS This study demonstrates equivalent final superiorly based pharyngeal flap tissue bulk for flaps composed of only mucosa when compared with conventional pharyngeal flaps. Thus, the mucosa-only pharyngeal flap may yield similar outcomes while potentially providing for an earlier return of normal pharyngeal function.
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Pharyngeal Flap Outcomes in Nonsyndromic Children with Repaired Cleft Palate and Velopharyngeal Insufficiency. Plast Reconstr Surg 2010; 125:290-298. [DOI: 10.1097/prs.0b013e3181c2a6c1] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yamashita RP, Trindade IEK. Long-term effects of pharyngeal flaps on the upper airways of subjects with velopharyngeal insufficiency. Cleft Palate Craniofac J 2008; 45:364-70. [PMID: 18616365 DOI: 10.1597/07-031.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To investigate the long-term effects of pharyngeal flap surgery (PFS) on nasal and nasopharyngeal dimensions of patients with velopharyngeal insufficiency (VPI) and to correlate the findings with the onset of respiratory complaints after surgery. DESIGN/PARTICIPANTS Prospective study in 58 nonsyndromic patients with repaired cleft palate and VPI, evaluated 2 days before and 5 months (POST1) and 1 year (POST2) after PFS, on average. Patients were divided into two groups: one consisting of patients with postoperative respiratory complaints (RC group) and the other without complaints (NRC group). INTERVENTIONS Superiorly based PFS. MAIN OUTCOME MEASURES Respiratory complaints (self reports of mouth breathing, snoring, and other sleep obstructive events) assessed at POST1 and POST2, and minimum nasal (NCSA) and nasopharyngeal (NPA) cross-sectional areas assessed by rhinomanometry at POST2. RESULTS Respiratory complaints were reported by 55% and 36% of the patients evaluated at POST1 and POST2, respectively. Posterior rhinomanometry showed a significant postoperative reduction of mean NCSA in the RC and NRC groups (p < .05), to subnormal levels in some of them. The decrease was more pronounced in the RC group. No significant changes in NCSA were observed by anterior rhinomanometry. Similar results were obtained when NPA was assessed by modified anterior rhinomanometry. CONCLUSION In the long-term, PFS yielded a significant reduction in upper airways dimensions beyond what should be expected and associated with persistent respiratory complaints in some cases.
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Affiliation(s)
- Renata Paciello Yamashita
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil.
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Complete soft palate necrosis and velopharyngeal insufficiency resulting from intranasal inhalation of prescription narcotics and cocaine. J Craniofac Surg 2008; 18:1482-5. [PMID: 17993909 DOI: 10.1097/scs.0b013e318068febc] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Lam E, Hundert S, Wilkes GH. Lateral Pharyngeal Wall and Velar Movement and Tailoring Velopharyngeal Surgery: Determinants of Velopharyngeal Incompetence Resolution in Patients with Cleft Palate. Plast Reconstr Surg 2007; 120:495-505. [PMID: 17632355 DOI: 10.1097/01.prs.0000267438.18295.e4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After primary palatoplasty, patients with cleft palate may still require secondary surgical procedures to correct residual velopharyngeal incompetence. This study evaluated speech outcomes of patients who underwent differential velopharyngeal surgery based on degree of lateral pharyngeal wall movement and velar movement. METHODS In this retrospective cohort study, 31 patients with cleft palate from 1992 to 2003 underwent tailor-made velopharyngeal surgery with complete preoperative and postoperative speech assessments. All patients were evaluated postoperatively for velopharyngeal incompetence resolution, persistent velopharyngeal incompetence, and hyponasality. RESULTS Velopharyngeal incompetence was resolved in 90 percent of patients. Severe hyponasality occurred as a complication in 16 percent, requiring subsequent division of the pharyngeal flap. Patients with lateral pharyngeal wall movement greater than 25 percent had a significantly greater chance of incompetence resolution compared with those with lateral pharyngeal wall movement less than 25 percent (p < 0.001). Regarding combined lateral pharyngeal wall movement plus velar movement, all groups showed significantly lower velopharyngeal competence scores following surgery (p < 0.001). Patients with lateral pharyngeal wall movement less than 25 percent and velar movement greater than 50 percent had the least successful speech outcome. The data also showed that various types of surgical operations performed on patients with similar combined degrees of lateral pharyngeal wall movement and velar movement can result in equally successful speech outcomes. This finding indicated flexibility in following the treatment algorithm for tailoring velopharyngeal surgery. CONCLUSION The degree of lateral pharyngeal wall movement and velar movement, rather than type of surgical procedure chosen, is a more important determinant of velopharyngeal incompetence resolution in patients with cleft palate.
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Affiliation(s)
- Eugene Lam
- Edmonton, Alberta, Canada From the Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, and Department of Speech Pathology and Audiology, Stollery Children's Hospital, University of Alberta, WC Mackenzie Health Science Center
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Abstract
OBJECTIVE To assess speech results and rate of obstructive sleep apnea using a modified, superiorly based pharyngeal flap performed after staged adenotonsillectomy in a group with velopharyngeal insufficiency. METHODS In this nonrandomized, retrospective case series (July 1, 1996, through June 30, 2003), patients were mainly children referred to a multispecialty craniofacial clinic. Patients underwent staged adenotonsillectomy 2 months before width-customized pharyngeal flap surgery. Short flaps were created high above the level of the palate, just long enough to reach the nasal surface. Donor sites were closed by superior advancement of the inferior posterior pharyngeal wall tissue. Cardiopulmonary and oximetry data were analyzed for immediate obstructive apnea. Speech results and airway symptoms were assessed at 6-month and yearly follow-up examinations. RESULTS In the 54 consecutive patients who underwent staged adenotonsillectomy, no apnea occurred immediately after surgery. Long-term clinical examination revealed 4 cases of loud snoring. Polysomnographic results were negative in all cases. Complications included 3 cases of bleeding, 1 requiring transfusion. Velopharyngeal insufficiency was eliminated in 94% of patients. CONCLUSION Complications related to obstructive sleep apnea have been significantly reduced while maintaining excellent speech results by a staged approach of removing tonsils and adenoids and by creating a short, high, wide, superiorly based pharyngeal flap with superior advancement of the inferior posterior wall to close the donor site.
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Affiliation(s)
- Burke E Chegar
- Center for Facial Plastics Head and Neck Surgery, Fayette Regional Health System, Connersville, Indiana, USA
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Gosain AK, Arneja JS. Management of the Black Hole in Velopharyngeal Incompetence: Combined Use of a Furlow Palatoplasty and Sphincter Pharyngoplasty. Plast Reconstr Surg 2007; 119:1538-1545. [PMID: 17415248 DOI: 10.1097/01.prs.0000256066.44095.00] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with velopharyngeal incompetence may have a combination of a large velopharyngeal gap and poor lateral wall motion on phonation, simulating a "black hole" on nasendoscopy. Pharyngeal flaps for treatment of velopharyngeal incompetence in these patients are of questionable efficacy, because poor lateral wall motion necessitates such a wide flap that nasal airway obstruction is likely. METHODS Thirteen patients with velopharyngeal incompetence were managed between 1994 and 2003 with a combined Furlow palatoplasty and sphincter pharyngoplasty by a single surgeon. A diagnosis of velopharyngeal incompetence was established by means of perceptual speech evaluation performed by a trained speech pathologist using a standardized speech/voice rating scale (0 to 13); scores of 4 or higher indicated an incompetent velopharyngeal valving mechanism. Surgical inclusion criteria were a large velopharyngeal gap (> or =7 mm) and poor lateral wall motion (1 or 2 of 5, with 3 being rated as average) measured by multiview videofluoroscopy and nasendoscopy. RESULTS The mean preoperative score on the speech and voice rating scale was 10.5 (range, 4 to 13), with a mean postoperative score of 1.9 (range, 0 to 8) following Furlow palatoplasty and sphincter pharyngoplasty in 13 patients. Two patients required an additional surgical procedure to achieve complete correction of velopharyngeal incompetence without nasal airway obstruction, to achieve a final mean score of 0.8 (range, 0 to 2) among the 12 patients who completed surgical management, achieving a highly significant reduction in nasality (p < 0.0001). CONCLUSIONS Patients with velopharyngeal incompetence who have a black hole on nasendoscopy consisting of a large velopharyngeal gap and poor lateral wall motion are at high risk for recurrent velopharyngeal incompetence or nasal airway obstruction following surgical management. Initial treatment with a Furlow palatoplasty and sphincter pharyngoplasty has a high rate of success in these patients and does not preclude further surgical correction if needed, with minimal risk of nasal airway compromise.
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Affiliation(s)
- Arun K Gosain
- Milwaukee, Wis. From the Division of Plastic Surgery, University Hospitals of Cleveland, and the Section of Plastic Surgery, Children's Hospital of Michigan and Wayne State University
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Noorchashm N, Dudas JR, Ford M, Gastman B, Deleyiannis FWB, Vecchione L, Jiang S, Cooper GM, Haralam MA, Losee JE. Conversion Furlow palatoplasty: salvage of speech after straight-line palatoplasty and "incomplete intravelar veloplasty". Ann Plast Surg 2006; 56:505-10. [PMID: 16641625 DOI: 10.1097/01.sap.0000210154.72830.3d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The straight-line palatoplasty with intravelar veloplasty (IVVP) is one option for cleft palate repair. However, not all IVVPs are performed uniformly. Many IVVPs only address the medialmost portion of the levator muscle, an "incomplete IVVP," failing to completely dissect and adequately transpose the entire levator muscle, "complete IVVP." We believe that for optimal speech results, IVVPs should completely mobilize and posteriorly displace the levator. We propose that a conversion Furlow palatoplasty performed with a "complete IVVP" will correct postoperative velopharyngeal insufficiency (VPI) and alleviate the need for pharyngoplasty. METHODS Nineteen patients with postoperative VPI, having had prior straight-line palatoplasty and reported "IVVP," underwent conversion Furlow palatoplasty. Those with a pre- and postoperative Pittsburgh Weighted Speech Scale (PWSS) value and no other history of palatal surgeries were included in this study. Statistical analysis was performed by using the Wilcoxon signed ranks test. RESULTS Patients' median age was 5.5 years (range, 4-15 years), with 13 males and 7 females. The median preoperative PWSS score was 11.00 (range, 3-24.5), and the median postoperative was 1.00 (range, 0-5) (P < 0.001). All subcategories of the PWSS were also improved. Eight children had a preoperative fistula, and all were successfully corrected. At the time of conversion Furlow palatoplasty, all patients demonstrated no evidence of previous IVVP as the levator muscle was found to be scarred to the posterior edge of the hard palate. CONCLUSION The conversion Furlow palatoplasty can be used to significantly improve VPI and salvage speech after a straight-line palatoplasty with an "incomplete IVVP." Patients with postoperative VPI should first be considered for conversion Furlow palatoplasty performed with a "complete IVVP" prior to progressing to pharyngoplasty.
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Affiliation(s)
- Negin Noorchashm
- Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Response to Dworkin et al. (2004). Lang Speech Hear Serv Sch 2006. [DOI: 10.1044/0161-1461(2006/026)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Perkins JA, Lewis CW, Gruss JS, Eblen LE, Sie KCY. Furlow Palatoplasty for Management of Velopharyngeal Insufficiency: A Prospective Study of 148 Consecutive Patients. Plast Reconstr Surg 2005; 116:72-80; discussion 81-4. [PMID: 15988249 DOI: 10.1097/01.prs.0000169694.29082.69] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objectives of the study were to describe speech outcomes in a large series of patients undergoing Furlow palatoplasty for management of velopharyngeal insufficiency and to test whether preoperative velopharyngeal gap size and other patient characteristics significantly affect those outcomes. METHODS Data collected included age at the time of surgery, surgeon, type of cleft, syndrome diagnosis, preoperative velopharyngeal gap size as determined by videonasendoscopy, and preoperative and postoperative perceptual speech assessments. Descriptive statistics were generated and ordinal logistic regression on the outcome variable, postoperative velopharyngeal insufficiency severity score, was performed. RESULTS In this series of 154 patients, 148 had complete perceptual speech data. Of these 148 patients, 72 percent had improvement in velopharyngeal insufficiency severity after the procedure and 56 percent had complete resolution of velopharyngeal insufficiency. Postoperative insufficiency was scored as none or minimal (i.e., resolution) in 38 of 52 patients (73 percent) with a small preoperative velopharyngeal gap, 26 of 51 patients (51 percent) with a moderate preoperative gap, and four of 21 patients (19 percent) with a large preoperative gap. Preoperative velopharyngeal gap size was significantly associated (p < 0.0001) with postoperative insufficiency on ordinal multivariate logistic regression after controlling for preoperative insufficiency and other covariates. There was not a significant association between syndrome diagnosis, age at Furlow palatoplasty (younger than 5 years versus older), gender, surgeon, or presence of submucous cleft palate and postoperative speech outcome, in either the unadjusted or adjusted analyses. CONCLUSIONS Preoperative velopharyngeal gap size, as determined with nasendoscopy, was significantly associated with postoperative velopharyngeal insufficiency severity after Furlow palatoplasty. Small gap size is associated with a greater likelihood of resolution.
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Affiliation(s)
- Jonathan A Perkins
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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Chang HP, Chuang MC, Yang YH, Liu PH, Chang CH, Cheng CF, Lai JP. Maxillofacial Growth in Children with Unilateral Cleft Lip and Palate following Secondary Alveolar Bone Grafting: An Interim Evaluation. Plast Reconstr Surg 2005; 115:687-95. [PMID: 15731665 DOI: 10.1097/01.prs.0000152432.24053.52] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study evaluates the effect of alveolar bone grafting on the maxillofacial growth in children of mixed dentition with unilateral complete cleft lip-cleft palate. Twenty patients received an iliac crest alveolar bone graft between the ages of 6 years 10 months and 10 years 10 months, whereas 20 matched controls between the ages of 6 years 11 months and 10 years 6 months did not. Geometric morphometric assessments were used to localize alterations between the initial and final cephalographs in the two groups of cleft children, using Procrustes analysis and thin-plate spline analysis, in addition to conventional cephalometric techniques. It is concluded that no statistically significant difference in maxillofacial growth was found between the cleft children having received secondary alveolar bone grafting and the nongraft controls in general during the first to third postoperative years. Further investigation will be undertaken to determine the long-term effects after the age of skeletal maturity.
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Affiliation(s)
- Hong-Po Chang
- Department of Orthodontics, Faculty of Dentistry, and the Graduate Institute of Oral Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan.
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