Levator repositioning and palatal lengthening for submucous clefts

Submucous clefts of the palate may present with velopharyngeal incompetence (VPI) or a history of recurrent otitis media. Many surgeons have favored a pharyngeal flap as primary treatment of the velopharyngeal incompetence associated with this disorder. The increasing number of case reports of sleep apnea and airway compromise associated with pharyngeal flaps prompted the use of levator muscle repositioning with palatal lengthening as initial therapy in 15 patients in an attempt to correct the pathologic anatomy while avoiding the postoperative sequelae. Patients were divided into two groups: group A (N = 8) had surgery before age 2 (11.8 +/- 5.7 months), and group B (N = 7) had surgery after 2 years of age (64.3 +/- 24.2 months). No patient in group A required a secondary operative procedure for velopharyngeal incompetence. Normal speech was obtained in 75 percent (N = 6), and slight velopharyngeal incompetence not requiring secondary correction was obtained in 25 percent (N = 2). Group B obtained less dramatic speech results: normal in 14 percent (N = 1), slight velopharyngeal incompetence in 58 percent (N = 4), and no improvement or severe velopharyngeal incompetence requiring a secondary procedure in 28 percent (N = 2). Patients with preoperative otologic disorders (N = 10) obtained significant improvement in 90 percent of cases (p = 0.002). Early surgical intervention in patients with abnormal speech prior to age 2 appears to result in normal speech in the majority of instances. Late repair with levator repositioning and palatal lengthening provided improved speech in 72 percent of patients.

Practical application of flexible fiberoptic nasopharyngoscopy for evaluating velopharyngeal function

Flexible fiberoptic nasopharyngoscopy increasingly is recognized as a valuable tool for assessing velopharyngeal function. There are, however, few reports in the literature describing a method for routine use of nasoendoscopy, the outcome of such evaluations, the criteria for referral, and a mechanism for communicating findings. Results from a 2-year clinical nasoendoscopy data base are presented. Ninety-eight patients were referred for evaluation of velopharyngeal function during speech. Flexible fiberoptic nasopharyngoscopic evaluations were conducted in 85 patients. Patients ranged in age from 3 years to adult. Eighty-nine percent of the evaluations were completed successfully on a first attempt. A standard format has been designed to communicate the results of nasoendoscopic examinations to primary and tertiary care providers. Nasoendoscopy has become an integral part of our cleft team care and is used routinely for decisions regarding palatal management, fabrication and fitting of palatal prostheses, and treatment of resonance disorders following pharyngeal flap surgery.

Velopharyngeal incompetence as the presenting symptom of myotonic dystrophy

Velopharyngeal incompetence has previously been described in the late stages of myotonic dystrophy. However, we have seen three cases in which velopharyngeal incompetence was the presenting symptom. Despite different ethnic backgrounds, the patients shared a similar appearance, all three had the characteristic "myopathic facies," mandibulomaxillary disproportion, muscular weakness, and positive family history. Identifying a progressive neuromuscular disorder as the cause of velopharyngeal incompetence has important treatment and prognostic implications. Based on the experience described in this report, we feel that the velopharyngeal incompetence of the myotonic patient might best be managed nonsurgically.

Speech and nasendoscopic evaluation of velopharyngeal incompetence (VPI) in cleft palate patients

Cleft lip and palate patients exhibit several problems prior to and following surgical repair of their deformities. Hypernasality and speech defects remain one of the outstanding problems. 82 cleft palate patients were subjected to a systematised speech evaluation and an examination of the velopharyngeal mechanism. Nineteen patients did not have any surgery of the palate whilst the remaining 63 had at least one surgical procedure to the palate. 54 had a Veau-Wardill-Kilner (V-W-K) procedure and the remaining had either a second palatal repair or a superiorly based pharyngoplasty. Good correlation of speech assessment to nasendoscopic evaluation was found. An improvement in the speech and nasendoscopic coding was found in patients who had surgical intervention to the palate. A nasendoscopic examination, ideally performed by the surgeon and a speech therapist, is a useful adjunct to speech evaluation.

Diagnosis and treatment of submucous cleft palate: a review of 108 cases

The files of 108 patients with submucous cleft palate were reviewed. Special attention was focused on the findings of videonasoendoscopy, videofluoroscopy, and audiometry. Velopharyngeal insufficiency was found in 53 percent of the cases. Since surgical correction is indicated only in the presence of insufficiency, waiting until speech has developed is recommended before considering treatment. A relationship between coronal pattern of velopharyngeal closure and velopharyngeal insufficiency was found. This relationship appears to be caused by the malformation of the musculus uvulae in the submucous clefts. Conductive hearing loss was significantly associated with velopharyngeal insufficiency. This suggests that a velar muscle malformation, which is frequently responsible for the insufficiency in these patients, may also cause Eustachian tube malfunction, resulting in serous otitis with conductive hearing loss.

Laryngeal/voice findings in patients with velopharyngeal dysfunction

It is reported frequently that individuals with palatal clefts have a high occurrence of laryngeal/voice symptoms. It has been speculated that vocal pathology in this population is the result of laryngeal compensation for abnormal velopharyngeal valving. This paper describes the prevalence of laryngeal/voice findings in a group of 85 patients referred for multimethod evaluation of velopharyngeal dysfunction. Forty-one percent of the patients had auditorily perceived voice symptoms and/or observable laryngeal abnormalities. Twenty-one percent of the patients had vocal fold nodules or thickened vocal folds. There was no clear relationship between laryngeal/voice findings and nasoendoscopic or aerodynamic assessments of velopharyngeal dysfunction. However, there was a significant relationship between laryngeal/voice findings and estimated subglottal pressure. Patients with laryngeal/voice findings (with or without nodules) had average estimated subglottal pressure values which were outside the normal range more often than patients without laryngeal/voice findings. These results suggest patients referred for assessment of velopharyngeal dysfunction should receive a comprehensive evaluation which includes screening laryngeal structure and function.

Etiology of facial clefts: prospective evaluation of 428 patients

This article presents the results of prospective evaluation of 428 patients with facial clefts or velopharyngeal insufficiency who were evaluated through the Cleft Palate Program at Children's Hospital, San Diego. Children were examined for patterns of major and minor malformations, and an attempt was made to identify the etiology of the overall pattern of altered structure. Results indicate that 14 percent of 259 patients with cleft lip +/- cleft palate, 55 percent of 139 patients with cleft palate, 75 percent of 24 patients with velopharyngeal insufficiency, and 83 percent of 6 patients with atypical clefts had a multiple malformation syndrome. The frequency with which syndromic clefting occurs is higher than previously recognized. Recognition of underlying etiology is important with respect to prognosis and recurrence risk counseling of families and patients. In addition, the underlying diagnosis may significantly impact outcome of medical and surgical treatment of the cleft disorder.

Hypernasal speech caused by tonsillar hypertrophy

Twenty patients with hypernasal speech were studied with both flexible fiber optic nasopharyngoscopy and multi-view videofluoroscopy, as well as behavioral speech assessment. Characteristic diagnostic findings showed the hypernasality to be caused by hypertrophic tonsils with posterior placement of the upper poles of the tonsils into the oropharyngeal and nasopharyngeal airway. In 16 of the 20 cases, there was a complete resolution of hypernasal speech following only tonsillectomy with no other treatments. Three patients required a brief period of speech therapy and one additional patient required both speech therapy and temporary prosthetic treatment (speech bulb reduction).

Velopharyngeal insufficiency due to hypertrophic tonsils. A report of two cases

Two children in whom idiopathic hypernasality was diagnosed were referred for investigation of velopharyngeal function. Multiview videofluoroscopic assessments showed the tonsils prolapsing posteriorly during speech, preventing the palate from fully approximating the posterior pharyngeal wall. Tonsillectomy was recommended. Postoperative evaluations found that the hypernasal resonance was eliminated in both children.

Nasopharyngeal complications following uvulopalatopharyngoplasty

This report presents our experience with nasopharyngeal complications of UPPP in 85 patients undergoing the procedure from May, 1982 to January, 1985. Three patients developed nasopharyngeal stenosis and one patient developed permanent velopharyngeal insufficiency. Surgical management in two patients with nasopharyngeal stenosis resulted in adequate nasopharyngeal airway, while one patient still has a moderate stenosis following two surgical procedures. The patient with velopharyngeal insufficiency underwent Teflon paste injection in the posterior pharyngeal wall. This resulted in complete alleviation of his nasal regurgitation.

Risks and benefits of adenotonsillectomy for children with Down syndrome

A questionnaire survey of 74 parents of children with Down syndrome was conducted. Results indicated that adenotonsillectomy benefited their children by eliminating or reducing the symptoms of snoring, sleep apnea, nasal drainage, and mouth breathing. On the basis of parental responses, it appears that in the absence of nasal obstruction, adenotonsillectomy fails to improve drooling or tongue protrusion. Adenoid tissue is physiologically important to the child with Down syndrome and its removal can result in hypernasality. Two children in the survey sample who underwent adenoidectomy and/or tonsillectomy developed this complication. They were given complete speech and language testing and evaluated with cinefluoroscopy. Both structural and functional causes of hypernasality were identified. Structural abnormalities included a high-arched short hard palate and a short soft palate. Hypotonia, slowed motor learning, and oral motor developmental delay were confounding functional factors in these patients. The incidence of postoperative hypernasality found in these patients is higher than in the general population and should be an important consideration before performing an adenoidectomy.

Velopharyngeal insufficiency after adenoidectomy: an 8-year review

The characteristics of 137 patients referred to the Speech Clinic at The Hospital for Sick Children, Toronto, Canada during the past 8 years for the investigation of persistent hypernasality after adenoidectomy are reported. Over 30% of the patients had preoperative factors that are thought to increase the risk, such as submucous cleft palate, fluid regurgitation through the nose, a family history of velopharyngeal insufficiency or clefting, or hypernasality. Fifty percent of the patients required pharyngoplasty to correct hypernasality, 37% required speech therapy alone, and 13% improved with no treatment.

Palatal insufficiency: a surgical technique for reconstruction

Nasal regurgitation and hypernasality are the major complications after extirpation of the soft palate, retromolar trigone, and tonsillar areas. The surgical procedure described herein provides satisfactory correction of the defect. The combined approach of advancement-rotation palatoplasty and an advanced lateral pharyngeal wall flap appears to be an alternative solution to the use of an obturator or inferiorly based pharyngeal flap.

Some acoustic evidence for vocal abuse in adult speakers with repaired cleft palate

Acoustic evidence for vocal abuse in adult speakers with cleft palate and hypernasality has not been reported. This study was undertaken to determine if there was acoustic evidence of inappropriate vocal fold adduction during stop consonant production in this population. The results indicated that spectrograms of speakers without cleft palate and severe hypernasality exhibited acoustic characteristics different from spectrograms of speakers without cleft palate and speakers with cleft palate and mild hypernasality. Specifically, voiceless stop productions of severe hypernasal speakers resembled voiced stop productions. Their vocal folds were inappropriately adducted to provide a constriction inferior to the inadequately functioning velopharyngeal port to minimize the nasal air leak. The acoustic evidence supports the hypothesis that a cause of vocal abuse in the cleft palate population is due to compensatory laryngeal valving activities secondary to severe hypernasality.

Adult pharyngoplasty for velopharyngeal insufficiency

Nine adults underwent superiorly based pharyngeal flaps for the treatment of severe velopharyngeal insufficiency (VPI). The etiology of the VPI was failed pediatric cleft palate repair in eight and myasthenia gravis in the ninth. All patients were evaluated by a speech therapist pre-operatively. There were no significant early or late postsurgical complications. After extensive speech therapy all patients were noted subjectively and objectively to have a marked reduction in hypernasality and nasal air escape and improved speech intelligibility. The healed fibrotic flaps appeared to be adynamic and acted more as a viable midline obturator. Lateral pharyngeal wall contraction was necessary to close the lateral ports during phonation. The patient with myasthenia gravis had the least improvement presumably due to poor lateral wall mobility.

Prosthodontic considerations in the management of surgically compromised cleft palate patients

Prosthodontic habilitation with speech aid prostheses for surgically compromised cleft palate patients has been discussed. It can be concluded that surgical redivision of the soft palate with removal of the levator veli palatini muscles as an aid to construction of a pharyngeal obturator is contraindicated. Surgical redivision with removal of the levator muscles prevents subsequent surgical procedures and commits the patient to a prosthesis for life. The management of nonfunctional pharyngeal flaps, large soft palate perforations, and patients with palatopharyngeal insufficiency and/or incompetency secondary to surgical repairs was also discussed. If the prosthodontist is routinely consulted in the initial treatment planning, alternatives to surgical management might be considered for patients with high potential for postsurgical deficiencies.

Delayed hard palate closure: the philosophy revisited

Delaying surgical closure of the hard palate in children with cleft lip and palate has become increasingly popular. This essay is a review of the rationale and supporting evidence for this procedure, with emphasis on its effect on speech, particularly articulation and velopharyngeal function. We have concluded that the assumptions on which this method is based have never been proven, and that the deleterious effects on speech often noted have not received appropriate attention.