Timing of Primary Surgery for Cleft Palate

BACKGROUND

Among infants with isolated cleft palate, whether primary surgery at 6 months of age is more beneficial than surgery at 12 months of age with respect to speech outcomes, hearing outcomes, dentofacial development, and safety is unknown.

METHODS

We randomly assigned infants with nonsyndromic isolated cleft palate, in a 1:1 ratio, to undergo standardized primary surgery at 6 months of age (6-month group) or at 12 months of age (12-month group) for closure of the cleft. Standardized assessments of quality-checked video and audio recordings at 1, 3, and 5 years of age were performed independently by speech and language therapists who were unaware of the trial-group assignments. The primary outcome was velopharyngeal insufficiency at 5 years of age, defined as a velopharyngeal composite summary score of at least 4 (scores range from 0 to 6, with higher scores indicating greater severity). Secondary outcomes included speech development, postoperative complications, hearing sensitivity, dentofacial development, and growth.

RESULTS

We randomly assigned 558 infants at 23 centers across Europe and South America to undergo surgery at 6 months of age (281 infants) or at 12 months of age (277 infants). Speech recordings from 235 infants (83.6%) in the 6-month group and 226 (81.6%) in the 12-month group were analyzable. Insufficient velopharyngeal function at 5 years of age was observed in 21 of 235 infants (8.9%) in the 6-month group as compared with 34 of 226 (15.0%) in the 12-month group (risk ratio, 0.59; 95% confidence interval, 0.36 to 0.99; P = 0.04). Postoperative complications were infrequent and similar in the 6-month and 12-month groups. Four serious adverse events were reported (three in the 6-month group and one in the 12-month group) and had resolved at follow-up.

CONCLUSIONS

Medically fit infants who underwent primary surgery for isolated cleft palate in adequately resourced settings at 6 months of age were less likely to have velopharyngeal insufficiency at the age of 5 years than those who had surgery at 12 months of age. (Funded by the National Institute of Dental and Craniofacial Research; TOPS ClinicalTrials.gov number, NCT00993551.).

Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review

PURPOSE

Following transoral robotic surgery (TORS) for oropharyngeal carcinoma (OPC), velopharyngeal incompetence (VPI) is a known consequence that may contribute to swallowing and speech disorders. As the incidence of OPC increases affecting a younger demographic, a better understanding of VPI is required to support speech and swallowing rehabilitation.

METHOD

A scoping review was conducted using Arskey & O'Malley's framework. Studies were identified from five databases between 2007 and 2020. The methodological quality was measured with the RevMan Risk of Bias Tool by two independent evaluators.

RESULT

A total of seven studies met the inclusion criterion. There was a combined total of 306 participants, their average age was 59.2 years. A high risk of bias and degree of heterogeneity across all seven cohort studies was observed. Validated and instrumental evaluations of VPI were present in two papers, with the majority only reporting the presence or absence of VPI. The incidence of VPI reported in each study ranged from 0 to 53%, (median 3.5%).

CONCLUSION

There are few high-quality studies and considerable heterogeneity in the terminology, inclusion criteria and measurement of VPI. Instrumentation, to date, has been rarely used but is necessary for a normed and validated approach to VPI. Based on this review, there is considerable need for larger studies which instrumentally and longitudinally assess VPI as a consequence of TORS, in order to guide patient education and management prior to, and following their surgery.

Does pharyngoplasty work? Outcomes of 100 consecutive operations over 10 years

BACKGROUND

Velopharyngeal insufficiency is a commonly encountered problem in Cleft Surgery, with pharyngoplasty being the mainstay of surgical management. In this study we aim to investigate the indications and outcomes of a single institution's experience and compare to international literature.

METHODS

A retrospective review was performed looking at over 100 consecutive primary pharyngoplasty operations for velopharyngeal dysfunction over a 10-year period at a single institution. Aetiology, peri-operative course and speech outcomes for the cohort between January 2010 through January 2020 were assessed. A comprehensive literature review was performed for comparison and analysis of the studies' data.

RESULTS

Ninety-seven consecutive patients were included in the study on which 103 operations were performed. Average age at time of surgery was 7.25 years old. Approximately 37% of the patients had a diagnosed syndrome, sequence or chromosomal abnormality. Ninety-seven of the 103 operations were primary pharyngoplasties, 4 were revision pharyngoplasties and 2 return to theatre procedures. Regarding speech outcomes, 51% of the patients that had formal speech assessments were found to have a significant improvement, 42% moderate improvement and 7% had no improvement. 93% of the patients that underwent pharyngoplasty in this study had significant or moderate improvement in speech outcomes. These speech outcomes and post-operative complications such as obstructive sleep apnoea are analysed.

CONCLUSION

This study demonstrates that pharyngoplasty is a safe procedure for velopharyngeal insufficiency with a good overall success rate. The major outcomes assessed including complications & safety, revision rate and speech outcomes are comparative to previous international studies.

Overlapping Intravelar Veloplasty Improves the Speech Outcomes in Submucous Cleft Palate

BACKGROUND

Submucous cleft palate (SMCP) is a subgroup of cleft palate that can present as velopharyngeal insufficiency due to muscle displacement. The pharyngeal flap and Furlow palatoplasty have been introduced to correct SMCP patient with velopharyngeal insufficiency. However, pharyngeal flap and Furlow palatoplasty can occur various complications. We consider the overlapping intravelar veloplasty (IVVP) can overcome these complications. Therefore, we present the speech outcomes of overlapping IVVP for the treatment of patients with SMCP.

METHODS

We retrospectively reviewed 12 patients with SMCP underwent overlapping IVVP between April 2016 and October 2018. The patients who underwent speech evaluation, nasometry, and nasoendoscopy before and after surgery and who were followed up for >18 months were enrolled in this study.

RESULTS

The average age of the patients was 5 years (range, 3-11 years) and the postoperative follow-up period ranged from 18 to 24 months (mean, 20 months). The preoperative perceptual speech evaluation was moderate and the postoperative evaluation was normal ( P < 0.01). The preoperative and postoperative nasalance scores obtained using a nasometer were 37.00 and 12.50, respectively, ( P < 0.01). Preoperative and postoperative velopharyngeal movements were grades 3 and 0, respectively, ( P < 0.01).

CONCLUSIONS

Our study showed that overlapping IVVP could provide successful correction of velopharyngeal insufficiency in patients with SMCP, including relatively old patients.

IS SURGICAL TREATMENT OF VELOPHARYNGEAL INSUFFICIENCY BY MYOMUCOSAL POSTERIOR PHARYNGEAL FLAP A CONTRAINDICATION FOR NASAL INTUBATION? A NARRATIVE REVIEW

Velopharyngeal insufficiency is a disorder where the soft palate directs the air through the nose. It is often present in patients with previous cleft or short palate, but also in many other conditions. Symptoms are primarily to be found in speech, with very distinct nasal sound. After clinical evaluation and nasal endoscopy, surgery is considered. Several surgical techniques are in use, with posterior pharyngeal flap pharyngoplasty being most widely used. This method leaves the base of the posterior pharyngeal flap attached to the posterior pharyngeal wall, with two lateral ports on each side of the flap. Permanent nasopharyngeal obstruction is a very challenging pathology for anesthesiologists in case of mandatory nasal intubation since it is a relative contraindication for nasal intubation. Patients with previous palatoplasty will regularly appear in our routine anesthetic practice, in all surgical segments. The high risk of damage to the flap with possible bleeding can put the anesthesiologist in a very unpleasant situation if not aware of the permanent effect of this surgery. During preanesthetic assessment, if there is information on a previous pharyngoplasty, one should consider alternative options for nasotracheal intubation. All nasal insertion procedures must be either avoided or carried out with great caution, under fiberoptic visual control.

Criteria for early and late velopharyngoplasty in 61 children with cleft palate

BACKGROUND

Velopharyngeal insufficiency persists in 15 to 30% of children with cleft palate, despite early velar surgery. Pharyngoplasty using a superior pedicle flap is the most common secondary surgery to treat velopharyngeal insufficiency. This study aims to identify the criteria leading to indicate velopharyngoplasty in 3 groups of age.

MATERIALS AND METHODS

we conducted a retrospective single center study in the reference center for cleft palate in Paris from 2013 to 2016. We included 61 children with non-syndromic cleft operated on with a velopharyngoplasty for velopharyngeal insufficiency. Pre-operative speech and surgical assessments, as well as the operative reports of the children, were analyzed retrospectively using multivariate models.

RESULTS

We included 61 patients. The only criteria factor for an early velopharyngoplasty was the Pittsburgh Weighted Speech Scale (PWSS) score (OR 1.20, CI 95% 1.07 to 1.4 ; P=.006). Criteria for a late velopharyngoplasty were a degradation of the velopharyngeal function (OR 16.07, CI 95% 1.7 to 518.7 ; P=.041) and lost of follow-up (OR 5.78, CI 95% 3.9 to 4320 ; P=.017).

CONCLUSION

Criteria for early and late velopharyngoplasty were identified, and we demonstrated the insufficiency of Borel-Maisonny classification for scientific clinical study.

Speech Outcomes of Treatment for Velopharyngeal Insufficiency: Combined Use of an Overlapping Intravelar Veloplasty and Dynamic Sphincter Pharyngoplasty

BACKGROUND

Velopharyngeal insufficiency involving a large velopharyngeal gap and poor lateral wall movement is referred to as a "black hole" and remains a challenging problem for cleft surgeons. The effect of the pharyngeal flap on this form of velopharyngeal insufficiency is still debatable because a wide pharyngeal flap is associated with a high incidence of airway obstruction. The present study aimed to evaluate the speech outcomes of combined overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency.

METHODS

Between March 2016 and June 2019, 15 patients with velopharyngeal insufficiency were treated with a combination of overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty. Preoperative speech evaluation was performed on the basis of perceptual speech evaluation, nasometry, and nasoendoscopy. Postoperative speech evaluation using the same approach as that used preoperatively was performed after completion of speech therapy.

RESULTS

All 15 patients achieved satisfactory velopharyngeal port closure and speech phonation after completion of speech therapy. No additional procedures were performed to improve velopharyngeal port closure and speech production. The preoperative and postoperative results of perceptual speech evaluation, nasometry, and nasoendoscopy evaluation were significantly different (P < 0.01).

CONCLUSION

Combined treatment with overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty can correct the velopharyngeal insufficiency "black hole" with highly reliable results and minimal risk of airway obstruction.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Videofluoroscopic Findings as Predictors of Velopharyngeal Insufficiency After Orthognathic Surgery in Patients With Cleft Lip and Palate

BACKGROUND

Midface retrusion is a common problem in patients with cleft lip and palate owing to the lack of adequate growth of the maxilla. Midface advancement surgery is a definite treatment for midface retrusion; however, the subsequent oropharyngeal airway changes might result in velopharyngeal insufficiency (VPI) in affected patients. Determining the predictors of VPI beforehand and modifying the surgical procedure would be beneficial.

MATERIALS AND METHODS

A retrospective review of 42 patients with cleft lip and palate who underwent orthognathic surgery from 2013 to 2014 was performed. A total of 25 patients met the inclusion criteria and had undergone complete pre- and postsurgery videofluoroscopy, nasopharyngoscopy (NPS), and speech assessment. We compared 2 groups of patients, those who showed NPS finding changes of more than 0.1 (8 patients) and those without changes (17 patients), by measuring the distances of the contact point to the tip of the velum, gap size at maximum closure (MC) and rest, contact area length, lateral wall closure rate, closure velocity, and 2 angles (from the velum to the hard palate and genu) at MC and rest. The amount of maxillary advancement was also recorded.

RESULTS

Among the 8 patients with NPS finding changes, 3 underwent Furlow palatoplasty for VPI. No significant difference was found in the amount of maxillary advancement between the groups (5.8 vs 5.7 mm). Significant differences were found in the preoperative gap size at MC and angle at the genu at MC (P = 0.035 and .012). These could be considered as the predictors before surgery. After surgery, a significant difference was found in the contact area, lateral wall closure rate, and gap size at MC (P = 0.005, 0.018, and 0.01).

CONCLUSION

Videofluoroscopy is a relatively applicable method of determining dynamic changes in the velum function. By performing videofluoroscopy before midface advancement surgery in patients with cleft lip and palate, we may predict the risk of VPI and consider alternative surgical strategies.

Speech pathology telepractice for children with cleft palate in the times of COVID-19 pandemic

OBJECTIVE

To study whether providing Speech and Language Pathology (SLP) interventions by telepractice (TP) could effectively improve speech performance in children with cleft palate (CCP).

METHODS

Forty-three CCP were treated with TP intervention in 45 min sessions, 2 times per week for a period of one month. Children ages ranged 4-12 years (X = 7.04; SD = 2.59). All children presented with velopharyngeal insufficiency (VPI) and compensatory articulation (CA) after palatal repair. TP was provided in small groups (5-6 children) following the principles of the Whole Language Model (WLM). Severity of CA was evaluated by a standardized scale at the onset and at the end of the TP period.

RESULTS

At the onset of the TP intervention period, 84% of the patients demonstrated severe CA. At the end of the TP period there was a significant improvement in severity of CA (p < 0.001).

CONCLUSION

The results of this study suggests that TP can be a safe and reliable tool for improving CA. Considering that the COVID-19 pandemic will radically modify the delivery of Health Care services in the long term, alternate modes of service delivery should be studied and implemented.

Non-Interventional Factors Influencing Velopharyngeal Function For Speech In Initial Cleft Palate Repair: A Systematic Review Protocol

BACKGROUND

This systematic review aims to inform the development of a screening tool which pre-operatively predicts which children are likely to develop velopharyngeal insufficiency, one of the causes of poor speech outcomes, following cleft palate repair. This would be highly beneficial as it would inform pre-operative counselling of parents, allow targeted speech and language therapy, and enable meaningful comparison of outcomes between surgeons, techniques, and institutions. Currently, it is unclear which factors influence speech outcomes. A systematic review investigating the non-interventional factors which potentially influence speech outcomes following cleft palate repair is warranted. This may be illuminating in itself or provide foundations for future studies.

METHODS

A systematic review will be carried out according to Cochrane methodology and reported according to PRISMA guidelines (PLoS Med 6: e1000097, 2009). Systematic review software will be used to facilitate three-stage screening by two independent reviewers experienced in cleft lip and palate. Thereafter, data extraction and GRADE assessment will be performed in duplicate by five independent reviewers experienced in cleft lip and palate. Studies reporting the proportion of patients who were recommended or underwent secondary speech surgery for velopharyngeal insufficiency following primary surgery for cleft palate will be included. The study findings will be tabulated and summarised. The primary outcome measure will be further speech surgery (either recommended or performed). The secondary outcome measure will be perceptual speech assessment for the presence of velopharyngeal insufficiency. A meta-analysis is planned. However, if this is not possible, due to the anticipated marked heterogeneity of study characteristics, pre-operative assessment, and the recorded outcome measures, a narrative synthesis will be undertaken.

DISCUSSION

This systematic review may provide sufficient data to inform the development of a screening tool to predict the risk of velopharyngeal insufficiency prior to cleft palate repair. However, it is anticipated that these findings will provide the foundation for future studies in this area.

SYSTEMATIC REVIEW REGISTRATION

Registered on 19 December 2016 with PROSPERO CRD42017051624.

Speech outcomes following Sommerlad primary palatoplasty: Results of the Ghent University Hospital

OBJECTIVE AND SUBJECTS

Speech outcomes were described for 16 patients with cleft palate (mean age: 5.4 years) following Sommerlad primary palatoplasty performed by a single surgeon of the Ghent University Hospital. These speech outcomes were compared with those of an age and gender matched control group without cleft palate (mean age: 5.3 years).

METHODS

Speech intelligibility/distinctiveness, resonance, nasal airflow and articulation, were perceptually evaluated. Additionally, nasalance values and the NSI 2.0 were determined.

RESULTS

In seven patients, speech intelligibility/distinctiveness was disordered. Hypernasality was present in twelve participants, whereas nasal emission and nasal turbulence were perceived in thirteen and five patients respectively. Both perceptual and instrumental speech evaluations were significantly poorer in the patient group in comparison to the control group.

CONCLUSIONS

Patients still present with both obligatory and compensatory speech disorders following Sommerlad's palatoplasty. In the future, a Dutch speech assessment protocol will be developed in order to standardize follow-up of these patients and to allow for within-center and inter-center comparisons.

Magnetic Resonance Imaging of the Levator Veli Palatini Muscle in Speakers with Repaired Cleft Palate

Objective:

To obtain detailed anatomic and physiologic information on the levator veli palatini muscle from MRI in individuals with repaired cleft palate and to compare the results with those from normal subjects reported by Ettema et al. (2002).

Design:

Prospective study.

Setting:

University-based hospital.

Participants:

Four men (ages 22 to 43 years) with repaired cleft lip and palate.

Main Outcome Measures:

Four quantitative measurements of the levator veli palatini muscle from rest position and dynamic speech magnetic resonance images were obtained: the distance between the origins of the muscle, angle of origin of the muscle, muscle length, and muscle thickness.

Results:

The length and thickness of the levator veli palatini muscle varied among the subjects and were different from measurements obtained from normal subjects in a previous study. The distance between origin points, length, and thickness of the levator veli palatini muscle were smaller than those of the normal subjects. There were systematic changes of the levator veli palatini muscle, depending upon vowel and consonant types. Levator veli palatini muscle angle of origin and length became progressively smaller from rest, nasal consonants, low vowels, high vowels, and fricative consonants. These changes are consistent with those of the normal subjects.

Conclusions:

This study contributes to a better understanding of cleft palate anatomy in comparison with normal anatomy of the levator veli palatini muscle. The use of MRI shows promise as an important tool in the diagnosis and eventual aid to treatment decisions for individuals born with cleft palate.

Buccinator Sandwich Pushback: A New Technique for Treatment of Secondary Velopharyngeal Incompetence

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.

Comparison of Obstructive Sleep Apnea Syndrome in Children with Cleft Palate following Furlow Palatoplasty or Pharyngeal Flap for Velopharyngeal Insufficiency

Objective

To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI).

Patients

A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI.

Interventions

An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively.

Main Outcome Measures

Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured.

Results

In the P group, the mean percentage of stage 2 sleep was lower than the F group (p < .05). The mean RDI and DI were larger in the P group, compared with the F group (p < .001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p < .001 and p = 0.05, respectively).

Conclusions

A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.

Speech in Children with an Isolated Cleft Palate: A Longitudinal Perspective

Objective

To describe articulation and speech symptoms related to velopharyngeal impairment in children born with an isolated cleft palate.

Design

Blind assessment of speech at 3, 5, 7, and 10 years of age was performed. Two subgroups were formed based on the results at age 5 years, the no-VPI group and the VPI group, and they were compared with controls.

Setting

A university hospital.

Patients

Twenty-six children born with isolated cleft palate. Seventeen children served as controls.

Interventions

Soft palate closure at 7 months and hard palate closure at a mean age of 3 years and 11 months if the cleft extended into the hard palate.

Main Outcome Measures

Perceptual assessments of four variables related to velopharyngeal function and of articulation errors were performed at all ages. Phonetic transcriptions of target speech sounds were obtained at 5, 7, and 10 years and nasalance scores were obtained at age 10 years.

Results

The no-VPI group continued to have no or minor difficulties. The VPI group improved but continued to have moderate velopharyngeal impairment. Both groups differed significantly from the controls at age 10 years. Persistent velopharyngeal impairment, as well as glottal misarticulation, were mostly found in children with the cleft as a part of a syndrome or together with multiple malformations.

Conclusion

Small changes in velopharyngeal impairment were found across ages. Improvement seemed to be related to surgical intervention, and persistent problems seemed to be related to the presence of additional multiple malformations or syndromes.

Nasalance Scores in Wearers of a Palatal Lift Prosthesis in Comparison with Normative Data for Japanese

Objective

This study was designed to examine whether nasalance score is changed in association with placement of a palatal lift prosthesis (PLP) and whether normative data previously reported are applicable to evaluate the effect of a PLP on velopharyngeal function as it relates to nasality.

Design

Nasalance scores were obtained as subjects read the Kitsutsuki Passage three times with the PLP in place and then removed.

Participants

Forty-three children (mean age 9.0 years, SD = 3.6 years) with repaired cleft palate who were treated with a PLP were selected as subjects. Their speech was characterized by nasal emission of air, slight hypernasality without a PLP but within normal limits with a PLP in place, or both.

Main Outcome Measures

Comparisons were made between normative scores and the average mean nasalance score of subjects with and without the PLP.

Results

Average values of the mean nasalance score for subjects were 17.3% (SD 7.6%) with the PLP in place and 33.5% (SD 13.3%) without the PLP in place. These scores were greater than the mean score of 9.1% (SD 3.9%) obtained from normal controls previously reported.

Conclusion

A PLP can decrease nasalance scores for speakers with repaired cleft palate who exhibit velopharyngeal incompetence. It was suggested that the normative score obtained from normal adult speakers is not applicable to evaluate the effect of a PLP to improve velopharyngeal function for children wearing the PLP.

Evaluation of Potential Modifiers of the Palatal Phenotype in the 22q11.2 Deletion Syndrome

Objective

To evaluate potential modifiers of the palatal phenotype in individuals with the 22q11.2 deletion syndrome.

Design

Data from 356 subjects enrolled in a study of the 22q11.2 deletion syndrome were used to evaluate potential modifiers of the palatal phenotype. Specifically, subjects with and without velopharyngeal inadequacy and/or structural malformations of the palate were compared with respect to gender, race, and genotype for variants of seven genes that may influence palatal development.

Methods

The chi-square test or Fisher exact test was used to evaluate the association between palatal phenotype and each potential modifier. Odds ratios and their associated 95% confidence intervals were used to measure the magnitude of the association between palatal phenotype, subject gender and race, and each of the bi-allelic variants.

Results

The palatal phenotype observed in individuals with the 22q11.2 deletion syndrome was significantly associated with both gender and race. In addition, there was tentative evidence that the palatal phenotype may be influenced by variation within the gene that encodes methionine synthase.

Conclusions

Variation in the palatal phenotype observed between individuals with the 22q11.2 deletion syndrome may be related to personal characteristics such as gender and race as well as variation within genes that reside outside of the 22q11.2 region.

Morphological Evaluation of Changes in Velopharyngeal Function following Maxillary Distraction in Patients with Repaired Cleft Palate during Mixed Dentition

Objective

To describe the morphological changes of nasopharyngeal components after maxillary distraction and clarify whether the morphological characteristics are related to velopharyngeal function (VPF).

Design

Perceptual judgments of hypernasality and nasendoscopy were performed before and after treatment. Lateral cephalograms were obtained to describe the morphological changes.

Setting

Department of Oral and Maxillofacial Surgery, Miyazaki Medical College, Miyazaki, Japan.

Participants

Nine patients with repaired cleft palate in the mixed dentition stage underwent maxillary distraction using a face mask and an intraoral fixed appliance system.

Outcome Measures

The severity of hypernasality, velopharyngeal insufficiency, and measurements such as pharyngeal depth, velar length, and the rotation of the palatal plane were evaluated.

Results

Increase in pharyngeal depth was not always proportional to the amount of advancement. It depended on the posture of the posterior pharyngeal wall and the rotation of palatal plane.

Conclusion

Cephalometric measurements of the nasopharynx before and after surgery confirmed subsequent changes in VPF. These were suggested to be useful in predicting future VPF. When performing maxillary distraction in patients with cleft palate in the mixed dentition stage, and when velopharyngeal closure is found to occur by velar contact against the hypertrophied adenoid, patients should be counseled about risks of subsequent deterioration in their speech before surgery.

Management of the Impaired Adult Cleft Patient: The Last Chance

Objective

Unfortunately, not all patients receive the benefits of a well-trained, experienced, multidisciplinary cleft team, and a significant number of patients reach adulthood with severe neglected cleft related problems. The vast majority of this group have made their way through several surgical procedures, usually performed by different surgeons in different centers, and still carry the original cleft stigmata aggravated by variable degrees of maxillary hypoplasia, fistulae, scarring, muscle pull, soft tissue tension, lost teeth, dental adaptation, and instability of bony fragments. Adult patients who reach this stage with their original deformities have, in most instances, lost their best opportunity to be properly treated. With this assumption in mind, an aggressive surgical plan focused mainly on the deformities that can objectively achieve functional and aesthetical improvement should be individualized for each patient. In this article, experience with 38 consecutive adult patients with cleft managed following a two-stage protocol used at our cleft clinic for the last 4 years is presented.

Conclusion

An algorithm to help definitively solve these deformities is suggested.

Speech Production of Preschoolers with Cleft Palate

Objective

The present investigation was conducted to examine the prevalence of preschoolers with cleft palate who require speech therapy, demonstrate significant nasalization of speech, and produce compensatory articulations. The relationship among these three dependent variables and the independent variables of cleft type and age of primary palatal surgery was also examined.

Participants

The participants included 212 preschoolers with repaired cleft palate aged 2 years 10 months to 5 years 6 months.

Main Outcome Measures

Chi-square analyses were performed to examine the relationship between two independent variables (cleft type and age of surgery) and three dependent variables (percentage of children requiring speech therapy, percentage demonstrating moderate to severe hypernasality and receiving secondary management for velopharyngeal insufficiency, and percentage producing glottal/pharyngeal substitutions).

Results

Sixty-eight percent of the children were enrolled in (or had previously received) speech therapy. Thirty-seven percent of the children demonstrated moderate-severe hypernasality or had received secondary surgical management for velopharyngeal insufficiency. Chi-square analyses revealed a significant relationship between cleft type and the number of children referred for speech therapy as well as the number of children with significant hypernasality. The analyses also revealed a significant relationship between age of palatal surgery and number of children with significant hypernasality.

Conclusions

Despite advances in surgical management and the advantages offered by team care, the majority of preschoolers with cleft palate continue to demonstrate delays in speech sound development that require direct speech therapy. An optimal treatment regimen for these children is one that includes primary palatal surgery no later than 13 months of age.

A Comparison of Oral-Nasal Balance Patterns in Speakers who are Categorized as “Almost but Not Quite” and “Sometimes but Not Always”

Objective

The purpose of this study was to determine whether amplitude or temporal patterns of oral-nasal balance differentiate speakers with cleft palate who are classified as belonging to the “almost but not quite” (ABNQ) and “sometimes but not always” (SBNA) subgroups of marginal velopharyngeal inadequacy.

Design

The nasal accelerometric vibrational index (NAVI) was used to measure amplitude and temporal aspects of oral-nasal balance during the productions of oral and nasal syllables, words, and sentences. NAVI measures obtained include mean amplitude, time integral (area under the curve), duration, rise time, and fall time.

Setting

Tertiary care center for patients with cleft palate–craniofacial anomalies.

Participants

Seventeen patients with repaired cleft palate who were assigned by perceptual assessment to the ABNQ subgroup and 17 patients who were assigned to the SBNA subgroup.

Results

No differences were found between the ABNQ and SBNA subgroups with regard to patterns of nasalization. Further analysis as a function of level of production and phonetic context revealed no differences between the subgroups.

Conclusions

Although clinicians may report perceived differences in the resonance patterns of speakers who fall within the category of marginal velopharyngeal inadequacy, further division into the ABNQ and SBNA subgroups has yet to be validated.

Surgical Repair of Unidirectional Palatopharyngeal Epignathus: Case Report and Review of Literature

Epignathus is an extremely rare, benign, congenital teratoma that arises from within the oral cavity and may be attached to the mandible, palate, or base of the skull. Because of its location, it can cause airway and feeding problems, as well as secondary defects due to the presence of an intraoral tumor. This tumor usually causes death in neonates, due to airway obstruction. Surgical removal is usually impossible, especially in large tumors (Stone, 1951; Bennett, 1970).

A patient with a neonatally diagnosed nonobstructive palatopharyngeal epignathus is described. It was associated with a shortened palate, cleft uvula, and velopharyngeal insufficiency, and was successfully excised surgically.

Prosthodontic Management of Palatopharyngeal Incompetency - A Case Report on Palatal Lift Prosthesis

The palatal lift prostheses (PLP) are commonly used in the prosthetic management of palatopharyngeal incompetency. These prostheses work by lifting the soft palate upward and backward and also have physical and psychological benefits. In this case report, a PLPwas provided to the patient for her speech problems. The soft palate was mechanically lifted upward and backward. PLPreduced the diameter of palatopharyngeal sphincter. This decreased the dysarthria and led to an increase in patient confidence. Surgically repaired cleft palate of this patient with hyper-nasality was successfully managed with PLP. It was concluded that PLP is acceptable and effective in the prosthodontic management of palatopharyngeal incompetency.