Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution

INTRODUCTION

Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction.

METHODS

Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05).

RESULTS

Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014).

CONCLUSION

This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study

BACKGROUND

The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center.

METHODS

A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included.

RESULTS

A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0.

CONCLUSION

Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.

Repeat Buccal Flaps Successfully Reduce Hypernasality in a Patient with Cleft Palate

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI.

Preoperative Imaging in Patients with 22q11 Deletion Syndrome Undergoing Velopharyngeal Surgery

OBJECTIVE

To evaluate the utility of preoperative imaging before velopharyngeal dysfunction (VPD) surgery in children with 22q11 Deletion Syndrome (22qDS) in evaluating internal carotid artery (ICA) medialization.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Following PRISMA guidelines, a systematic review was performed. Studies of children with 22qDS who underwent preoperative imaging (MRA or CTA) to identify ICA anomalies were included. High-risk medialized ICAs were defined as either submucosal, retropharyngeal, Pfeiffer Grade III-IV, or <3 mm from the pharyngeal mucosa. Meta-analyses of proportions were performed.

RESULTS

Eleven studies met inclusion criteria, comprising 398 patients with 22qDS (weighted mean age 7.6 years). In 372 patients with imaging, the rate of ICA medialization on imaging was 47.1% (95%CI 29.2-65.5), of which 46.3% (95%CI 27.4-65.8) were determined high risk. Operative plans were modified in 19.4% (95%CI 5.7-38.8) of 254 surgeries due to medialized ICA. In studies attempting to use nasopharyngoscopy pulsations to identify medialization for 214 patients, the true-positive rate was 53.9% (95%CI 27.5-79.2) and the false-positive rate was 16.2% (95%CI 7.9-26.8). Nine of eleven studies (81.8%) recommended universal preoperative imaging of the ICAs in children with 22qDS undergoing VPD surgery. No cases of perioperative bleeding secondary to ICA injury were identified.

CONCLUSION

Although most studies endorse routine preoperative imaging to assess for ICA medialization in children with 22qDS undergoing VPD surgery, only a minority of these cases led to surgical modification. Additional studies are needed to compare outcomes in children with and without preoperative imaging given the low rates of ICA injury in the literature.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2551-2561, 2024.

Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair

OBJECTIVE

To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI).

DESIGN

Prospective observational multicenter study.

SETTING

Twelve hospitals across the United States and Canada.

PARTICIPANTS

Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants.

INTERVENTIONS

Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team.

MAIN OUTCOME MEASURE(S)

The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings.

RESULTS

Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter.

CONCLUSIONS

Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date.

Establishing a Clinical Protocol for Velopharyngeal MRI and Interpreting Imaging Findings

Traditional imaging modalities used to assess velopharyngeal insufficiency (VPI) do not allow for direct visualization of underlying velopharyngeal (VP) structures and musculature which could impact surgical planning. This limitation can be overcome via structural magnetic resonance imaging (MRI), the only current imaging tool that provides direct visualization of salient VP structures. MRI has been used extensively in research; however, it has had limited clinical use. Factors that restrict clinical use of VP MRI include limited access to optimized VP MRI protocols and uncertainty regarding how to interpret VP MRI findings. The purpose of this paper is to outline a framework for establishing a novel VP MRI scan protocol and to detail the process of interpreting scans of the velopharynx at rest and during speech tasks. Additionally, this paper includes common scan parameters needed to allow for visualization of velopharynx and techniques for the elicitation of speech during scans.

The Early Operative Burden for Children Born with Cleft lip and Palate

OBJECTIVES

to audit the surgical management of infants born with non-syndromic cleft lip and palate (CLP) at an Australian cleft unit in a large tertiary paediatric hospital.

DESIGN

Retrospective cohort study.

SETTING

A tertiary Cleft centre.

PATIENTS

193 infants born with non-syndromic CLP were referred to the centre and underwent primary repair of their CLP between 2009 and 2020.Main Outcome Measures: (1) The timing and surgical repairs performed; (2) the frequency of postoperative complications; (3) the frequency of secondary Cleft surgery; and (4) the total Cleft-related operations performed for infants born with CLP.

RESULTS

Four different surgical repair techniques were performed by six surgeons, and postoperative complications were uncommon (n = 14). Rates of oronasal fistula surgery (10.5% at five years of age; 14.3% at eight years of age) and velopharyngeal insufficiency surgery (8.7% at five years of age; 14.3% at eight years of age) were not significantly different across the surgical repair groups (p-value >0.05) and were comparable to international Cleft centres. Children underwent an average of four operative procedures in this audit period, including primary Cleft repair, ear, nose and throat surgery, and dental care. Surgery for managing Eustachian tube dysfunction was the most common surgical intervention following primary Cleft repair.

CONCLUSIONS

Children born with non-syndromic CLP have a high early operative burden, with outcomes similar across the spectrum of techniques and surgeons.

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

BACKGROUND

Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV-mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes.

METHODS

This retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated.

RESULTS

Fifty-five patients were included. Mean and median follow-up was 34 months. 98% of patients were AJCC stage I/II. Recurrence-free survival was 96% with no local recurrences. Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009).

CONCLUSION

Loss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.

Effectiveness of secondary furlow palatoplasty with buccal myomucosal flap in correction of velopharyngeal insufficiency in patients with cleft palate

OBJECTIVES

The main purpose of this study was evaluation of the effectiveness of secondary furlow palatoplasty with buccal myomucosal flap (FPBF) for the treatment of velopharyngeal insufficiency (VPI) in patients with a cleft palate who were treated with two flap palatoplasty (TFP) in their primary palate repair.

MATERIAL AND METHODS

Twenty-three medically free children aged 4-8 years with non-syndromic and previously repaired cleft palate via TFP participated in the study. All patients received secondary surgery following the technique of FPBF. Preoperative speech evaluation was done before the secondary repair and 3 months after the surgery using a hypernasal speech scale, speech intelligibility scale, and nasopharyngoscopy.

RESULTS

A statistically significant improvement was observed regarding the degree of hypernasality and speech intelligibility while comparing the preoperative scores after the primary surgery to the postoperative scores after the secondary surgery. In addition, a statistically significant improvement was found in the nasopharyngoscopic assessment.

CONCLUSIONS

The incorporation of a buccal myomucosal flap with Furlow palatoplasty was successful in improving hypernasality, speech intelligibility, and nasopharyngoscopic scores in patients with cleft palate.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05626933).

CLINICAL RELEVANCE

This technique might be the surgical technique of choice while treating patients who are suffering from VPI after cleft palate repair.

Superiorly Based Posterior Pharyngeal Flaps: Using A Care Pathway to Optimize Speech and Airway Outcomes

BACKGROUND

Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency, but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) preoperative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient-specific surgical approach via appropriately sized PFs can result in excellent speech outcomes while limiting occurrence of OSA.

METHODS

This was a retrospective chart review of all patients with velopharyngeal insufficiency (VPI) (aged 2-20 years) seen at the University of Rochester from 2015 to 2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine PF width. Patients underwent polysomnography and speech evaluation before and at least 6 months after PF surgery.

RESULTS

Forty-one children aged 8.5 ± 4.1 years (range, 4 to 18 years) who underwent posterior PF surgery for VPI were identified. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin sequence. Thirty-nine patients had both pre- and postoperative speech data and underwent both a pre- and postoperative sleep study. Polysomnography showed no significant difference in obstructive apnea-hypopnea index after posterior PF surgery (obstructive apnea-hypopnea index preop, 1.3 ± 1.2 events per hour; postop, 1.7 ± 2.1 events per hour; P = 0.111). Significant improvements in speech outcome were seen in patients who underwent PF (modified Pittsburgh score preop, 11.52 ± 1.37; postop, 1.09 ± 2.35; P < 0.05).

CONCLUSIONS

Use of preoperative staged adenotonsillectomy as well as patient-specific PF dimensions results in effective resolution of VPI and a low risk of OSA.

Early Cleft Palate Repair by a Modified Technique Without Relaxing Incisions

OBJECTIVE

This study sought to evaluate a modified palatoplasty technique (MPT) concerning the postoperative outcomes and associated influencing factors.

DESIGN

A retrospective cohort study.

PARTICIPANTS AND SETTING

One hundred forty-three consecutive patients with non-syndromic cleft palate, who received MPT before one year of age within an oral and maxillofacial surgery department of a university-affiliated tertiary hospital between 2011-2017, were reviewed.

MAIN MEASURES

The postoperative wound healing and velopharyngeal function (VPF) were the primary outcome measures. The sex, age at surgery, cleft type, cleft width, palatal width, soft palate length, pharyngeal cavity depth, and operation duration were preselected as influencing factors. Univariate and multivariate analyses were conducted.

RESULTS

The mean age at surgery was 9 ± 1.31 months (5-11), and the average cleft width was 9.03 ± 2.41 mm (4-15). The rate of incomplete cleft palate was 84.6% while the complete cleft palate was 15.4%. Complete wound healing was reported in 96.5% while the others (3.5%) had persistent oronasal fistula. About 90.2% of cases have shown normal velopharyngeal function whereas the others (9.8%) had sustained velopharyngeal insufficiency. The wound healing appeared to be significantly impacted by cleft width and pharyngeal cavity depth (P = .015 and 0.049, respectively). However, none of the factors had a significant association with VPF.

CONCLUSIONS

The present modified palatoplasty technique has obtained a low fistula rate and appropriate speech outcome. Therefore, this MPT could be promoted for early repairing cleft palate of different severities.

Outcomes of primary repair of cleft palate using sommerled intravelar veloplasty associated with velocardiofacial syndrome

OBJECTIVES

Velocardiofacial syndrome, a prevalent microdeletion syndrome occurring in 1 in 2000-4000 live births, is marked by speech and language disorders, notably velopharyngeal dysfunction. This study investigates speech outcomes, nasometric and videofluoroscopic results before and after primary repair of cleft palate using the Sommerlad intravelar veloplasty (SIVV) technique within the Isfahan cleft care team for patients with velocardiofacial syndrome.

METHODS

Employing a quasi-experimental design, 19 participants with velocardiofacial syndrome, who underwent primary cleft palate repair by the Isfahan cleft care team, were included through convenience sampling. Perceptual and instrumental outcomes were assessed pre-and post-operatively. Statistical analysis encompassed paired t-tests and the non-parametric Wilcoxon signed-rank test (p < 0.05).

RESULTS

The study identified no statistically significant differences between pre-and post-surgical speech outcome parameters and nasalance scores. Nonetheless, a significant distinction emerged in the velopharyngeal closure ratio based on fluoroscopic evaluation (p = 0.038).

CONCLUSION

The efficacy of the SIVV technique in treating velopharyngeal dysfunction in velocardiofacial syndrome patients is inconclusive, demanding further research. Post-surgical speech outcomes are influenced by surgical technique, hypotonia, apraxia of speech, and surgery timing. Notably, an elevated velopharyngeal valve closure ratio, though anatomically indicative, does not exclusively predict surgical success.

Three-dimensional finite element analysis on stress distribution after different palatoplasty and levator veli palatini muscle reconstruction

OBJECTIVES

To establish a three-dimensional finite element model of the upper palate, pharyngeal cavity, and levator veli palatini muscle in patients with unilateral complete cleft palate, simulate two surgical procedures that the two-flap method and Furlow reverse double Z method, observe the stress distribution of the upper palate soft tissue and changes in pharyngeal cavity area after different surgical methods, and verify the accuracy of the model by reconstructing and measuring the levator veli palatini muscle.

MATERIALS AND METHODS

Mimics, Geomagic, Ansys, and Hypermesh were applied to establish three-dimensional finite element models of the pharyngeal cavity, upper palate, and levator veli palatini muscle in patients with unilateral complete cleft palate. The parameters including length, angle, and cross-sectional area of the levator veli palatini muscle etc. were measured in Mimics, and two surgical procedures that two-flap method and Furlow reverse double Z method were simulated in Ansys, and the area of pharyngeal cavity was measured by hypermesh.

RESULTS

A three-dimensional finite element model of the upper palate, pharyngeal cavity, and bilateral levator veli palatini muscle was established in patients with unilateral complete cleft palate ; The concept of horizontal projection characteristics of the palatal dome was applied to the finite element simulation of cleft palate surgery, vividly simulating the displacement and elastic stretching of the two flap method and Furlow reverse double Z method during the surgical process; The areas with the highest stress in the two-flap method and Furlow reverse double Z method both occur in the hard soft palate junction area; In resting state, as measured, the two flap method can narrow the pharyngeal cavity area by 50.9%, while the Furlow reverse double Z method can narrow the pharyngeal cavity area by 65.4%; The measurement results of the levator veli palatini muscle showed no significant difference compared to previous studies, confirming the accuracy of the model.

CONCLUSIONS

The finite element method was used to establish a model to simulate the surgical procedure, which is effective and reliable. The area with the highest postoperative stress for both methods is the hard soft palate junction area, and the stress of the Furlow reverse double Z method is lower than that of the two-flap method. The anatomical conditions of pharyngeal cavity of Furlow reverse double Z method are better than that of two-flap method in the resting state.

CLINICAL RELEVANCE

This article uses three-dimensional finite element method to simulate the commonly used two-flap method and Furlow reverse double Z method in clinical cleft palate surgery, and analyzes the stress distribution characteristics and changes in pharyngeal cavity area of the two surgical methods, in order to provide a theoretical basis for the surgeon to choose the surgical method and reduce the occurrence of complications.

Surgical Management of Submucous Cleft Palate by Radical Muscle Dissection Veloplasty: Speech Outcomes in Patients with 22q11.2 Deletion Syndrome

OBJECTIVE

To evaluate the benefit of anatomical muscle dissection repair for velopharyngeal insufficiency (VPI) in patients with submucous cleft palate (SMCP) with 22q11.2 deletion syndrome.

DESIGN

Retrospective blinded randomised analysis of a surgeon's management over 10 years.

SETTING

The study was performed at a specialised Paediatric hospital in the United Kingdom.

PATIENTS

Children with SMCP and 22q11.2 deletion syndrome.

INTERVENTIONS

All participants underwent radical muscle dissection veloplasty.

OUTCOMES MEASURED

Pre- and post- operative measurements included severity of anatomical defect, speech samples and lateral images which were digitised, randomised then externally and blindly analysed using validated techniques. Stata software was used to perform statistical analysis.

RESULTS

57 children with 22q11.2 deletion syndrome were included in this analysis. Intra-operatively, the majority of cases were identified as SMCP Grade I anomalies. Post-operatively, a statistically significant improvement in hypernasality, resting palate length, palate length at maximum closure, palate excursion and gap size at maximum closure was observed. Secondary surgery was performed for 59% of patients by ten years.

CONCLUSION

Muscle dissection repair improves hypernasality, palate closure function and the closure gap in patients with 22q11.2 deletion syndrome. Although over 50% of patients may require further surgery, muscle dissection repair should be a first step due to its utility at a younger age, when invasive investigations are impossible, its lower morbidity, speech and language benefits or altering the plans for less obstructive secondary surgery when it lead to reduced velo-pharyngeal gap and improved palate mobility even when adequate velo-pharyngeal closure was not achieved.

Cleft Maxillary Hypoplasia: Comparison of Techniques and Proposal of a Novel Treatment Protocol for Management

This study was designed to compare different techniques of managing cleft maxillary hypoplasia and to propose a treatment protocol taking patient's age of presentation, amount of maxillary hypoplasia, and presence/absence of velopharyngeal insufficiency (VPI) into consideration. Five treatment modalities, viz. facemask therapy (Group I), anterior maxillary distraction (Group II), total maxillary distraction osteogenesis using rigid external distraction devices (Group III) and internal distraction devices (Group IV), and conventional orthognathic surgery (Group V), were assessed retrospectively using lateral cephalograms (taken at 3 intervals) and speech records (studied pre- and post-operatively). The results were subjected to statistical analysis. A P value of less than 0.05 was considered statistically significant. The mean advancement achieved in groups I, II, III, IV, and V was 4.2±1.54, 9.03±2.62, 11.82±1.18, 10.41±1.42, and 7.24±2.44 mm, respectively. The mean horizontal relapse noted in Groups I, II, III, IV, and V was 2.3 mm (n=8), 2.1 mm (n=14), 3.4 mm (n=10), 1.4 mm (n=5), and 2.4 mm (n=24), respectively. Compared to other groups, group II had fewer patients exhibiting relapse, a statistically significant observation. Similarly, statistically significant improvement in speech outcomes was found only in group II compared to other groups. Based on the results, a treatment protocol was proposed. The authors conclude that the proposed protocol would enable surgeons to decide the most appropriate treatment modality paying attention to not only the age of presentation and amount of advancement but also presence/absence of VPI which is instrumental in deciding upon the most appropriate treatment.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience

BACKGROUND

Measurements of postoperative velopharyngeal dysfunction (VPD) can be used to determine the efficacy of a palatoplasty operation. Hypernasality and audible nasal air emission are typical manifestations of VPD during speech. We aimed to longitudinally compare VPD outcomes in postpalatoplasty patients who underwent Furlow repair versus straight line repair with intravelar veloplasty (IVVP). Additionally, we examined the relationship between VPD outcomes and select pre-existing patient characteristics.

METHODS

Retrospective chart review was performed to identify primary palatoplasty patients treated from April 2012 to March 2021. Variables collected included gender, syndromic status, primary language, Veau cleft type, type of speech assessment, age at time of surgery, degree of hypernasality, presence of audible nasal air emission, and overall adequacy of velopharyngeal function. Pearson χ 2 test and multivariable t tests were used to analyze variables. Logistic regression was used to control for statistically significant variables.

RESULTS

Of the 118 patients included, 38 received a Furlow procedure and 80 received a straight line with IVVP procedure. Audible nasal air emission was present in 57.3% of straight line with IVVP patients and 42.9% of Furlow patients, with no statistically significant difference between groups. Clinically significant hypernasality was present in 42.1% of straight line with IVVP patients and 22.9% of Furlow patients ( P= 0.05). Velopharyngeal function was classified as adequate in 63.5% of straight line with IVVP patients and 83.3% of Furlow patients ( P= 0.03). However, after stratifying by syndromic versus nonsyndromic status, there was no statistically significant difference between straight line with IVVP and Furlow patients for postoperative hypernasality and velopharyngeal function.

CONCLUSIONS

This study suggests that there are no statistically significant differences between straight line with IVVP and Furlow palatoplasty techniques regarding speech outcomes including hypernasality, audible nasal air emission, and overall VP function. Furthermore, select patient characteristics such as gender, primary language, syndromic status, age at repair, and Veau cleft type do not significantly impact postoperative speech outcomes.

Surgical treatment of velopharyngeal dysfunction: Incidence and associated factors in the Swedish cleft palate population

INTRODUCTION

Speech in children with cleft palate can be affected by velopharyngeal dysfunction, which persists after primary palate repair. The incidence of surgery to correct velopharyngeal dysfunction in this patient group has previously been reported as 2.6-37%. We aimed to investigate the incidence of velopharyngeal dysfunction surgery in Swedish children with cleft palate and to examine potential associations of independent variables with this incidence.

METHODS

In this cohort study, we analysed data from the Swedish cleft lip and palate quality registry for 1093 children with cleft palate with or without cleft lip. Kaplan-Meier analysis was used to estimate the risk of having velopharyngeal dysfunction surgery. Multivariable Cox proportional hazards models were used to estimate the associated effect of cleft subtype, additional diagnoses, gender, and age at and number of stages for primary palate repair on the primary outcome.

RESULTS

The risk of having velopharyngeal dysfunction surgery was 25.6%. Complete primary palate repair after the age of 18 months or in more than one stage was associated with a higher risk, but it could not be determined which of these was the more significant factor. Cleft soft palate was associated with a significantly lower risk than other cleft subtypes.

CONCLUSIONS

Primary palate repair at a higher age or in more than one stage may increase the risk of having velopharyngeal dysfunction surgery. Further analysis of potential unknown confounding factors and the association between the incidence of velopharyngeal dysfunction and surgery to correct this condition is needed.

The Incidence of Velopharyngeal Insufficiency in Stickler Syndrome

OBJECTIVE

Stickler Syndrome (SS) is an inherited collagenopathy characterized by heterogenous orofacial, ocular, auditory, and skeletal abnormalities. The orofacial manifestations are variable and some patients present with cleft palate and velopharyngeal insufficiency (VPI). The incidence of VPI in SS is poorly studied and no studies have compared the incidence of VPI between Type I (COL2A1) and Type II (COL11A1) SS. The objective of this study is to compare the incidence of VPI between SS subtypes and discuss the surgical techniques used to treat them.

DESIGN

Single-institution, retrospective chart review.

SETTING

Tertiary pediatric hospital.

PATIENTS/PARTICIPANTS

Forty-three children were diagnosed with SS between January 2003 and December 2018. Genetic testing results, genetics notes, craniofacial clinic notes, and operative reports were reviewed. Patients without genetic testing or craniofacial/otolaryngologic evaluation were excluded. Thirty-one patients met criteria and were included.

MAIN OUTCOME MEASURE

Primary outcome was VPI incidence.

RESULTS

There were 18 patients with Type I SS and 13 with Type II SS. Five (16%) patients had VPI, 2 (11%) with Type I SS compared to 3 (23%) with Type II SS (P > .05). All patients with VPI underwent surgery with either sphincter pharyngoplasty (3) or pharyngeal flap (2). Two patients with Type II SS underwent revision sphincter pharyngoplasty, with one conversion to pharyngeal flap.

CONCLUSION

VPI is common for patients with SS. In this study, there was no significant difference in the incidence of VPI between SS subtypes. Future studies are needed to confirm these findings, which could be important for patient counseling and treatment planning.

Primary Cleft Palate Repair

There are several factors to consider when planning cleft palate repair. It is important to review the patient's associated comorbidities, as they impact decisions on perioperative management and family counseling. Many comorbidities change the risk of postoperative airway obstruction, velopharyngeal insufficiency, or fistula formation. It is also critical to determine the type of cleft palate to be addressed, as this influences the decision on which technique is most appropriate for optimal patient outcome. Common surgical techniques for palatoplasty are reviewed in detail and outcomes are discussed as it relates to various techniques. Intraoperative photographs are included to detail the procedures.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Simulation of Velopharyngeal Biomechanics Identifies Differences in Sphincter Pharyngoplasty Outcomes: A Matched Case-Control Study

The purpose of this study was to develop a framework for 3D subject-specific computational models capable of simulating velopharyngeal biomechanics for anatomic changes that occur following pharyngoplasty and to gain insight into biomechanical factors that may lead to different speech/surgical outcomes. Patient-specific models for two, matched participants with differing speech/surgical outcomes were developed: one with a successful pharyngoplasty outcome and one with a failed pharyngoplasty outcome. Surgical scenarios were simulated to model pharyngoplasty location, identify LVP muscle biomechanics, and identify an optimal pharyngoplasty location for each participant. These simulations illustrate the potential for optimizing pharyngoplasties based on patient-specific geometry.

A novel technique predicting velopharyngeal insufficiency risk in newborns following primary cleft repair. A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty

The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.

Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps

SUMMARY

The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.