Image analysis of lateral velopharyngeal closure in repaired cleft palates and normal palates

How differences in anatomy and physiology and other aetiology affect the way we label and describe speech in individuals with cleft lip and palate

BACKGROUND

Speech in individuals with cleft lip and/or palate (CLP) is a complex myriad of presenting symptoms. It is uniquely associated with the structural difference of velopharyngeal insufficiency (VPI), together with a wide and heterogeneous range of other aetiologies which often co-occur. The nature of the speech sound disorder (SSD) including VPI may also change over the course of an individual's care pathway. Differences in terminology and approaches to analysis are currently used, resulting in confusion internationally. Additionally, current diagnostic labels and classification systems in SSD do not capture the complexity and full nature of speech characteristics in CLP.

AIMS

This paper aims to explore the different aetiologies of cleft palate/VPI speech and to relate aetiology with speech characteristic(s). In so doing, it attempts to unravel the different terminology used in the field, describing commonalities and differences, and identifying overlaps with the speech summary patterns used in the United Kingdom and elsewhere. The paper also aims to explore the applicability of current diagnostic labels and classification systems in the non-cleft SSD literature and illustrate certain implications for speech intervention in CLP.

METHODS AND PROCEDURES

The different aetiologies were identified from the literature and mapped onto cleft palate/VPI speech characteristics. Different terminology and approaches to analysis are defined and overlaps described. The applicability of current classification systems in SSD is discussed including additional diagnostic labels proposed in the field.

OUTCOMES AND RESULTS

Aetiologies of cleft palate/VPI speech identified include developmental (cognitive-linguistic), middle ear disease and fluctuating hearing loss, altered oral structure, abnormal facial growth, VPI-structural (abnormal palate muscle) and VPI-iatrogenic (maxillary advancement surgery). There are four main terminologies used to describe cleft palate/VPI speech: active/passive and compensatory/obligatory, which overlap with the four categories used in the UK speech summary patterns: anterior oral cleft speech characteristics (CSCs), posterior oral CSCs, non-oral CSCs and passive CSCs, although not directly comparable. Current classification systems in non-cleft SSD do not sufficiently capture the full nature and complexity of cleft palate/VPI speech.

CONCLUSIONS AND IMPLICATIONS

Our attempt at identifying the heterogeneous range of aetiologies provides clinicians with a better understanding of cleft palate/VPI speech to inform the management pathway and the nature and type of speech intervention required. We hope that the unravelling of the different terminology in relation to the UK speech summary patterns, and those used elsewhere, reduces confusion and provides more clarity for clinicians in the field. Diagnostic labels and classification require international agreement.

WHAT THIS PAPER ADDS

What is already known on the subject Speech associated with cleft palate/velopharyngeal insufficiency (VPI) is a complex myriad of speech characteristics with a wide and heterogeneous range of aetiologies. Different terminology and speech summary patterns are used to describe the speech characteristics. The traditional classification of cleft palate/VPI speech is Articulation Disorder, although evidence is building for Phonological Disorder and contrastive approaches in cleft speech intervention. What this paper adds to existing knowledge This paper explores the range of aetiologies of cleft palate/VPI speech (e.g., altered oral structure, abnormal facial growth, abnormal palate muscle and iatrogenic aetiologies) and attempts to relate aetiology with speech characteristic(s). An attempt is made at unravelling the different terminology used in relation to a well-known and validated approach to analysis, used in the United Kingdom and elsewhere. Complexities of current diagnostic labels and classifications in Speech Sound Disorder to describe cleft palate/VPI speech are discussed. What are the potential or actual clinical implications of this work? There needs to be a common language for describing and summarising cleft palate/VPI speech. Speech summary patterns based on narrow phonetic transcription and correct identification of aetiology are essential for the accurate classification of the speech disorder and identification of speech intervention approaches. There is an urgent need for research to identify the most appropriate type of contrastive (phonological) approach in cleft lip and/or palate.

Paediatric velopharyngeal insufficiency following adenotonsillar surgery

OBJECTIVE

Paediatric velopharyngeal insufficiency (VPI) is a known but rare complication following adenotonsillar surgery that can have significant adverse effects on the communication as well as psychological well-being of the patient and their family. We sought to assess risk factors, aetiology, assessment and management of these patients through a dedicated multidisciplinary clinic.

METHODS

Retrospective data collection was performed for patients seen in the Great Ormond Street Hospital for Children multidisciplinary VPI clinic from the 1^st of January 2015 until 30^th of April 2020. Paediatric patients with previous adenotonsillar surgery and no evidence of cleft palate or speech and language disorder were included in the study.

RESULTS

29 patients met the inclusion criteria, with 16 having previous adenotonsillectomy and 13 isolated adenoidectomy. In our VPI clinic, patients were seen on average for 4.9 occasions over a 38.3-month period. Clinical assessment was conducted using GOS.SP.ASS '98 speech assessment tool, speech videofluoroscopy and nasoendoscopy, as per individual needs. The main cause of post-adenoidectomy VPI was identified in 72.5% of the cases. Speech videofluoroscopy was performed in 27 cases. Associated anatomic features identified included deep pharynx (37%), long palate (22.2%) and variable levator position. Severe hypernasality was noted in 3 patients, while in 20 cases moderate or mild hypernasality was found. There were no patients with normal speech. Ten patients were treated with speech therapy alone, whereas surgical intervention was required in seventeen cases. In the population who received treatment and had adequately recorded follow-up, improvement in speech was noted in 86.9%, with 30.4% having oral resonance on last review. Of the patients with severe hypernasality, all improved but had some persistent hyper nasality on last clinic review.

CONCLUSIONS

We present our multidisciplinary management of post adenoidectomy VPI. Through the investigations in our dedicated specialist VPI clinic, the cause of VPI was found more frequently than in previous reports in the literature. Intense treatment is usually required with lengthy follow-up and multiple attendances in VPI clinic. Main modalities of management include SLT, surgery and speech prostheses. Most patients' speech will improve with intervention. We highlight the importance of early recognition, referral and a multi-disciplinary approach in treating this condition. We advise ENT surgeons to ensure patients are adequately aware of this complication given its potential impact.

A perceptual outcome measure of velopharyngeal function based on the Cleft Audit Protocol for Speech-Augmented (CAPS-A VPC-Sum): Validation through a speech osteotomy study

BACKGROUND

The status of the velopharyngeal mechanism can be inferred from perceptual ratings of specified speech parameters. Several studies have proposed the measure of an overall velopharyngeal composite score based on these perceptual ratings and have reported good validity. The Cleft Audit Protocol for Speech-Augmented (CAPS-A) is a validated and reliable perceptual framework for the assessment of cleft speech and velopharyngeal function used by all Regional Cleft Services in the UK and Ireland. An overall velopharyngeal composite summary score based on the CAPS-A would serve as an important surgical outcome measure of speech.

AIMS

To develop and validate a velopharyngeal composite summary score based on perceptual ratings made on the CAPS-A (CAPS-A VPC-Sum) using data from a maxillary osteotomy (MO) study.

METHODS & PROCEDURES

There were two surgical groups: a cleft lip and palate (CLP) (N = 20) group and a non-CLP group (N = 10), and a normal control group (N = 20). Participants in groups 1 and 2 were seen for perceptual and instrumental assessments of speech and velopharyngeal function preoperatively (T1), 3 months (T2) and 12 months (T3) postoperatively. Perceptual speech data were collected and rated by independent listeners using CAPS-A.

OUTCOMES & RESULTS

Moderate to strong interrater reliability for perceptual data (r_s = 0.503-1.000, all p < 0.01) and strong to very strong reliability for videofluoroscopic measurements (r_s = 0.746-0.947) were found. Construct validity of the CAPS-A VPC-Sum was shown by an increase in postoperative scores for the CLP group only ϰ² (2) = 9.769, p = 0.008 and significant differences between the CLP and the other two groups at T2 and T3 using independent t-tests. Convergent and divergent validity was indicated by a positive moderate correlation with related parameters (e.g., hypernasality r_s = 0.869, p < 0.01) and a weak correlation with unrelated parameters (e.g., amount of forward advancement r_s = 0.160, p = 0.526). Criterion validity was found by a moderate correlation between closure ratio r_s = -0.541, p = 0.020 and CAPS-A VPC-Sum.

CONCLUSIONS & IMPLICATIONS

A velopharyngeal composite score based on perceptually rated parameters serves as an important surgical speech outcome measure. The CAPS-A VPC-Sum is a useful, reliable and valid outcome measure of velopharyngeal function. There are added positive implications for other clinicians using geographically and language-specific adapted versions of the CAPS-A internationally.

WHAT THIS PAPER ADDS

What is already known on this subject Velopharyngeal composite scores based on perceptually rated speech parameters have been shown to have both clinical and research utility, serving as a useful surgical outcome measure. However, such a composite score must be specifically validated on the perceptual speech framework upon which it is based, as there are differences in measurement methods and terminology across cleft speech perceptual frameworks internationally. What this paper adds to existing knowledge The CAPS-A is a nationally used tool in the UK and Ireland for audit and research purposes with validated and adapted international versions. This paper reports on the validation of the derived velopharyngeal composite score measure based on the CAPS-A and an English-speaking sample, providing evidence of its validity through a speech osteotomy study. What are the potential or actual clinical implications of this work? This work provides CLP teams who use CAPS-A with a validated surgical speech outcome measure of velopharyngeal function. It has positive implications also for adapted versions of the CAPS-A internationally.

Identifying Predictors of Acquired Velopharyngeal Insufficiency in Cleft Lip and Palate Following Maxillary Osteotomy Using Multiple Regression Analyses

BACKGROUND

Maxillary osteotomy is typically undertaken to correct abnormal facial growth in cleft lip and palate. The surgery can cause velopharyngeal insufficiency resulting in hypernasality. This study aims to identify valid predictors of acquired velopharyngeal insufficiency following maxillary osteotomy by using a range of perceptual and instrumental speech investigations and multiple regression.

METHODS

A prospective study was undertaken consisting of a consecutive series of patients with cleft lip and palate (N = 20) undergoing maxillary osteotomy by a single surgeon. Participants were seen at: 0 to 3 months pre-surgery (T1), 3-months (T2), and 12-months (T3) post-surgery. Hypernasality was rated using the cleft audit protocol for speech-augmented (CAPS-A) and visual analog scales, and nasalance was measured on the Nasometer II 6400. For lateral videofluorosopic and nasendoscopic images, visual perceptual ratings and quantitative ratiometric measurements were undertaken. Multiple regression analyses were undertaken to identify predictors.

RESULTS

T3 models with hypernasality as the dependent variable were found to be a good fit and significant (eg, CAPS-A: R2 = 0.920, F(11,7) = 7.303, P = 0.007). Closure ratio (a quantitative ratiometric measurement) and proportion of palate contacting the posterior pharyngeal wall (a visual perceptual rating) were identified as significant predictors for the CAPS-A model (P = 0.030, P = 0.002).

Effect of Maxillary Osteotomy on Speech in Cleft Lip and Palate: Instrumental Outcomes of Velopharyngeal Function

Objective:

To investigate the effect of maxillary osteotomy on velopharyngeal function in cleft lip and palate (CLP) using instrumental measures.

Design:

A prospective study.

Participants:

A consecutive series of 20 patients with CLP undergoing maxillary osteotomy by a single surgeon were seen at 0 to 3 months presurgery (T1), 3 months (T2), and 12 months (T3) post-surgery.

Interventions:

Nasalance was measured on the Nasometer II 6400. For videofluoroscopy and nasendoscopy data, visual perceptual ratings, for example, palatal lift angle (PLAn), and quantitative ratiometric measurements, for example, closure ratio (CRa), were made using a validated methodology and computer software. Reliability studies were undertaken for all instrumental measures.

Main Outcome Measures:

Repeated measures analysis of variance (with time at 3 levels) for nasalance and each velar parameter. Planned comparisons across pairs of time points (T1-T2, T1-T3, and T2-T3) including effect sizes.

Results:

A significant difference over time was found for nasalance ( P = .001) and planned comparisons across pairs of time points were significant between T1 and T2 ( P = .008), T1 and T3 ( P = .002), but not between T2 and T3 ( P = .459) providing evidence that maxillary osteotomy can impact on nasalance adversely and that the changes seen are permanent and stable. There were also significant differences over time for PLAn ( P = .012) and CRa ( P = −.059) and planned comparisons for both velar parameters reflected similar findings to those of nasalance.

Conclusions:

Maxillary osteotomy can adversely affect velopharyngeal function in patients with CLP. The study provides evidence for a much earlier post-surgery review even as early as 3 months after surgery.

Velopharyngeal Closure and Resonance in Children Following Early Cleft Palate Repair: Outcome Measurement

Introduction Timing of cleft palate repair and the method of speech outcome measurement in children with cleft lip and palate are much debated topics. The associated problems and quality of life in these children depend on the timing of the surgery.

Aim The aim of this study was to investigate the velopharyngeal (VP) function and resonance parameters in children following early cleft palate repair.

Method A total of 25 Kannada-speaking children with early repaired cleft palate were subjected to speech assessment and videofluoroscopic assessment. Perceptual speech parameters measured were severity of hypernasality and presence of nasal air emission. Videofluoroscopy was interpreted in terms of closure ratios to predict the severity of VP dysfunction.

Results The analysis of videofluoroscopic images indicated that 48% of children had complete VP closure and 52% had perceptually normal resonance. A good correlation was found between the closure ratio and hypernasality.

Conclusion Understanding the perceptual speech parameters and their structural correlates for outcome measurement will give better evidence for refining the existing treatment protocols. Data on a larger population are warranted for establishing predictors of optimum speech outcome.

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.

Plus ça change: selected papers on speech research from the 1964 issue of the Cleft Palate Journal

This review is part of a series of papers by the editorial board reflecting on the 1964 volume of the journal, thereby marking the 50th anniversary of the Cleft-Palate Craniofacial Journal. Twelve speech-related contributions from that year are reviewed. The papers are sorted into four broad thematic categories: quantitative assessment of hypernasality, perceptual assessment of speech, radiological imaging of velopharyngeal function, and speech prosthetics. The 1964 contributions are discussed with regards to their relevance to today's research and clinical practice.

Palate Lengthening by Buccinator Myomucosal Flaps for Velopharyngeal Insufficiency

Objective

To assess the outcome of palate lengthening by myomucosal buccinator flaps for velopharyngeal insufficiency both in terms of speech and changes in palate length.

Design

Thirty-two consecutive patients who underwent the buccinator flap procedure were reviewed retrospectively. Palate length and the presence or absence of a velopharyngeal gap were assessed on pre- and postoperative videofluoroscopic recordings using a calibrated image analysis system. Hypernasality, nasal emission, nasal turbulence, and passive cleft type articulation errors were evaluated blindly by a speech-language pathologist external to the team using pre- and postoperative speech recordings.

Setting

Multidisciplinary cleft team based in a tertiary referral center.

Results

In 81% of patients, speech outcome was such that no further velopharyngeal surgery was considered necessary at the time of follow-up. The buccinator flap procedure resulted in a mean palate lengthening of 7.5 mm (±5.5 SD). After the operation, there was a complete elimination of the velopharyngeal gap on lateral videofluoroscopy in 77% of patients. There were significant decreases in hypernasality ratings and passive cleft type articulation errors postoperatively.

Conclusion

Palatal lengthening with myomucosal buccinator flaps in patients with velopharyngeal insufficiency is effective and safe. It has become one of our routinely practiced procedures for velopharyngeal insufficiency.

Magnetic resonance imaging assessment of the velopharyngeal mechanism at rest and during speech in Chinese adults and children

PURPOSE

Recent applications of the magnetic resonance imaging (MRI) technique introduced accurate 3-dimensional measurements of the velopharyngeal mechanism. Further standardization of the data acquisition and analysis protocol was successfully applied to imaging adults at rest and during phonation. This study was designed to test and modify a noninvasive protocol for evaluating young children without using general anesthesia. In addition, the velopharyngeal structures and their maximal motion were compared between adults and children.

METHOD

MRI data were acquired in 12 young adults and 9 children at rest and during speech production. Multiple measurements were made on the velopharyngeal and craniofacial structures as well as on the levator veli palatini muscle.

RESULTS

Most of the ratio measurements of structural shape and maximal motion in the velopharyngeal and craniofacial regions were not significantly different between the adults and the children, despite the fact that the children had much smaller structures than the adults.

CONCLUSION

The proportion of the velopharyngeal mechanism remains stable in young children and adults so that the motions of the velum and pharyngeal walls are adequate to close the velopharyngeal port completely.

Biomechanical Properties of the Human Soft Palate

Objective:

To measure biomechanical properties of the human soft palate and the variation across anatomic regions.

Design:

Ex vivo analysis of human tissue.

Patients/participants:

Ten palates harvested from 10 normal adult human cadavers (age range, 37 to 90 years).

Interventions:

Computer-controlled uniaxial stress-relaxation mechanical properties tested in physiological saline at 37°C.

Main Outcome Measures:

Measurement of Young modulus, Poisson ratio, and determination of viscoelastic constants c, τ1, and τ2 by curve-fitting of the reduced relaxation function to the data.

Results:

One hundred sections were tested from the 10 palates, representative of 10 anatomic zones. The mean Young modulus range was 585 Pa at the posterior free edge to 1409 Pa at regions of attachment. The mean Poisson ratio in the inferior-superior direction was 0.45 (SD 0.26) and in the lateral direction, was 0.30 (SD 0.21). The mean viscoelastic constants for 1-mm extensions were C  =  −0.1056 (±0.1303), τ1  =  11.0369 (±9.1865) seconds, and τ2  =  0.2128 (±0.0792) seconds, and for 2-mm extensions were C  =  −0.1111 (±0.1466), τ1  =  14.3725 (±5.2701) seconds, and τ2  =  0.2094 (±0.0544) seconds.

Conclusions:

The results show agreement with values of the Young modulus estimated by authors (Ettema and Kuehn, 1994; Berry et al., 1999) undertaking finite element modeling of the palate. However, other modulus measurements based on closing pressure are considerably different. The spatial distribution of viscoelastic parameters across the palate shows good consistency.

Surgical management of velopharyngeal incompetence in velocardiofacial syndrome

OBJECTIVES

To analyze the results of surgery for velopharyngeal incompetence (VPI) in velocardiofacial syndrome.

DESIGN

Prospective data collection, with randomized, blind assessment of speech and velopharyngeal function on lateral videofluoroscopy and nasendoscopy.

SETTING

Two-site, tertiary referral cleft unit.

PATIENTS

Forty-two consecutive patients with the 22q11 deletion underwent surgery for symptomatic VPI by a single surgeon.

INTERVENTIONS

Intraoral examinations, lateral videofluoroscopy (+/- nasendoscopy) and intraoperative evaluation of the position of the velar muscles through the operating microscope. Based on these findings, either a radical dissection and retropositioning of the velar muscles (submucous cleft palate [SMCP repair]) or a Hynes pharyngoplasty (posterior pharyngeal wall augmentation pharyngoplasty) was performed. As anticipated, a proportion of patients undergoing SMCP repair subsequently required a Hynes. The aim of this staged approach was to maximize velar function, thereby enabling a less obstructive pharyngoplasty to be performed. Thus, there were three surgical groups for analysis: SMCP alone, Hynes alone, and SMCP+Hynes.

MAIN OUTCOME MEASURES

Blind perceptual rating of resonance and nasal airflow; blind assessment of velopharyngeal function on lateral videofluoroscopy and nasendoscopy; and identification of predictive factors.

RESULTS

Significant improvement in hypernasality in all three groups. The SMCP+Hynes group also showed significant improvement in nasal emission. There were significant improvements in the extended and resting velar lengths following SMCP repair and a trend toward increased velocity of closure.

CONCLUSIONS

Depending on velopharyngeal anatomy and function, there is a role for SMCP repair, Hynes pharyngoplasty, and a staged combination of SMCP+Hynes, all of which are procedures with a low morbidity.

Submucous cleft palate: a grading system and review of 40 consecutive submucous cleft palate repairs

OBJECTIVES

This study was designed to determine whether velar surgery was worthwhile for submucous cleft palate (SMCP) and evaluate whether results were dependent on the degree of the anatomical abnormality.

DESIGN

A prospective study of a consecutive series of patients fulfilling the entry criteria, assessed blindly from records arranged randomly.

PATIENTS

Fifty-eight patients diagnosed with SMCP and operated on by a single surgeon between June 1991 and April 1997 were reviewed. Forty patients fulfilled the entry criteria. Minimum follow-up was 6 years.

INTERVENTION

Radical reconstruction of the soft palate musculature was performed by one surgeon using the operating microscope. A scoring system was devised for grading the anatomical severity of submucous cleft (SMCP score).

MAIN OUTCOME MEASURES

Postoperative hypernasality and nasal emission scores and the degrees of improvement were considered the primary outcome measures, and the degree of velopharyngeal closure was also assessed.

RESULTS

There were highly significant improvements in hypernasality, nasal emission, and velopharyngeal closure. A preoperative gap size of more than 13 mm was associated with less satisfactory outcomes, but gap size was not predictive of improvement. Severity of the SMCP did not correlate with the degree of preoperative speech abnormality but was a significant predictor of outcome of surgery, with the less severe (total SMCP score of 0 to 3) having less satisfactory end results and lesser degrees of improvement. Patients with less abnormal muscle anatomy had lesser degrees of improvement.

CONCLUSION

Repair of the muscle abnormality in SMCP is recommended as the first line of treatment in most cases.

Unilateral Moore pharyngoplasty in the treatment of unilateral or asymmetric velopharyngeal incompetence

OBJECTIVE

To describe the use of a unilateral modification of the Moore pharyngoplasty in the treatment of unilateral or asymmetric velopharyngeal incompetence (VPI) and analyze the results in a consecutive series of patients operated on by a single surgeon.

DESIGN

Blind assessment of randomized speech and nasendoscopy recordings.

SETTING

A two-site tertiary referral cleft unit.

PATIENTS

Eighteen consecutive patients with asymmetrical or unilateral VPI of varying etiology.

INTERVENTIONS

A unilateral Moore pharyngoplasty was performed in all patients. Three patients underwent radical dissection and retropositioning of the velar muscles at the same time as the unilateral Moore pharyngoplasty.

MAIN OUTCOME MEASURES

Pre- and postoperative nasality and nasal airflow using the CAPS score, assessment of nasendoscopy recordings, and the rate of further surgery.

RESULTS

There was a significant improvement in hypernasality (p =.014). There was a highly significant decrease in the size of the velopharyngeal gap on the side on which the Moore pharyngoplasty was performed (p =.004) as well as a highly significant decrease in the total gap size (p =.003). The Moore flap was effective in obliterating the lateral pharyngeal recess in 11 of 12 patients (p =.004). Three patients required further velopharyngeal surgery.

CONCLUSIONS

In appropriately selected patients, a unilateral Moore pharyngoplasty is a safe and effective treatment for unilateral or asymmetric VPI. If indicated, a radical dissection and retropositioning of the velar muscles may be combined with a Moore pharyngoplasty.

Palate re-repair revisited

OBJECTIVE

To analyze the results of a consecutive series of palate re-repairs performed using the operating microscope and identify predictive factors for outcome.

DESIGN

Prospective data collection, with blind assessment of randomized recordings of speech and velar function on lateral videofluoroscopy and nasendoscopy.

PATIENTS

One hundred twenty-nine consecutive patients with previously repaired cleft palates and symptomatic velopharyngeal incompetence (VPI) and evidence of anterior insertion of the levator veli palatini underwent palate re-repairs by a single surgeon from 1992 to 1998. Syndromic patients, those who had significant additional surgical procedures at the time of re-repair (23 patients), and all patients with inadequate pre- or postoperative speech recordings were excluded, leaving a total of 85 patients in the study.

INTERVENTIONS

Palate re-repairs, with radical dissection and retropositioning of the velar muscles, were performed using the operating microscope with intraoperative grading of anatomical and surgical findings.

MAIN OUTCOME MEASURES

Pre- and postoperative perceptual speech assessments using the Cleft Audit Protocol for Speech (CAPS) score, measurement of velar function on lateral videofluoroscopy, and assessment of nasendoscopy recordings.

RESULTS

There were significant improvements in hypernasality, nasal emission, and nasal turbulence and measures of velar function on lateral videofluoroscopy, with improvement in the closure ratio, velopharyngeal gap at closure, velar excursion, velar movement angle, and velar velocity.

CONCLUSIONS

Palate re-repair has been shown to be effective in treating VPI following cleft palate repair, both in patients who have not had an intravelar veloplasty and those who have had a previous attempt at muscle dissection and retropositioning. Palate re-repair has a lower morbidity and is more physiological than a pharyngoplasty or pharyngeal flap.

A study of the measurement errors associated with the analysis of velar movements assessed from lateral videofluoroscopic investigations

OBJECTIVE

The analysis of lateral videofluoroscopic images of velar movements during speech is a commonly used tool in the management of the cleft palate patient. This study tests the general hypothesis that measurements of velar movements taken from lateral videofluoroscopic images are accurate and reliable.

METHOD

A measurement system was used that allowed for the rapid assessment of velopharyngeal distance, soft palate velocity during the closure cycle, extension of the soft palate at maximum closure, and the angular lift of the soft palate above the plane of the hard palate. Ten recordings of soft palate movement during speech were randomly chosen from lateral X-rays of 27 normal adults. The video recordings were captured by digital frame grabber for subsequent analysis by three operators using a standard PC that was running image-analysis software. The uncertainties associated with the above measurements were analyzed in terms of the errors introduced by the inherent calibration and nonlinearity of the imaging system, the inaccuracy of the patient setup, and the operator-dependent measurement error.

RESULTS

For both absolute dimensions and ratiometric measurements, the measurement uncertainties related to the inherent nonlinearity in the imaging system were shown to be less than 2%. Typical patient misalignments as a result of a 10 degree head rotation and a 10-mm translation out of the measurement plane introduced errors of between 2% and 3%. Results showed that the average standard deviation for measurement of gap size was 1.2 mm, extension ratio was 0.11, angular lift was 3.1 degrees, and soft palate velocity was 15.5 mm/second. The intra-class correlation coefficient generally showed a good agreement between operators, typically in the range 0.8 to 0.9.

CONCLUSION

Measurements of velopharyngeal distance, extension of the soft palate at maximum closure, and the angular lift of the soft palate above the plane of the hard palate assessed from lateral videofluoroscopic images are reliable and accurate. The soft palate velocity during the closure cycle can also be determined, but clinical interpretations based on this parameter should be constrained by the measurement uncertainties.

Objective evaluation of the Tajima secondary cleft lip nose correction

The early and late results of the Tajima cleft nose correction were objectively measured by computer on 24 unilateral complete cleft lip and palate patients (age range 5-29 years, median 14). Follow-up records were divided into early (within 3 months), intermediate (3 months to 1 year) and late (1 year+); the longest follow-up was 4.2 years. Comparison of the preoperative records with the early and intermediate follow-up photographs showed an improvement in symmetry (Wilcoxon signed rank, P < 0.01). In the late follow-up group the deformity recurred and the nasal shape could not be statistically separated from the preoperative appearance. A group of 25 normal control faces showed no changes, whilst 20 control cleft patients had some worsening of nasal symmetry over the same time scale. Analysis of the components of the corrected noses showed the best improvement (and later relapse) was in dome symmetry.

Primary repair of the unilateral cleft lip nose: completion of a longitudinal study

The first 10 consecutive unilateral cleft subjects operated on in 1975 by a technique of primary cleft nose correction, developed by the author (HKM), were reviewed at ages 10 and 18. No further nasal surgery had been performed on these cases. The anteroposterior and inferior facial appearances of each of the cases have been published for evaluation. A computer-based method of measuring nasal asymmetry was used to objectively analyze the results and compare them with normal and cleft control faces that were age matched. The results support the observation that nasal growth of the cleft side of the nose is unaffected by early primary nasal surgery and that the vertical shortening of the nose by the alar lift technique is preserved into adult life. Residual nostril asymmetry from septal deviation persists into adulthood.

Cleft palate re-repair--a clinical and radiographic study of 32 consecutive cases

The results of clinical and radiographic assessment of palate re-repair (by a single operator) in 32 patients are presented. This has shown that radical muscle correction as a secondary procedure (following limited or no muscle correction in primary repair) has produced measurable improvement in velar function and should be considered as the first option in many patients with velopharyngeal incompetence. The results also support the concept of muscle dissection and retropositioning in primary cleft palate repair.