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Kimia R, Solot CB, McCormack SM, Cohen M, Blum JD, Villavisanis DF, Vora N, Valenzuela Z, Taylor JA, Low DW, Jackson OA. Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients. Cleft Palate Craniofac J 2024; 61:1007-1017. [PMID: 36749038 DOI: 10.1177/10556656231154808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients. SETTING An academic tertiary pediatric care center. METHODS Retrospective cohort study. PATIENTS Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL). OUTCOME MEASURES The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS). RESULTS 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05). CONCLUSION Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.
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Affiliation(s)
- Rotem Kimia
- Division of Plastic and Reconstructive Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Cynthia B Solot
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marilyn Cohen
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica D Blum
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dillan F Villavisanis
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nisha Vora
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary Valenzuela
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Marston AP, Tollefson TT. Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions. Curr Opin Otolaryngol Head Neck Surg 2024:00020840-990000000-00129. [PMID: 38837190 DOI: 10.1097/moo.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction. RECENT FINDINGS Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea. SUMMARY Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.
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Affiliation(s)
- Alexander P Marston
- University of California Davis Health, Department of Otolaryngology - Head and Neck Surgery, Sacramento, California, USA
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Cohen M. Secondary Procedures on the Palate to Correct/Improve Speech: Past, Present and Future. J Craniofac Surg 2024:00001665-990000000-01629. [PMID: 38781426 DOI: 10.1097/scs.0000000000010221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/14/2024] [Indexed: 05/25/2024] Open
Abstract
Speech production in general and in patients with cleft palate in particular is multifactorial. In addition to the complex velopharyngeal mechanism, all structures of the oral cavity have some contribution for correct speech production. Therefore, in addition to the velopharynx the surgeons and other cleft/craniofacial team members need to perform a thorough and complete evaluation of all structures to fully appreciate the causative factor(s) responsible for inadequate speech production after palatoplasty and to prescribe the most appropriate, personalized management plan. The purpose of this communication is to stress the importance of areas other than the velopharyngx that could have a negative impact on speech. More specifically, the issues of palatoplasty failures and palatal revisions will be presented. This is an area of significant importance and could represent the first line of defense before considering procedures altering the anatomy of the velopharynx, such as pharyngeal flaps, pharyngoplasties, and others. Issues covering the effects of skeletal and dental problems, such as malocclusion, partial or complete edentulism can also affect speech but are outside the scope of this communication.
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Affiliation(s)
- Mimis Cohen
- Division of Plastic, Reconstructive and Cosmetic Surgery and The Craniofacial Center, University of Illinois Chicago, Chicago, IL
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Sitzman TJ, Baylis AL, Perry JL, Weidler EM, Temkit M, Ishman SL, Tse RW. Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair. Cleft Palate Craniofac J 2024; 61:870-881. [PMID: 36562144 PMCID: PMC10287832 DOI: 10.1177/10556656221147159] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas J. Sitzman
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Adriane L. Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Plastic and Reconstructive Surgery and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Speech Language Hearing Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Jamie L. Perry
- Department of Communication Sciences and Disorders East Carolina University, Greenville, North Carolina, USA
| | - Erica M. Weidler
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, USA
| | - M’hamed Temkit
- Department of Clinical Research, Phoenix Children’s Hospital, Phoenix, Arizona, USA
| | - Stacey L. Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Raymond W. Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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Aboulhassan MA, Elrouby IM, Refahee SM, Abd-El-Ghafour M. Effectiveness of secondary furlow palatoplasty with buccal myomucosal flap in correction of velopharyngeal insufficiency in patients with cleft palate. Clin Oral Investig 2024; 28:257. [PMID: 38630186 PMCID: PMC11024043 DOI: 10.1007/s00784-024-05607-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/09/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
| | | | - Shaimaa Mohsen Refahee
- Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Fayoum University, Fayoum, Egypt.
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Williams JL, Perry JL, Snodgrass TD, Singh DJ, Temkit M, Sitzman TJ. Can MRI Replace Nasopharyngoscopy in the Evaluation of Velopharyngeal Insufficiency? Cleft Palate Craniofac J 2024:10556656241239459. [PMID: 38490221 DOI: 10.1177/10556656241239459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVE To investigate whether flexible nasopharyngoscopy, when performed in addition to magnetic resonance imaging (MRI), influences the type of surgery selected or success of surgery in patients with velopharyngeal insufficiency (VPI). DESIGN Cohort study. SETTING A metropolitan children's hospital. PATIENTS Patients with non-syndromic, repaired cleft palate presenting for management of VPI. INTERVENTIONS MRI and nasopharyngoscopy or MRI alone for preoperative imaging of the velopharyngeal mechanism. MAIN OUTCOME MEASURES (1) Surgical selection and (2) resolution of hypernasality. All speech, MRI, and nasopharyngoscopy measurements were performed by raters blinded to patients' medical and surgical history. RESULTS Of the 25 patients referred for nasopharyngoscopy, 76% completed the exam. Of the 41 patients referred for MRI, the scan was successfully completed by 98% of patients. Completion of nasopharyngoscopy was significantly (p=0.01) lower than MRI. Surgical selection did not significantly differ (p=0.73) between the group receiving MRI and nasopharyngoscopy and the group receiving MRI alone, nor was there a significant difference between these groups in the proportion of patients achieving resolution of hypernasality postoperatively (p=0.63). Percent total velopharyngeal closure assessments on nasopharyngoscopy and MRI were strongly correlated (r=0.73). CONCLUSIONS In patients receiving MRI as part of their preoperative VPI evaluation, the addition of nasopharyngoscopy did not result in a difference in surgical selection or resolution of hypernasality. Routine inclusion of nasopharyngoscopy may not be necessary for the evaluation of velopharyngeal anatomy when MRI is available.
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Affiliation(s)
- Jessica L Williams
- Phoenix Children's Center for Cleft and Craniofacial, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
- Program of Speech and Hearing Science, College of Health Solutions, Arizona State University, Tempe, AZ, USA
| | - Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Taylor D Snodgrass
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Davinder J Singh
- Phoenix Children's Center for Cleft and Craniofacial, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - M'hamed Temkit
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Thomas J Sitzman
- Phoenix Children's Center for Cleft and Craniofacial, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
- Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
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Kauffmann P, Kolle J, Quast A, Wolfer S, Schminke B, Meyer-Marcotty P, Schliephake H. Two-stage palatal repair in non-syndromic CLP patients using anterior to posterior closure is associated with minimal need for secondary palatal surgery. Head Face Med 2024; 20:18. [PMID: 38461271 PMCID: PMC10924352 DOI: 10.1186/s13005-024-00418-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/16/2024] [Indexed: 03/11/2024] Open
Abstract
OBJECTIVE The aim of the present study was to assess the need for secondary palatal corrective surgery in a concept of palate repair that uses a protocol of anterior to posterior closure of primary palate, hard palate and soft palate. METHODS A data base of patients primarily operated between 2001 and 2021 at the Craniofacial and Cleft Care Center of the University Goettingen was evaluated. Cleft lips had been repaired using Tennison Randall and Veau-Cronin procedures in conjunction with alveolar cleft repair. Cleft palate repair in CLP patients was accomplished in two steps with repair of primary palate and hard palate first using vomer flaps at the age of 10-12 months and subsequent soft palate closure using Veau/two-flap procedures 3 months later. Isolated cleft palate repair was performed in a one-stage operation using Veau/two-flap procedures. Data on age, sex, type of cleft, date and type of surgery, occurrence and location of oronasal fistulae, date and type of secondary surgery performed for correction of oronasal fistula (ONF)and / or Velophyaryngeal Insufficiency (VPI) were extracted. The rate of skeletal corrective surgery was registered as a proxy for surgery induced facial growth disturbance. RESULTS In the 195 patients with non-syndromic complete CLP evaluated, a total number of 446 operations had been performed for repair of alveolar cleft and cleft palate repair (Veau I through IV). In 1 patient (0,5%), an ONF occurred requiring secondary repair. Moreover, secondary surgery for correction of VPI was required in 1 patient (0,5%) resulting in an overall rate of 1% of secondary palatal surgery. Skeletal corrective surgery was indicated in 6 patients (19,3%) with complete CLP in the age group of 15 - 22 years (n = 31). CONCLUSIONS The presented data have shown that two-step sequential cleft palate closure of primary palate and hard palate first followed by soft palate closure has been associated with minimal rate of secondary corrective surgery for ONF and VPI at a relatively low need for surgical skeletal correction.
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Affiliation(s)
- Philipp Kauffmann
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Goettingen, Germany.
- Georg-August-University Goettingen, Robert-Koch-Straße 40, Goettingen, 37099, Germany.
| | - Johanna Kolle
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Anja Quast
- Department of Orthodontics, University Medical Center Goettingen, Goettingen, Germany
| | - Susanne Wolfer
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Boris Schminke
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Goettingen, Germany
| | | | - Henning Schliephake
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Goettingen, Germany
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Arganbright J. Surgical Management of Velopharyngeal Dysfunction. Facial Plast Surg Clin North Am 2024; 32:69-83. [PMID: 37981418 DOI: 10.1016/j.fsc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Velopharyngeal dysfunction (VPD) is caused by inadequate closure of the velopharyngeal port. VPD can hinder a child's ability to communicate and can impact his/her quality of life. Evaluation of children with VPD is often completed in a multidisciplinary setting and often involves studies that allow for the visualization of the velopharyngeal closure during voluntary speech (ie, nasopharyngoscopy). Multiple surgical options exist for the treatment of VPD including pharyngeal flap, sphincter pharyngoplasty, buccal myomucosal flaps, Furlow palatoplasty, palate re-repair, intravelar veloplasty, and injection pharyngoplasty. Each speech surgery has its unique benefits and drawbacks and the decision on which surgery to recommend should be tailored to each patient's specific needs and weighing the risk/benefit profile for their specific surgeries.
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Affiliation(s)
- Jill Arganbright
- Children's Mercy Hospital, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Pitkanen VV, Geneid A, Saarikko AM, Hakli S, Alaluusua SA. Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty. J Craniofac Surg 2023:00001665-990000000-01192. [PMID: 37955448 DOI: 10.1097/scs.0000000000009822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/06/2023] [Indexed: 11/14/2023] Open
Abstract
Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.
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Affiliation(s)
- Veera V Pitkanen
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Ahmed Geneid
- Department of Otolaryngology and Phoniatrics-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki
| | - Anne M Saarikko
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Sanna Hakli
- Department of Otolaryngology and Phoniatrics, Oulu University Hospital and PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Suvi A Alaluusua
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
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Sitzman TJ, Perry JL, Snodgrass TD, Temkit M, Singh DJ, Williams JL. Comparative Effectiveness of Secondary Furlow and Buccal Myomucosal Flap Lengthening to Treat Velopharyngeal Insufficiency. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5375. [PMID: 37928635 PMCID: PMC10624468 DOI: 10.1097/gox.0000000000005375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 11/07/2023]
Abstract
Background Secondary Furlow (Furlow) and buccal myomucosal flaps (BMMF) treat velopharyngeal insufficiency by lengthening the palate and retropositioning the levator veli palatini muscles. The criteria for choosing one operation over the other remain unclear. Methods A single-center retrospective cohort study was conducted. Thirty-two patients with nonsyndromic, repaired cleft palate were included. All patients underwent a Furlow or BMMF. Outcome measures included (1) resolution of hypernasality 12 months postoperatively, (2) degree of improvement of hypernasality severity; and (3) change in velar length, as measured on magnetic resonance imaging scans obtained preoperatively and 12 months postoperatively. All measures were performed by raters blinded to participants' medical and surgical history. Results Hypernasality was corrected to normal in 80% of the Furlow group and in 56% of the BMMF group. Patients receiving BMMF had more severe hypernasality during preoperative speech evaluation. Both groups had a median decrease of two scalar rating points for severity of hypernasality (P = 0.58). On postoperative magnetic resonance imaging, patients who underwent Furlow had a median increased velar length of 6.9 mm. Patients who received BMMF had a median increased velar length of 7.5 mm. There was no statistically significant difference between groups regarding increase in velar length (P = 0.95). Conclusions Furlow and BMMF procedures increase velar length with favorable speech outcomes. The same degree of improvement for hypernasality was observed across groups, likely explained by the similar increase in velar length achieved. Anatomic changes in palate length and levator veli palatini retropositioning persist 1 year after surgery.
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Affiliation(s)
- Thomas J. Sitzman
- From Phoenix Children’s Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Ariz
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Jamie L. Perry
- Department of Communication Sciences and Disorders East Carolina University, Greenville, N.C
| | - Taylor D. Snodgrass
- Department of Communication Sciences and Disorders East Carolina University, Greenville, N.C
| | - M’hamed Temkit
- Department of Clinical Research, Phoenix Children’s Hospital, Phoenix, Ariz
| | - Davinder J. Singh
- From Phoenix Children’s Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Ariz
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Jessica L. Williams
- From Phoenix Children’s Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Ariz
- Program of Speech and Hearing Science, College of Health Solutions, Arizona State University, Tempe, Ariz
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Zhang B, Shi B, Zheng Q, Li J. Prognostic Factors for Speech Outcome among Patients with Submucous Cleft Palate Managed by Furlow Palatoplasty or Posterior Pharyngeal Flap. Plast Reconstr Surg 2023; 152:876e-884e. [PMID: 36940158 DOI: 10.1097/prs.0000000000010446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Submucous cleft palate (SMCP) is a particular subtype of cleft deformity for which the optimal surgical timing and technique are still under debate. This study aimed to identify potential prognostic factors for the speech outcome of patients with SMCP and provide evidence for further management strategy optimization. METHODS The authors reviewed patients with nonsyndromic SMCP who received either Furlow palatoplasty (FP) or posterior pharyngeal flap (PPF) between 2008 and 2021 in a tertiary hospital-based cleft center. Both univariate and multivariate logistic regression models were used to screen preoperative variables, including cleft type (overt or occult), age at surgery, mobility of velum and pharyngeal wall, velopharyngeal closure ratio, and pattern. The receiver operating characteristic curve was used to determine the cutoff value of the significant predictors for subgroup comparison. RESULTS A total of 131 patients were enrolled, with 92 receiving FP and 39 receiving PPF. Age at operation and cleft type were identified as having significant effects on FP outcome. Patients operated on before 9.5 years of age had a significantly higher velopharyngeal competence (VPC) rate than those operated on after that age. The speech outcome among patients with occult SMCP was significantly worse than that of patients with overt SMCP after FP treatment. No preoperative variable was found to be correlated with PPF outcome. PPF yielded a higher VPC rate than did FP among patients operated on after 9.5 years of age. CONCLUSIONS The prognosis of patients with SMCP treated with FP is sensitive to age at surgery and cleft type. PPF may be considered for older patients in settings with limited access to multiple surgical procedures, especially when occult SMCP is diagnosed. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Bei Zhang
- From the State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University
| | - Bing Shi
- From the State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University
| | - Qian Zheng
- From the State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University
| | - Jingtao Li
- From the State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University
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Tse RW, Sie KC, Tollefson TT, Jackson OA, Kirshner R, Fisher DM, Bly R, Arneja JS, Dahl JP, Soldanska M, Sitzman TJ. Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations. Cleft Palate Craniofac J 2023:10556656231181359. [PMID: 37441787 PMCID: PMC10787042 DOI: 10.1177/10556656231181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.
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Affiliation(s)
- Raymond W Tse
- Craniofacial and Pediatric Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Plastic Surgery, University of Washington, Seattle, WA, USA
| | - Kathleen C Sie
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Travis T Tollefson
- Otolaryngology Head and Neck Surgery, University of California, Davis, Sacramento, CA, USA
| | - Oksana A Jackson
- Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Kirshner
- Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David M Fisher
- Plastic Surgery, The Hospital for Sick Children, Toronto, ON, USA
- Plastic Surgery, University of Toronto, Toronto, ON, USA
| | - Randall Bly
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Jugpal S Arneja
- Plastic Surgery, BC Children's Hospital, Vancouver, BC, USA
- Plastic Surgery, University of British Columbia, Vancouver, BC, USA
| | - John P Dahl
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | | | - Thomas J Sitzman
- Plastic Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Vale F, Paula AB, Travassos R, Nunes C, Ribeiro MP, Marques F, Pereira F, Carrilho E, Marto CM, Francisco I. Velopharyngeal Insufficiency Treatment in Cleft Palate Patients: Umbrella Review. Biomimetics (Basel) 2022; 7:biomimetics7030118. [PMID: 36134922 PMCID: PMC9496528 DOI: 10.3390/biomimetics7030118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Velopharyngeal insufficiency may occur as a result of an anatomical or structural defect and may be present in patients with cleft lip and palate. The treatment options presented in the literature are varied, covering invasive and non-invasive methods. However, although these approaches have been employed and their outcomes reviewed, no conclusions have been made about which approach is the gold-standard. This umbrella review aimed to synthesize the current literature regarding velopharyngeal insufficiency treatments in cleft lip and palate patients, evaluating their effectiveness based on systematic reviews. A standardized search was carried out in several electronic databases, namely PubMed via Medline, Web of Science, Cochrane Library, and Embase. The quality of the included studies was evaluated using AMSTAR2 and degree of overlap was analyzed using Corrected Covered Area. Thirteen articles were included in the qualitative review, with only 1 in the non-invasive method category, and 12 in the invasive method category. All reviewed articles were judged to be of low quality. In symptomatic patients, treatment did not solely comprise speech therapy, as surgical intervention was often necessary. Although there was no surgical technique considered to be the gold standard for the correction of velopharyngeal insufficiency, the Furlow Z-plasty technique and minimal incision palatopharyngoplasty were the best among reported techniques.
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Affiliation(s)
- Francisco Vale
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Correspondence:
| | - Anabela Baptista Paula
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3000-075 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3030-370 Coimbra, Portugal
- Institute of Integrated Clinical Practice, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Raquel Travassos
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
| | - Catarina Nunes
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
| | - Madalena Prata Ribeiro
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
| | - Filipa Marques
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
| | - Flávia Pereira
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
| | - Eunice Carrilho
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3000-075 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3030-370 Coimbra, Portugal
- Institute of Integrated Clinical Practice, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Carlos Miguel Marto
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3000-075 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3030-370 Coimbra, Portugal
- Institute of Integrated Clinical Practice, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Institute of Experimental Pathology, Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Inês Francisco
- Institute of Orthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal
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A treatment algorithm for secondary cleft palate repair based on age and preoperative velopharyngeal closure ratio. J Craniomaxillofac Surg 2022; 50:705-711. [DOI: 10.1016/j.jcms.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/03/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022] Open
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15
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Palatal Re-Repair With Z-Plasty in Treatment of Velopharyngeal Insufficiency of Syndromic and Nonsyndromic Patients With Cleft Palate. J Craniofac Surg 2021; 32:685-690. [PMID: 33705010 DOI: 10.1097/scs.0000000000007343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) often results from palatal shortening or insufficient levator function after cleft palate repair. AIMS To assess the efficacy of palatal re-repair with Z-plasty in treatment of VPI for patients with isolated cleft palate (ICP). METHODS This retrospective analysis comprised 130 consecutive patients who had ICP with VPI that required Z-plasty as secondary surgery between 2008 and 2017. Pre- and post-operative evaluation of velopharyngeal function was done perceptually and instrumentally by Nasometer. RESULTS Median patient age at Z-plasty was 6.8 years (range 3.0-20.1). Of the 130 patients, preoperatively VPI was severe in 73 (56%), mild-to-moderate in 55 (42%), and borderline in 2 (2%). Postoperatively, 105 (81%) of patients achieved adequate (normal or borderline) velopharyngeal competence and 16 (12%) required second operation for residual VPI. The success rate was 84% in nonsyndromic patients, 79% in nonsyndromic Pierre Robin sequence patients, and 58% in syndromic patients. In syndromic children, the speech outcome was significantly worse than in nonsyndromic children (P = 0.014). Complications included wound healing problems in 3 patients (2%), mild infection in 1 patient (1%), postoperative bleeding in 1 (1%), and postoperative fistula in 2 (2%). CONCLUSION Palatal re-repair with Z-plasty is a safe operation for VPI correction in patients with ICP with a success rate of 81%. In syndromic patients, the procedure did not seem to work as well as in nonsyndromic patients.
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