Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair

Magnetic Resonance Imaging of the Velopharynx: Clinical Findings in Patients with Velopharyngeal Insufficiency

BACKGROUND

Magnetic resonance imaging (MRI) is the only imaging modality capable of directly visualizing the levator veli palatini (LVP) muscles: the primary muscles responsible for velopharyngeal closure during speech. MRI has been used to describe normal anatomy and physiology of the velopharynx in research studies, but there is limited experience with use of MRI in the clinical evaluation of patients with velopharyngeal insufficiency (VPI).

METHODS

MRI was used to evaluate the velopharyngeal mechanism in patients presenting for VPI management. The MRI followed a fully awake, nonsedated protocol with phonation sequences. Quantitative and qualitative measures of the velopharynx were obtained and compared with age- and sex-matched individuals with normal speech resonance.

RESULTS

MRI was completed successfully in 113 of 118 patients (96%). Compared with controls, patients with VPI after cleft palate repair had a shorter velum (P < 0.001), higher incidence of LVP discontinuity (P < 0.001), and shorter effective velar length (P < 0.001). Among patients with persistent VPI after pharyngeal flap placement, findings included a pharyngeal flap base located inferior to the palatal plane [11 of 15 (73%)], shorter velum (P < 0.001), and higher incidence of LVP discontinuity (P = 0.014). Patients presenting with noncleft VPI had a shorter (P = 0.004) and thinner velum (P < 0.001) and higher incidence of LVP discontinuity (P = 0.014).

CONCLUSIONS

MRI provides direct evidence of LVP muscle anomalies and quantitative evaluation of both velar length and velopharyngeal gap. This information is unavailable with traditional VPI imaging tools, suggesting that MRI may be a useful tool for selecting surgical procedures to address patient-specific anatomic differences.

Risk of Malocclusion Among Patients Undergoing Single-Stage Versus Two-Stage Cleft Palate Repair

OBJECTIVE

Evaluate impact of single-stage versus staged palate repair on the risk of developing malocclusion among patients with cleft palate (CP).

DESIGN

Retrospective cohort study 2000-2016.

SETTING

Academic, tertiary children's hospital.

PATIENTS

Patients undergoing CP repair between 1999-2015.

INTERVENTIONS

CP repair, categorized as either single-stage or staged.

MAIN OUTCOME MEASURE

Time to development of Class III malocclusion.

RESULTS

967 patients were included; 60.1% had a two-stage CP repair, and 39.9% had single-stage. Malocclusion was diagnosed in 28.2% of patients. In the model examining all patients at ≤5 years (n = 659), patients who were not white had a higher risk of malocclusion (HR 2.46, p = 0.004) and staged repair was not protective against malocclusion (HR 0.98, p = 0.91). In all patients >5 years (n = 411), higher Veau classification and more recent year of birth were significantly associated with higher hazard rates (p < 0.05). Two-staged repair was not protective against developing malocclusion (HR 0.86, p = 0.60). In the model examining patients with staged repair ≤5 years old (n = 414), higher age at hard palate closure was associated with reduced malocclusion risk (HR 0.67, p < 0.001) and patients who were not white had increased risk (HR 2.56, p = 0.01). In patients with staged repair >5 years old, more recent birth year may be associated with a higher risk of malocclusion (HR 1.06, p = 0.06) while syndrome may be associated with lower risk of malocclusion diagnosis (HR 0.46, p = 0.07).

CONCLUSION

Our data suggests that staged CP repair is not protective against developing Class III malocclusion.

Primary palatoplasty: A comparison of results by various techniques - A retrospective study

Introduction:

To identify a better method for primary cleft palate (CP) repairs with respect to velopharyngeal function.

Materials and Methods:

A retrospective, longitudinal review of medical charts of patients with congenital CP who underwent four different techniques of palatoplasty, performed by three different surgeons in the Department of Maxillofacial Surgery of the National Center for Maternal and Child Health. Nasopharyngoscopy (NPS) was used for velopharyngeal function evaluation. CP was classified according to the Veau system and the “Golding-Kushner” scale for NPS results was used for assessing the patient’s velopharyngeal function and its association with cleft types and the primary palatoplasty techniques. Pearson’s Chi-square analysis and binary logistic regression were used for statistical analysis.

Results:

A total of 335 patients were included in the study. The mean age at primary palate repair was 22.9 ± 13.6 months. There were 56, 42, 177, and 60 patients with Veau-I, Veau-II, Veau-III, and Veau-IV types, respectively, whereas for primary palatoplasty 65 patients underwent Furlow, 148 patients – Mongolian, 108 patients – two flap, 34 patients – von Langenbeck technique. NPS assessment of adequate velopharyngeal function was followed by Furlow’s technique in 89.4% of cases, Mongolian technique in 62.2% of cases but by “two flap” only in 48.1% and von Langenbeck in 47.1% of cases.

Discussion:

The Furlow and Mongolian techniques were superior for maintaining velopharyngeal function after primary palatoplasty.

Comparing Quality of Life and Perceptual Speech Ratings in Children With Cleft Palate

OBJECTIVE

To delineate the relationship between patient and parent-reported quality of life (QOL) ratings and perceptual characteristics of speech assigned by a speech-language pathologist (SLP) in children with repaired cleft palate.

DESIGN

Prospective.

SETTING

Academic Children's Hospital.

PARTICIPANTS

This population-based sample included children, aged 3 to 18 with a history of repaired cleft palate, and their parents.

INTERVENTION

Participants completed the Velopharyngeal Insufficiency Effects on Life Outcomes Questionnaire (VELO). Children's speech was judged perceptually by an expert SLP using the Pittsburgh Weighted Speech Scale (PWSS).

MAIN OUTCOME MEASURE(S)

Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire assessed participant and parent perceptions of impact of velopharyngeal function on QOL. Pittsburgh Weighted Speech Scale assessed nasal emissions, facial grimacing, nasality, quality of phonation, and articulation.

RESULTS

Enrollment included 48 participant parent dyads. Overall, participants reported high QOL scores within the 95% CI with children reporting slightly better yet not significantly different QOL (86.27 ± 8.96) compared to their parents (81.81 ± 15.2). Children received an average score of 1.38 ± 1.96 on the PWSS corresponding to borderline velopharyngeal competence. A significant moderate negative correlation was found between PWSS total score and parent VELO total score (r = -0.51103, P = .0002). Mild-moderate significant negative correlations were measured between PWSS total and the 5 subscales of the VELO. No significant correlations were measured between PWSS and child VELO total responses or between total scores and subscales.

CONCLUSIONS

Results suggest that as perceptual analysis of speech improves, overall QOL improves moderately.