Management of Velopharyngeal Insufficiency in Cleft Patients With and Without Multidisciplinary Team Care

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.

Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis

OBJECTIVES

In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome.

MATERIALS AND METHODS

A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model.

RESULTS

One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11).

CONCLUSIONS

A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair.

CLINICAL RELEVANCE

Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.

American Indian and Alaska Native Accessibility to Comprehensive Cleft Lip and Palate Treatment

American Indians and Alaska Natives (AI/AN) have the highest incidence of cleft lip and palate (orofacial clefts [OFCs]) when compared to other ethnic groups. We aim to determine the AI/AN populations' proximity and accessibility to American Cleft Palate-Craniofacial Association accredited centers (ACPA centers) for treatment of OFCs. Our hypothesis is an unacceptable proportion of the AI/AN population lacks reasonable accessibility to ACPA centers and comprehensive craniofacial care.

A cross-sectional study of ACPA centers and AI/AN populations were analyzed for possible disparities.

ACPA centers were mapped using Geographic Information Systems (GIS) and compared with 2018 census population data and 2017 Tribal Census Tract data to visually display possible disparities. Total annual potential pediatric cleft care need for selected high-density AI/AN populated lands were estimated.

GIS mapping demonstrates geographical isolation of AI/AN populations from ACPA centers. Two states with high AI/AN populated lands (ND, WY) have no ACPA centers. 47.1% of ACPA centers in high AI/AN populated lands have no craniofacial trained surgeons versus 78.9% craniofacial staffed ACPA centers nationally. The potential unmet cleft and craniofacial care need in selected high-density AI/AN populated lands is 1042 children.

AI/AN populations are likely underserved by ACPA centers and by craniofacial fellowship-trained staffed centers. Not addressing OFCs with comprehensive care can lead to worsened outcomes and further marginalization of these children. With future studies, we will be capable of making data-driven, informed decisions to more effectively ensure AI/AN access to comprehensive cleft and craniofacial care.

How Early Can We Predict the Need for VPI Surgery?

Velopharyngeal dimensions change as a child with cleft palate (CP) grows. The aim of this study was to assess if the decision for velopharyngeal insufficiency (VPI) surgery can be made by the age of 3 years among CP children with moderate-to-severe VPI. In addition, we sought to clarify if speech therapy before VPI surgery is beneficial for VPI speech characteristics.

METHODS

This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years.

RESULTS

Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics.

CONCLUSIONS

Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.