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Xepoleas MD, Naidu P, Nagengast E, Collier Z, Islip D, Khatra J, Auslander A, Yao CA, Chong D, Magee WP. Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique. J Craniofac Surg 2023; 34:1644-1649. [PMID: 37646567 PMCID: PMC10445635 DOI: 10.1097/scs.0000000000009555] [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] [Received: 06/08/2021] [Accepted: 05/19/2023] [Indexed: 09/01/2023] Open
Abstract
Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.
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Affiliation(s)
| | - Priyanka Naidu
- Operation Smile Inc, Virginia Beach, VA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC
| | - Eric Nagengast
- Operation Smile Inc, Virginia Beach, VA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC
| | - Zach Collier
- Operation Smile Inc, Virginia Beach, VA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC
| | - Delaney Islip
- University of California, Los Angeles, School of Dentistry
| | | | - Allyn Auslander
- Operation Smile Inc, Virginia Beach, VA
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles
| | - Caroline A. Yao
- Operation Smile Inc, Virginia Beach, VA
- Department of Plastic Surgery, Shriners Hospital for Children, Los Angeles, CA
| | - David Chong
- Royal Children’s Hospital, Melbourne, VIC, Australia
| | - William P. Magee
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles
- Department of Plastic Surgery, Shriners Hospital for Children, Los Angeles, CA
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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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Garland K, Dworschak-Stokan A, Matic D. Patient and Surgical Factors that Affect Development of Velopharyngeal Insufficiency. J Plast Reconstr Aesthet Surg 2022; 75:3813-3816. [DOI: 10.1016/j.bjps.2022.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/23/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
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Anderson BJ, Fallah KN, Lignieres AA, Moffitt JK, Luu KL, Cepeda A, Doringo IL, Nguyen PD, Teichgraeber JF, Greives MR. Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair. Cleft Palate Craniofac J 2021; 59:825-832. [PMID: 34396792 DOI: 10.1177/10556656211026861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population. DESIGN A single-institution, retrospective review. SETTING Multidisciplinary clinic in a tertiary academic institution. PATIENTS A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded. MAIN OUTCOME MEASURES Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology. RESULTS Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2). CONCLUSIONS Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.
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Affiliation(s)
- Brady J Anderson
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kasra N Fallah
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Austin A Lignieres
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Joseph K Moffitt
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kim-Loan Luu
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Alfredo Cepeda
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Irene L Doringo
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Phuong D Nguyen
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - John F Teichgraeber
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew R Greives
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
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An Observational Study to Evaluate Association Between Velopharyngeal Anatomy and Speech Outcomes in Adult Patients With Severe Velopharyngeal Insufficiency. J Craniofac Surg 2021; 32:2753-2757. [PMID: 34238870 DOI: 10.1097/scs.0000000000007853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE By measuring velopharyngeal structure and evaluating speech intelligibility, to explore and observe the association between velopharyngeal anatomy and speech outcomes in these patients. METHODS Thirty-one adult patients with velopharyngeal insufficiency after the primary palatoplasty aged 18 to 35 years (mean 22.03 years) were enrolled as the study group. The patients had significant hypernasality and audible nasal emission. The degree of velopharyngeal closure assessed by electronic nasopharyngeal fiberoptic endoscopy was grade III. Cephalometric analysis was performed on lateral cephalograms to measure velopharyngeal structure, including hard palate length (ANS-PNS), velar length (PNS-U), pharyngeal depth (PNS-PPW), and oropharyngeal airway space (U-MPW). Their speech intelligibility was evaluated through the Mandarin Chinese speech intelligibility test, and each speech sample was examined by 2 speech and language pathologists. The results were assessed with the SPSS 23.0 software package, and regression analysis was used to examine the relationship between velopharyngeal structure and speech outcomes. RESULTS A significant negative correlation was confirmed between speech intelligibility and pharyngeal depth. Pharyngeal depth also showed a linear relationship with speech intelligibility, and there was no significant correlation between speech intelligibility and other measures (hard palate length, velar length, oropharyngeal airway space). CONCLUSIONS In the velopharyngeal anatomy, only pharyngeal depth was associated with speech intelligibility in adult patients with severe velopharyngeal insufficiency, this is consistent with our clinical observation. It suggests that appropriate reduction of pharyngeal depth during palatopharyngoplasty may have a good effect on the speech recovery in patients with cleft palate and patients with velopharyngeal insufficiency after palatorrhaphy.
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Abdollahi Fakhim S, Nouri-Vaskeh M, Amiri F, Shahidi N. Comparison of two-flap palatoplasty plus intravelar veloplasty technique with and without double-layer Z-plasty on the soft palate length in children with cleft palate. Oral Maxillofac Surg 2020; 24:495-499. [PMID: 32653995 DOI: 10.1007/s10006-020-00884-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Velopharyngeal failure occurs as a result of a nasopharyngeal gap following inadequate velopharyngeal closure for structural or functional cause. We aimed to compare the soft palate length in two-flap palatoplasty with intravelar veloplasty (IVV) and two-flap palatoplasty with IVV plus double-layer Z-plasty combination in patients with cleft palate. METHODS This clinical trial was conducted on infants aged 9 to 12 months with cleft palate in two groups. The method of two-flap palatoplasty with IVV technique and two-flap palatoplasty with IVV plus double-layer Z-plasty was compared in terms of soft palate length which was measured during operation and short-term complications. RESULTS This study was conducted on 62 infants including 30 patients in two-flap palatoplasty with IVV group and 32 patients in two-flap palatoplasty with IVV plus double-layer Z-plasty group. The soft palate length in two-flap palatoplasty and IVV with and without Z-plasty groups before surgery was 17.56 ± 2.05 and 17.68 ± 1.88 mm, respectively (P = 0.561). After surgery, the soft palate length was significantly higher in two-flap palatoplasty with IVV plus Z-plasty group (22.43 ± 2.73 mm vs. 20.56 ± 2.42 mm) (P = 0.032). CONCLUSION The two-flap palatoplasty with IVV plus Z-plasty technique is a suitable method for increasing the palatal length in infants with cleft palate. On the other hand, the addition of Z-plasty method could increase the length of the palate. Moreover, the complications are very low and further trials for development of this method on patients with cleft palate are recommended. TRIAL REGISTRATION NUMBER (TRN) IRCT2017032423559N11.
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Affiliation(s)
- Shahin Abdollahi Fakhim
- Department of Otorhinolaryngology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Faezeh Amiri
- Department of Otorhinolaryngology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nikzad Shahidi
- Department of Otorhinolaryngology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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