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Gardiner S, Bjornson L, Pawliuk C, Bucevska M, Bone J, Arneja JS. What Technique Results in the Lowest Rate of Velopharyngeal Insufficiency in Patients With Submucous Cleft Palate? A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2024; 32:226-234. [PMID: 38681241 PMCID: PMC11046285 DOI: 10.1177/22925503221110066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/15/2021] [Accepted: 05/02/2022] [Indexed: 05/01/2024] Open
Abstract
Objective: To determine which surgical technique offers the lowest rate of velopharyngeal insufficiency (VPI) without the need for further operative intervention, in pediatric patients with nonsyndromic submucous cleft palate (SMCP). Methods: This systematic review and meta-analysis included articles reporting on nonsyndromic pediatric patients treated surgically during childhood for SMCP, with data on postoperative speech outcomes and/or recommendations for secondary surgery. Main outcome measures included rates of unfavorable speech outcomes defined as persistent VPI requiring secondary surgery and speech outcome data. Results: 15 articles met our inclusion criteria, reporting on 383 children who underwent surgical treatment; 343 patients were included in studies reporting recommendations for secondary surgery. There was 1 randomized comparative trial, 4 comparative studies, and 10 single cohort studies. Eight articles used validated speech assessment tools. Our model showed the proportion of patients recommended for secondary surgery varied between techniques, ranging from 0.0% (CI 0.0, 1000) in pharyngeal flap to 17.8% (CI 8.9, 32.5) in straight line repair techniques, but there was no statistically significant difference between treatments (P = .33). Speech improvement ranged from 44.4% to 100%, with 9 studies recommending secondary surgery for some of their patient series. Conclusions: Although not of statistical significance, pharyngeal flap yields the lowest rate of reoperation as a primary technique for pediatric patients with nonsyndromic SMCP. Delayed repair age inherent to SMCP may render operations that rely on a functional levator muscle with less favorable outcomes. The absence of standardized surgical techniques, speech outcomes, speech therapy, and assessment make comparative analysis and recommendation difficult. We advocate for standardized speech assessment tools to improve future quantitative assessment of cleft surgery outcomes and a randomized controlled trial to better elucidate the preferred first-line technique.
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Affiliation(s)
- Sarah Gardiner
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lindsay Bjornson
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colleen Pawliuk
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Marija Bucevska
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jugpal S. Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
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2
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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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3
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Ghanem AM, Borg TM, Youssef G, Ridout D, Gilleard O, Birch M, Sell D, Sommerlad BC. Surgical Management of Submucous Cleft Palate by Radical Muscle Dissection Veloplasty: Speech Outcomes in Patients with 22q11.2 Deletion Syndrome. Cleft Palate Craniofac J 2024; 61:498-507. [PMID: 36624582 DOI: 10.1177/10556656221150707] [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: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate the benefit of anatomical muscle dissection repair for velopharyngeal insufficiency (VPI) in patients with submucous cleft palate (SMCP) with 22q11.2 deletion syndrome. DESIGN Retrospective blinded randomised analysis of a surgeon's management over 10 years. SETTING The study was performed at a specialised Paediatric hospital in the United Kingdom. PATIENTS Children with SMCP and 22q11.2 deletion syndrome. INTERVENTIONS All participants underwent radical muscle dissection veloplasty. OUTCOMES MEASURED Pre- and post- operative measurements included severity of anatomical defect, speech samples and lateral images which were digitised, randomised then externally and blindly analysed using validated techniques. Stata software was used to perform statistical analysis. RESULTS 57 children with 22q11.2 deletion syndrome were included in this analysis. Intra-operatively, the majority of cases were identified as SMCP Grade I anomalies. Post-operatively, a statistically significant improvement in hypernasality, resting palate length, palate length at maximum closure, palate excursion and gap size at maximum closure was observed. Secondary surgery was performed for 59% of patients by ten years. CONCLUSION Muscle dissection repair improves hypernasality, palate closure function and the closure gap in patients with 22q11.2 deletion syndrome. Although over 50% of patients may require further surgery, muscle dissection repair should be a first step due to its utility at a younger age, when invasive investigations are impossible, its lower morbidity, speech and language benefits or altering the plans for less obstructive secondary surgery when it lead to reduced velo-pharyngeal gap and improved palate mobility even when adequate velo-pharyngeal closure was not achieved.
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Affiliation(s)
| | - Tiffanie-Marie Borg
- Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesborough, UK
- Academic Plastic Surgery Group, Barts and the London School of Medicine, London, UK
| | - Gehad Youssef
- Milner Therapeutics Institute, Cambridge University, Cambridge, UK
| | | | - Onur Gilleard
- Plastic and Reconstructive Surgery, Barts Health, London, UK
| | - Malcolm Birch
- Director of Clinical Physics, Barts Health, London, UK
| | - Debbie Sell
- Great Ormond Street Hospital for Children, NHS Trust, London, UK
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4
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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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Pitkänen V, Szwedyc A, Alaluusua S, Geneid A, Vuola P, Saarikko A. Outcomes of Primary Furlow Double-Opposing Z-plasty for the Treatment of Symptomatic Submucous Cleft Palate. J Craniofac Surg 2023; 34:2066-2070. [PMID: 37221637 PMCID: PMC10521778 DOI: 10.1097/scs.0000000000009385] [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: 11/03/2022] [Accepted: 02/25/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Submucous cleft palate (SMCP) requires surgical repair if symptomatic. The Furlow double-opposing Z-plasty is the preferred method in Helsinki cleft center. AIMS To assess the efficacy and complications of Furlow Z-plasty in the treatment of symptomatic SMCP. METHODS This retrospective study reviewed documentation of 40 consecutive patients with symptomatic SMCP who underwent primary Furlow Z-plasty by 2 high-volume cleft surgeons at a single center between 2008 and 2017. Patients underwent perceptual and instrumental evaluation of velopharyngeal function (VPF) by speech pathologists preoperatively and postoperatively. RESULTS The median age at Furlow Z-plasty was 4.8 years (SD 2.6, range 3.1-13.6). The overall success rate, including postoperative competent or borderline competent VPF, was 83%, and 10% required secondary surgery for residual velopharyngeal insufficiency. The success rate was 85% in nonsyndromic, and 67% in syndromic patients with no significant difference ( P =0.279). Complications arose in only 2 (5%) patients. No children were found to have obstructive sleep apnea postoperatively. CONCLUSION Furlow primary Z-plasty is a safe and effective operation for symptomatic SMCP with a success rate of 83% with only 5% rate of complications.
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Affiliation(s)
- Veera Pitkänen
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Anika Szwedyc
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Suvi Alaluusua
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Ahmed Geneid
- Department of Otolaryngology and Phoniatrics - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Pia Vuola
- Department of Plastic Surgery, Cleft and Craniofacial Center
| | - Anne Saarikko
- Department of Plastic Surgery, Cleft and Craniofacial Center
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Srivastav S, Tewari N, Antonarakis GS, Duggal R, Saji S, Lokade AK, Yadav R. Evidence Mapping and Quality Analysis of Systematic Reviews on Various Aspects Related to Cleft Lip and Palate. J Clin Med 2023; 12:6002. [PMID: 37762942 PMCID: PMC10532364 DOI: 10.3390/jcm12186002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Management of cleft lip and palate is interdisciplinary. An evidence-mapping approach was envisaged to highlight the existing gaps in this field, using only the highest level of evidence. OBJECTIVES To conduct evidence mapping and quality analysis of systematic reviews and meta-analyses related to any aspect of cleft lip and palate. SEARCH METHODS The cleft lip and palate field was divided into 9 domains and 50 subdomains and a method of categorization of systematic reviews was established. A comprehensive search strategy was carried out in seven databases along with the search of gray literature and references of included articles. SELECTION CRITERIA Systematic reviews related to any aspect of cleft lip and palate, conducted by a minimum of two reviewers, with a comprehensive search strategy and adequate quality analysis were included. DATA COLLECTION AND ANALYSIS A self-designed, pre-piloted data-extraction sheet was used to collect information that was analyzed through an expert group discussion. Quality analysis was performed using ROBIS-I, AMSTAR 2, and the PRISMA checklist. RESULTS A total of 144 systematic reviews published between 2008 and 2022 were included. The largest number of these could be categorized in the therapeutic domain (n = 58). A total of 27% of the studies were categorized as inconclusive, 40% as partially conclusive, and 33% as conclusive. As per ROBIS-I, 77% of reviews had high risk of bias while 58% were graded as critically low in quality as per AMSTAR 2. The majority of systematic reviews showed low reporting errors. CONCLUSIONS The majority of systematic reviews related to cleft lip and palate relate to therapeutic and prognostic domains and show high risk of bias and critically low quality regardless of the source journal. The results of this paper might serve as a starting point encouraging authors to carry out high-quality research where evidence is lacking. REGISTRATION A multidisciplinary expert-group formulated an a priori protocol, registered in Open Science Framework (DOI 10.17605/OSF.IO/NQDV2).
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Affiliation(s)
- Sukeshana Srivastav
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, 8000 Aarhus, Denmark
- Division of Paediatric and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
- Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Nitesh Tewari
- Division of Paediatric and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Gregory S. Antonarakis
- Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Ritu Duggal
- Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Seba Saji
- Division of Paediatric and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Amol Kumar Lokade
- Division of Paediatric and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rahul Yadav
- Division of Oral and Maxillofacial Surgery, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi 110029, India
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Álvarez Carvajal DC, Inostroza-Allende F, Geldres Meneses MB, Giugliano Villarroel C. Speech Outcomes and Velopharyngeal Function in Children Undergoing Submucous Cleft Palate Repair. J Craniofac Surg 2023; 34:1766-1771. [PMID: 37526200 DOI: 10.1097/scs.0000000000009570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/27/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE Describe and compare the results of speech and velopharyngeal function in children with classic and occult submucous cleft palate undergoing interdisciplinary treatment at the Gantz Foundation. METHODS The clinical history of all patients born between 2012 and 2017 with a diagnosis of classic or occult submucous cleft palate was retrospectively reviewed. Preoperative and postoperative medical, surgical, and speech and language history were collected. RESULTS Twenty-eight cases diagnosed at the age of 44.8±23.9 months were included. Of these, 71.4% presented classic submucous cleft, and 28.6% occult. Before primary surgery, 7.1% had a diagnosis of the syndrome, and 21.4% were under study. A total of 39.3% had hearing difficulties and 21.4% used tympanic ventilation tubes. A total of 60.7% had language problems, 39.3% had compensatory articulation, 17.9% had absent hypernasality, and 21.4% had absent nasal emission. The team indicated primary palate surgery in 71.4%, of which 85% performed the surgery at the mean age of 61.7±24.7 months. The surgical technique was Furlow in 88.2% of the cases and intravelar veloplasty in the remaining 11.8%. Then, 3 cases underwent velopharyngeal insufficiency surgery; 2 of them eliminated hypernasality and reduced nasal emission. The age of diagnosis ( P =0.021) and the performance of velopharyngeal insufficiency surgery ( P =0029) of the occult submucous cleft palate group was significatively later than the classic cleft palate group. CONCLUSIONS Language, hearing, compensatory articulation, hypernasality, and nasal emission problems were recorded. A high percentage required primary surgery. Of these, a low proportion also required a velopharyngeal insufficiency surgery, which improved the velopharyngeal function of the children but did not completely adapt it. In this regard, early diagnosis is essential, as well as an analysis of each center primary closure protocol.
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Affiliation(s)
| | - Felipe Inostroza-Allende
- Speech Therapy Unit, Gantz Foundation-Cleft Children's Hospital
- Speech Therapy Department, University of Chile
| | | | - Carlos Giugliano Villarroel
- Department of Plastic Surgery, Gantz Foundation-Cleft Children's Hospital
- Department of Plastic Surgery, Surgery Service, Clínica Alemana de
- Smile Train-South American Medical Advisory Council-SAMAC, Santiago, Chile
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Suzzi C, Di Gennaro G, Baylon H, Captier G. A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence. Int Arch Otorhinolaryngol 2023; 27:e351-e361. [PMID: 37125364 PMCID: PMC10147477 DOI: 10.1055/s-0043-1763501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/09/2022] [Indexed: 03/31/2023] Open
Abstract
Abstract
Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options.
Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech.
Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study.
Results Among the patients (median [range] age 7 [4–48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique.
Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.
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9
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Raby-Smith W, Hall P, Southby L, Parfect V, Linford G, Bannister S, Miyagi K. A retrospective analysis of speech and hearing in patients receiving surgery for submucous cleft palate. J Plast Reconstr Aesthet Surg 2023; 77:123-130. [PMID: 36566640 DOI: 10.1016/j.bjps.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/19/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022]
Abstract
Submucous cleft palate (SMCP) is an uncommon subtype of cleft palate that is associated with symptoms of velopharyngeal insufficiency (VPI), the most common being hypernasal speech. A high proportion of patients also suffer from conductive hearing loss, which is thought to be due to eustachian tube dysfunction. A number of surgical techniques have been proposed to correct the anatomical defect that is responsible for VPI. This exploratory study aims to describe surgical techniques and clinical outcomes in a series of patients who underwent surgical repair of SMCP at a single regional specialist cleft centre between 1999 and 2018. Through a retrospective case note review, records of 57 patients who underwent SMCP repair between the ages of 6 months and 16 years were examined. Patients underwent one of the three surgical techniques: Intravelar Veloplasty, Furlow or a novel technique we have termed as "Hemi-Furlow". Hypernasality, measured on the Great Ormond Street Speech Assessment, showed evidence of improvement post-operatively in all three surgical groups (P<0.005), with no evidence to favour any specific approach. Post-operative complications, including wound dehiscence and fistulae, occurred in nine patients (15.8%). Nine patients (15.8%) required revisional surgery, either due to post-operative complications or persistent speech problems. Otological disease was present in 54.4% of patients, comprising conductive hearing loss due to otitis media with effusion (52.6%) and sensorineural hearing loss (1.8%). There is now a need for large, multi-centre studies with robust outcomes measures to further examine relationships between surgical techniques and clinical outcomes in people born with SMCP.
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Affiliation(s)
- Will Raby-Smith
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP, United Kingdom; Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.
| | - Per Hall
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Lucy Southby
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Victoria Parfect
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Georgina Linford
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Sam Bannister
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Kana Miyagi
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
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10
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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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Ghanem AM, Ghorbanian S, Borg TM, Sell D, Sommerlad BC. Submucous Cleft Palate (SMCP): Indications and Outcomes of Radical Muscle Dissection Palatoplasty in Children Under 4 Years of Age. Cleft Palate Craniofac J 2022:10556656221088170. [PMID: 35306868 DOI: 10.1177/10556656221088170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To delineate the indications, referral sources and outcomes of radical muscle dissection palate repair in the first 4 years of life for patients with submucous cleft palate (SMCP). This study presents a retrospective analysis of a single surgeon's management. All children were treated at Great Ormond Street Hospital, United Kingdom. Twenty-three children with nonsyndromic SMCP were included in this study. All participants underwent radical muscle dissection repair before their fourth birthday. Parameters analyzed included: referral sources, indications for referral, extent of anatomical abnormality, and postoperative outcomes. Paediatricians provided the largest proportion of referrals to the cleft lip and palate clinic (39%) due to the presence of cleft lip/palate on prenatal scans or during neonatal examination. Over half (n = 12, 52%) of patients had severe anatomical anomalies being in grade IV (score 8-9), with the classical triad present to some extent in all but 2 of the patients. The main indication for surgery was nasal regurgitation of food and liquid (n = 9, 35%) followed by hypernasality (n = 6, 21%), difficulty feeding (n = 3, 8%), and severe anatomical defect (n = 2; 4%). Postoperatively, the presenting complaint improved in the majority of cases. Nonsyndromic SMCP is often missed, though may present with nasal regurgitation, feeding problems, and/or hypernasality, though may be missed in nonsyndromic children. Early radical muscle dissection repair in the first 4 years of life is safe and effective, facilitating normal speech development.
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Affiliation(s)
- Ali M Ghanem
- 4952Barts and the London School of Medicine and Dentistry, London, UK
| | - Samim Ghorbanian
- 4952Barts and the London School of Medicine and Dentistry, London, UK
| | | | - Debbie Sell
- 4956Great Ormond Street Hospital for Children NHS Trust, London, UK
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Instrum R, Dzioba A, Dworschak-Stokan A, Husein M. Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques. J Otolaryngol Head Neck Surg 2022; 51:3. [PMID: 35120565 PMCID: PMC8815226 DOI: 10.1186/s40463-021-00548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 10/31/2021] [Indexed: 12/02/2022] Open
Abstract
Background The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors.
Methods A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age. Results Mean perceptual scores improved significantly postoperatively (p < .0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p < .001, p < .02], [audible nasal emissions: p < .002, p < .05], [velopharyngeal function: p < .001, p < .05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p < .001) or sphincter pharyngoplasty (66.7%, p < .001). No significant difference was identified in success rate based on syndrome or cleft status. Conclusion Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed. Graphical abstract ![]()
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Affiliation(s)
- Ryan Instrum
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Agnieszka Dzioba
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | | | - Murad Husein
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada. .,Thames Valley Children's Centre, London, ON, Canada.
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Preliminary Study in Relationship Between Cleft Lip and Palatal Bony Defect in Submucous Cleft Palate. J Craniofac Surg 2022; 33:2024-2027. [PMID: 35067530 PMCID: PMC9518965 DOI: 10.1097/scs.0000000000008458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/16/2021] [Indexed: 11/25/2022] Open
Abstract
Submucous cleft palate, presenting as varying degrees of palatal bony defect, can be difficult to detect in its early stage. The connection between submucous cleft palate and cleft lip has been noticed by clinicians but are rarely reported in literature.
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Smarius BJA, Guillaume CHAL, Slegers J, Mink van der Molen AB, Breugem CC. Surgical management in submucous cleft palate patients. Clin Oral Investig 2021; 25:3893-3903. [PMID: 33521885 PMCID: PMC8137618 DOI: 10.1007/s00784-020-03719-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/27/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVES The submucous cleft palate (SMCP) is considered to be the most subtle type of cleft palate. Early detection is important to allow on time intervention by speech therapy and/or surgical repair before the children already develop compensatory speech mechanisms. The purpose of this study was to investigate at what time children with a SMCP present, to determine when children are operated, and to analyze the postoperative outcomes for in SMCP children. PATIENT AND METHODS Medical records from 766 individuals registered in the cleft registry in the Wilhelmina's Children's' Hospital, Utrecht, were retrospectively reviewed. Inclusion criteria were children diagnosed with SMCP. The following data were collected: age at diagnosis, physical examination, age at surgery, surgical technique, speech therapy pre- and post-surgery, otitis media, secondary cleft surgery, family history, syndromes, and other anomalies. RESULTS In total, 56 SMCP children were identified. The mean age of diagnosis was 44.0 months (range 0-150, SD = 37.0). In 48 children (85.7%), surgical intervention was performed (Furlow plasty, intravelar veloplasty, pharyngoplasty, or Furlow combined with buccal flap). CONCLUSION This retrospective study reconfirms that SMCP often presents late, even in a country with a modern healthcare system and adequate follow-up of all newborns by the so-called youth doctors in "children's healthcare centers" up to the age of 4 years old. Almost 86% of patients ultimately needed palate surgery when SMCP was suspected. CLINICAL RELEVANCE Any child presenting with repeated episodes of otitis media, nasal regurgitation, or speech difficulties should have prompt consideration for SMCP as diagnosis.
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Affiliation(s)
- B. J. A. Smarius
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
| | - C. H. A. L. Guillaume
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
- Department of Plastic Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Pediatric Plastic Surgery, Emma Children’s Hospital, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - J. Slegers
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
| | - A. B. Mink van der Molen
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
- Department of Plastic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - C. C. Breugem
- Department of Plastic Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Pediatric Plastic Surgery, Emma Children’s Hospital, University Medical Center Amsterdam, Amsterdam, The Netherlands
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Clinical interventions and speech outcomes for individuals with submucous cleft palate. Arch Plast Surg 2020; 47:542-550. [PMID: 33238341 PMCID: PMC7700856 DOI: 10.5999/aps.2020.00612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/20/2020] [Indexed: 11/09/2022] Open
Abstract
Background This study aimed to identify the initial diagnostic characteristics and treatment status of children with submucous cleft palate (SMCP) and to examine the relationship between the timing of surgical correction and the degree of articulation and resonance improvement. Methods This retrospective study included 72 children diagnosed with SMCP between 2008 and 2016. The evaluation criteria were the age of the initial visit, total number of visits, age at the end of treatment, speech problems, resonance problems, and speech therapy. Results Children with SMCP first visited the hospital at an average age of 34.32 months, and speech problems were identified at an average age of 48.53 months. Out of 72 children, 46 underwent surgery at an average age of 49.74 months. Four of these children required secondary surgery at an average age of 83.5 months. Among the children who underwent surgery before 3 years of age, 70% exhibited articulation improvements, with mild-to-moderate hypernasality. Articulation improvements showed no statistically significant differences according to age at the time of surgery. However, children who underwent surgery before 4 years had a better hypernasality rating than those who underwent surgery after 4 years of age. Conclusions Children with SMCP tend to undergo delayed treatment because the anatomical symptoms in some children with SMCP are unclear, and surgical interventions are considered only after speech problems are clarified. Starting interventions as early as possible reduces the likelihood of receiving secondary surgery and speech therapy, while increasing expectations for positive speech function at the end.
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Preoperative velopharyngeal closure ratio correlates with Furlow palatoplasty outcome among patients with nonsyndromic submucous cleft palate. J Craniomaxillofac Surg 2020; 48:962-968. [DOI: 10.1016/j.jcms.2020.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/30/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022] Open
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A Comparative Study Evaluating Speech Outcomes in Classic versus Occult Submucous Cleft Palate Using a Primary Furlow Palatoplasty Technique. Plast Reconstr Surg 2020; 146:589-598. [PMID: 32459728 DOI: 10.1097/prs.0000000000007065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate-associated velopharyngeal insufficiency. METHODS Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate-associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome. RESULTS Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome. CONCLUSION The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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The Correlation Between Consonant Articulation and Velopharyngeal Function in Patients With Unoperated Submucous Cleft Palate. J Craniofac Surg 2020; 31:1070-1073. [PMID: 32149969 DOI: 10.1097/scs.0000000000006300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Submucous cleft palate (SMCP) is a congenital condition related to abnormal muscle attachments within the soft palate. Even though hypernasality and nasal emission, the primary symptom of SMCP, have been well-documented, research on articulation errors is currently lacking. The object of this study was to examine the consonant articulation in patients with unoperated SMCP and its possible correlation with the velopharyngeal function. This study analyzed the perceptual speech assessment and nasopharyngoscopy data of 338 patients with unoperated SMCP between years 2008 and 2016 retrospectively. The mean age of the patients was 13.27 years. About 125 patients showed velopharyngeal competence (VPC), 174 velopharyngeal incompetence (VPI), and 39 marginal VPI (MVPI). Among the 338 patients, 137 presented normal articulation, 124 consonant omission, 25 compensatory articulation, 36 consonant weakening, 51 consonant substitution, and 36 posterior placement. About 70.40% VPC patients, 17.24% VPI patients, and 48.72% MVPI patients demonstrated normal articulation. About 59.20% VPI patients showed consonant omission. The results demonstrated that consonant articulation varied among patients with unoperated SMCP and was correlated with their velopharyngeal functions, while consonant omission was the most common articulation error. Velopharyngeal closure pattern was not associated with either velopharyngeal function or consonant articulation.
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Li L, Strum D, Larson S, Preciado D. Quality of life outcomes following velopharyngeal insufficiency surgery. Int J Pediatr Otorhinolaryngol 2019; 127:109643. [PMID: 31442731 DOI: 10.1016/j.ijporl.2019.109643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Velopharyngeal insufficiency (VPI) may be due to functional or anatomic causes, and can lead to speech deficits, communication difficulty, and emotional strain on patients and their caregivers. The VPI Effects on Life Outcomes (VELO) instrument quantifies quality of life outcomes in VPI patients both before and after VPI surgery. This study aims to identify pre-operative patient characteristics associated with better post-operative quality of life. METHODS This study is a retrospective chart review of 51 patients who underwent VPI surgery between 2009 and 2018 at a tertiary free-standing children's hospital. A 26-item parent-proxy VELO questionnaire was administered by telephone to parents to assess their child's quality of life post-VPI surgery. RESULTS Twenty-seven parents responded to the VELO questionnaire. Average post-operative VELO score was significantly higher in non-syndromic patients as compared with syndromic patients. Average post-operative VELO score was not significantly different between patients with and without submucous cleft (SMC) or those with mild to moderate versus severe pre-operative hypernasality. On multivariate analysis, absence of genetic syndrome, lack of submucous cleft, and presence of severe-pre-operative hypernasality were significantly and positively associated with increased post-operative VELO scores. CONCLUSION Children who undergo VPI surgery are more likely to have better post-operative quality of life outcomes if their VPI was not associated with a genetic syndrome or submucous cleft. Non-syndromic and non-SMC patients with severe pre-operative hypernasality may benefit significantly from VPI surgery and have improved post-operative quality of life.
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Affiliation(s)
- Lilun Li
- Department of Otolaryngology, Children's National Health System, 111 Michigan, Washington, DC, 20010, USA; Division of Otolaryngology, George Washington University, 2300 M St, Washington, DC, 20037, USA
| | - David Strum
- Department of Otolaryngology, Children's National Health System, 111 Michigan, Washington, DC, 20010, USA; Division of Otolaryngology, George Washington University, 2300 M St, Washington, DC, 20037, USA
| | - Stephen Larson
- Department of Otolaryngology, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN, 38163, USA
| | - Diego Preciado
- Department of Otolaryngology, Children's National Health System, 111 Michigan, Washington, DC, 20010, USA; Division of Otolaryngology, George Washington University, 2300 M St, Washington, DC, 20037, USA.
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Park YH, Jo HJ, Hong IS, Leem DH, Baek JA, Ko SO. Treatment of velopharyngeal insufficiency in a patient with a submucous cleft palate using a speech aid: the more treatment options, the better the treatment results. Maxillofac Plast Reconstr Surg 2019; 41:19. [PMID: 31106163 PMCID: PMC6491524 DOI: 10.1186/s40902-019-0202-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/28/2019] [Indexed: 12/01/2022] Open
Abstract
Background The submucous cleft palate (SMCP) is a type of cleft palate that may result in velopharyngeal insufficiency (VPI). Palate muscles completely separate oral and nasal cavities by closing off the velopharynx during functional processes such as speech or swallow. Also, hypernasality may arise from anatomical or neurological abnormalities in these functions. Treatments of this issue involve a combination of surgical intervention, speech aid, and speech therapy. This case report demonstrates successfully treated VPI resulted from SMCP without any surgical intervention but solely with speech aid appliance and speech therapy. Case presentation A 13-year-old female patient with a speech disorder from velopharyngeal insufficiency that was caused by a submucous cleft palate visited to our OMFS clinic. In the intraoral examination, the patient had a short soft palate and bifid uvula. And the muscles in the palate did not contract properly during oral speech. She had no surgical history such as primary palatoplasty or pharyngoplasty except for tonsillectomy. And there were no other medical histories. Objective speech assessment using nasometer was performed. We diagnosed that the patient had a SMCP. The patient has shown a decrease in speech intelligibility, which resulted from hypernasality. We decided to treat the patient with speech aid (palatal lift) along with speech therapy. During the 7-month treatment, hypernasality measured by a nasometer decreased and speech intelligibility became normal. Conclusions Surgery remains the first treatment option for patients with velopharyngeal insufficiencies from submucous cleft palates. However, there were few reports about objective speech evaluation pre- or post-operation. Moreover, there has been no report of non-surgical treatment in the recent studies. From this perspective, this report of objective improvement of speech intelligibility of VPI patient with SMCP by non-surgical treatment has a significant meaning. Speech aid can be considered as one of treatment options for management of SMCP.
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Affiliation(s)
- Yun-Ha Park
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
| | - Hyun-Jun Jo
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
| | - In-Seok Hong
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
| | - Dae-Ho Leem
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
| | - Jin-A Baek
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
| | - Seung-O Ko
- 1Department of Oral and Maxillofacial Surgery, School of Dentistry, Chonbuk National University Dental Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea.,2Research Institute of Clinical Medicine-Biomedical Research Institute, Chonbuk National University Hospital, 20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do Republic of Korea
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Boyce JO, Kilpatrick N, Morgan AT. Speech and language characteristics in individuals with nonsyndromic submucous cleft palate-A systematic review. Child Care Health Dev 2018; 44:818-831. [PMID: 30136310 DOI: 10.1111/cch.12613] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Up to 80% of individuals with unrepaired submucous cleft palate (SMCP) experience speech difficulties secondary to velopharyngeal insufficiency. Language delays are reported in the broader cleft lip and/or palate population, suggesting that individuals with SMCP may also be at risk. However, contemporary understanding of this population remains limited as there has been no systematic examination of the literature. This review aims to systematically review and document the speech and language characteristics of individuals with nonsyndromic SMCP and, in addition, to identify factors reported to impact speech and language outcomes. METHOD This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were comprehensively searched using keywords and indexed headings. Included studies had to report speech or language outcomes of individuals with nonsyndromic SMCP. Risk of bias and methodological design quality were examined using tools from the Scottish Intercollegiate Guidelines Network. Relevant data were extracted for analysis. RESULTS Eighteen studies met inclusion criteria, yielding 598 participants. Study results showed that individuals with unrepaired nonsyndromic SMCP may have speech difficulties secondary to velopharyngeal insufficiency including increased nasal resonance and palatalized or glottal articulation. Lower age at primary surgical repair led to better postsurgical speech outcomes. There is a paucity of literature outlining motor or phonological aspects of speech and receptive or expressive language abilities of this population. CONCLUSION Individuals with nonsyndromic SMCP present with speech difficulties similar to those experienced by individuals with overt cleft palate. Health care professionals should be aware of possible presenting symptoms and consider early SMCP diagnoses where appropriate. Further research is needed to specify the broader communication profile in this population.
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Affiliation(s)
- Jessica O Boyce
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia
| | - Nicky Kilpatrick
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia.,The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Angela T Morgan
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Audiology and Speech Pathology, University of Melbourne, Parkville, Victoria, Australia.,The Royal Children's Hospital, Parkville, Victoria, Australia
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Swanson JW, Mitchell BT, Cohen M, Solot C, Jackson O, Low D, Bartlett SP, Taylor JA. The Effect of Furlow Palatoplasty Timing on Speech Outcomes in Submucous Cleft Palate. Ann Plast Surg 2017; 79:156-161. [DOI: 10.1097/sap.0000000000001056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Craniofacial structure variations in patients with palatal anomalies and velopharyngeal dysfunction. J Craniomaxillofac Surg 2017; 45:203-209. [DOI: 10.1016/j.jcms.2016.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/04/2016] [Accepted: 11/10/2016] [Indexed: 11/22/2022] Open
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