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Barry F, Schlund M, Ferri J. Strip pharyngoplasty as a secondary functional surgery for persistent velopharyngeal insufficiency in cleft palate. J Stomatol Oral Maxillofac Surg 2024; 125:101684. [PMID: 37951499 DOI: 10.1016/j.jormas.2023.101684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/09/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
Despite a satisfactory primary repair, velopharyngeal insufficiency (VPI) may be a sequel of soft palate clefts, resulting in hypernasality and phonation disorders. In order to increase the function of the pharyngeal flap during a secondary pharyngoplasty, we have developed a strip pharyngoplasty technique involving the middle constrictor muscle of the pharynx. This article describes the successive steps of the intervention and discuss its indications, advantages and limitations. Strip pharyngoplasty as a secondary functional surgery for persistent VPI after primary cleft palate repair is an attractive surgical procedure, particularly adapted to cases with defective muscle contraction by providing a muscle contingent in addition to the mucosal flap.
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Affiliation(s)
- Florent Barry
- Univ. Lille, CHU Lille, Inserm, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008 - Controlled Drug Delivery Systems and Biomaterials, Lille, France.
| | - Matthias Schlund
- Univ. Bordeaux, CHU Bordeaux, Inserm, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1026 BioTis - Bioengineering of Tissues, F-33000 Bordeaux, France
| | - Joël Ferri
- Univ. Lille, CHU Lille, Inserm, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008 - Controlled Drug Delivery Systems and Biomaterials, Lille, France
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Duckett KA, Poupore NS, Carroll WW, Pecha PP. Preoperative Imaging in Patients with 22q11 Deletion Syndrome Undergoing Velopharyngeal Surgery. Laryngoscope 2024; 134:2551-2561. [PMID: 38050953 PMCID: PMC11078621 DOI: 10.1002/lary.31181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/29/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE To evaluate the utility of preoperative imaging before velopharyngeal dysfunction (VPD) surgery in children with 22q11 Deletion Syndrome (22qDS) in evaluating internal carotid artery (ICA) medialization. DATA SOURCES PubMed, Scopus, and CINAHL. REVIEW METHODS Following PRISMA guidelines, a systematic review was performed. Studies of children with 22qDS who underwent preoperative imaging (MRA or CTA) to identify ICA anomalies were included. High-risk medialized ICAs were defined as either submucosal, retropharyngeal, Pfeiffer Grade III-IV, or <3 mm from the pharyngeal mucosa. Meta-analyses of proportions were performed. RESULTS Eleven studies met inclusion criteria, comprising 398 patients with 22qDS (weighted mean age 7.6 years). In 372 patients with imaging, the rate of ICA medialization on imaging was 47.1% (95%CI 29.2-65.5), of which 46.3% (95%CI 27.4-65.8) were determined high risk. Operative plans were modified in 19.4% (95%CI 5.7-38.8) of 254 surgeries due to medialized ICA. In studies attempting to use nasopharyngoscopy pulsations to identify medialization for 214 patients, the true-positive rate was 53.9% (95%CI 27.5-79.2) and the false-positive rate was 16.2% (95%CI 7.9-26.8). Nine of eleven studies (81.8%) recommended universal preoperative imaging of the ICAs in children with 22qDS undergoing VPD surgery. No cases of perioperative bleeding secondary to ICA injury were identified. CONCLUSION Although most studies endorse routine preoperative imaging to assess for ICA medialization in children with 22qDS undergoing VPD surgery, only a minority of these cases led to surgical modification. Additional studies are needed to compare outcomes in children with and without preoperative imaging given the low rates of ICA injury in the literature. LEVEL OF EVIDENCE N/A Laryngoscope, 134:2551-2561, 2024.
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Affiliation(s)
- Kelsey A Duckett
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Nicolas S Poupore
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - William W Carroll
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Phayvanh P Pecha
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Sitzman TJ, Baylis AL, Perry JL, Weidler EM, Temkit M, Ishman SL, Tse RW. Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair. Cleft Palate Craniofac J 2024; 61:870-881. [PMID: 36562144 PMCID: PMC10287832 DOI: 10.1177/10556656221147159] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI). DESIGN Prospective observational multicenter study. SETTING Twelve hospitals across the United States and Canada. PARTICIPANTS Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants. INTERVENTIONS Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team. MAIN OUTCOME MEASURE(S) The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings. RESULTS Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter. CONCLUSIONS Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date.
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Affiliation(s)
- Thomas J. Sitzman
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Adriane L. Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Plastic and Reconstructive Surgery and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Speech Language Hearing Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Jamie L. Perry
- Department of Communication Sciences and Disorders East Carolina University, Greenville, North Carolina, USA
| | - Erica M. Weidler
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, USA
| | - M’hamed Temkit
- Department of Clinical Research, Phoenix Children’s Hospital, Phoenix, Arizona, USA
| | - Stacey L. Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Raymond W. Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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Perry JL, Snodgrass TD, Gilbert IR, Sutton BP, Baylis AL, Weidler EM, Tse RW, Ishman SL, Sitzman TJ. Establishing a Clinical Protocol for Velopharyngeal MRI and Interpreting Imaging Findings. Cleft Palate Craniofac J 2024; 61:748-758. [PMID: 36448363 PMCID: PMC10243551 DOI: 10.1177/10556656221141188] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Traditional imaging modalities used to assess velopharyngeal insufficiency (VPI) do not allow for direct visualization of underlying velopharyngeal (VP) structures and musculature which could impact surgical planning. This limitation can be overcome via structural magnetic resonance imaging (MRI), the only current imaging tool that provides direct visualization of salient VP structures. MRI has been used extensively in research; however, it has had limited clinical use. Factors that restrict clinical use of VP MRI include limited access to optimized VP MRI protocols and uncertainty regarding how to interpret VP MRI findings. The purpose of this paper is to outline a framework for establishing a novel VP MRI scan protocol and to detail the process of interpreting scans of the velopharynx at rest and during speech tasks. Additionally, this paper includes common scan parameters needed to allow for visualization of velopharynx and techniques for the elicitation of speech during scans.
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Affiliation(s)
- Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Taylor D Snodgrass
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Imani R Gilbert
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Bradley P Sutton
- Bioengineering Department, University of Illinois at Urbana Champaign, Urbana, IL, USA
| | - Adriane L Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Erica M Weidler
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Raymond W Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Stacey L Ishman
- Division of HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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Abstract
OBJECTIVES to audit the surgical management of infants born with non-syndromic cleft lip and palate (CLP) at an Australian cleft unit in a large tertiary paediatric hospital. DESIGN Retrospective cohort study. SETTING A tertiary Cleft centre. PATIENTS 193 infants born with non-syndromic CLP were referred to the centre and underwent primary repair of their CLP between 2009 and 2020.Main Outcome Measures: (1) The timing and surgical repairs performed; (2) the frequency of postoperative complications; (3) the frequency of secondary Cleft surgery; and (4) the total Cleft-related operations performed for infants born with CLP. RESULTS Four different surgical repair techniques were performed by six surgeons, and postoperative complications were uncommon (n = 14). Rates of oronasal fistula surgery (10.5% at five years of age; 14.3% at eight years of age) and velopharyngeal insufficiency surgery (8.7% at five years of age; 14.3% at eight years of age) were not significantly different across the surgical repair groups (p-value >0.05) and were comparable to international Cleft centres. Children underwent an average of four operative procedures in this audit period, including primary Cleft repair, ear, nose and throat surgery, and dental care. Surgery for managing Eustachian tube dysfunction was the most common surgical intervention following primary Cleft repair. CONCLUSIONS Children born with non-syndromic CLP have a high early operative burden, with outcomes similar across the spectrum of techniques and surgeons.
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Affiliation(s)
- Teagan Fink
- Plastic and Maxillofacial Surgery Department, Royal Children's Hospital VIC AUS, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - Nicky Kilpatrick
- Plastic and Maxillofacial Surgery Department, Royal Children's Hospital VIC AUS, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - David Chong
- Plastic and Maxillofacial Surgery Department, Royal Children's Hospital VIC AUS, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
| | - Tony Penington
- Plastic and Maxillofacial Surgery Department, Royal Children's Hospital VIC AUS, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
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Wistermayer PR, Brown AE, Cave TB, Chang BA, Hinni ML, Hayden RE, Klusovsky LE, McGary A, Nagel TH. Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery. Head Neck 2024; 46:1178-1188. [PMID: 38506149 DOI: 10.1002/hed.27741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 01/27/2024] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV-mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes. METHODS This retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated. RESULTS Fifty-five patients were included. Mean and median follow-up was 34 months. 98% of patients were AJCC stage I/II. Recurrence-free survival was 96% with no local recurrences. Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009). CONCLUSION Loss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.
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Affiliation(s)
- Paul R Wistermayer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Adam E Brown
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Taylor B Cave
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Brent A Chang
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Michael L Hinni
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Richard E Hayden
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Laura E Klusovsky
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Alyssa McGary
- Quantitative Health Science Research, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas H Nagel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Aboulhassan MA, Elrouby IM, Refahee SM, Abd-El-Ghafour M. Effectiveness of secondary furlow palatoplasty with buccal myomucosal flap in correction of velopharyngeal insufficiency in patients with cleft palate. Clin Oral Investig 2024; 28:257. [PMID: 38630186 PMCID: PMC11024043 DOI: 10.1007/s00784-024-05607-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [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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Butterfield J, Pencek M, Sweitzer K, Marrinan E, Connolly H, Neimanis S, Morrison C. Superiorly Based Posterior Pharyngeal Flaps: Using A Care Pathway to Optimize Speech and Airway Outcomes. Ann Plast Surg 2024; 92:S101-S104. [PMID: 38556656 DOI: 10.1097/sap.0000000000003859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency, but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) preoperative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient-specific surgical approach via appropriately sized PFs can result in excellent speech outcomes while limiting occurrence of OSA. METHODS This was a retrospective chart review of all patients with velopharyngeal insufficiency (VPI) (aged 2-20 years) seen at the University of Rochester from 2015 to 2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine PF width. Patients underwent polysomnography and speech evaluation before and at least 6 months after PF surgery. RESULTS Forty-one children aged 8.5 ± 4.1 years (range, 4 to 18 years) who underwent posterior PF surgery for VPI were identified. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin sequence. Thirty-nine patients had both pre- and postoperative speech data and underwent both a pre- and postoperative sleep study. Polysomnography showed no significant difference in obstructive apnea-hypopnea index after posterior PF surgery (obstructive apnea-hypopnea index preop, 1.3 ± 1.2 events per hour; postop, 1.7 ± 2.1 events per hour; P = 0.111). Significant improvements in speech outcome were seen in patients who underwent PF (modified Pittsburgh score preop, 11.52 ± 1.37; postop, 1.09 ± 2.35; P < 0.05). CONCLUSIONS Use of preoperative staged adenotonsillectomy as well as patient-specific PF dimensions results in effective resolution of VPI and a low risk of OSA.
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Affiliation(s)
- James Butterfield
- From the Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Cantarella G, Aldè M, Mazzola RF. Comment on "Clinical application of endoscopic soft palate augmentation in the treatment of velopharyngeal insufficiency". Int J Oral Maxillofac Surg 2024; 53:351-352. [PMID: 37865530 DOI: 10.1016/j.ijom.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/23/2023]
Affiliation(s)
- G Cantarella
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Otolaryngology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - M Aldè
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Department of Specialist Surgical Sciences, Audiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - R F Mazzola
- Plastic surgery private practice, Milan, Italy.
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Sakran KA, Yin J, Yang R, Elayah SA, Alkebsi K, Zhang S, Wang Y, Shi B, Huang H. Early Cleft Palate Repair by a Modified Technique Without Relaxing Incisions. Cleft Palate Craniofac J 2024; 61:646-653. [PMID: 36300250 DOI: 10.1177/10556656221135288] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVE This study sought to evaluate a modified palatoplasty technique (MPT) concerning the postoperative outcomes and associated influencing factors. DESIGN A retrospective cohort study. PARTICIPANTS AND SETTING One hundred forty-three consecutive patients with non-syndromic cleft palate, who received MPT before one year of age within an oral and maxillofacial surgery department of a university-affiliated tertiary hospital between 2011-2017, were reviewed. MAIN MEASURES The postoperative wound healing and velopharyngeal function (VPF) were the primary outcome measures. The sex, age at surgery, cleft type, cleft width, palatal width, soft palate length, pharyngeal cavity depth, and operation duration were preselected as influencing factors. Univariate and multivariate analyses were conducted. RESULTS The mean age at surgery was 9 ± 1.31 months (5-11), and the average cleft width was 9.03 ± 2.41 mm (4-15). The rate of incomplete cleft palate was 84.6% while the complete cleft palate was 15.4%. Complete wound healing was reported in 96.5% while the others (3.5%) had persistent oronasal fistula. About 90.2% of cases have shown normal velopharyngeal function whereas the others (9.8%) had sustained velopharyngeal insufficiency. The wound healing appeared to be significantly impacted by cleft width and pharyngeal cavity depth (P = .015 and 0.049, respectively). However, none of the factors had a significant association with VPF. CONCLUSIONS The present modified palatoplasty technique has obtained a low fistula rate and appropriate speech outcome. Therefore, this MPT could be promoted for early repairing cleft palate of different severities.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Jiayi Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Renjie Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Eastern Clinic, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Shiming Zhang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Esmailzade Moghimi S, Rezaei P, Sadeghi S, Feizi A, Derakhshandeh F. Outcomes of primary repair of cleft palate using sommerled intravelar veloplasty associated with velocardiofacial syndrome. Int J Pediatr Otorhinolaryngol 2024; 179:111940. [PMID: 38588634 DOI: 10.1016/j.ijporl.2024.111940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES Velocardiofacial syndrome, a prevalent microdeletion syndrome occurring in 1 in 2000-4000 live births, is marked by speech and language disorders, notably velopharyngeal dysfunction. This study investigates speech outcomes, nasometric and videofluoroscopic results before and after primary repair of cleft palate using the Sommerlad intravelar veloplasty (SIVV) technique within the Isfahan cleft care team for patients with velocardiofacial syndrome. METHODS Employing a quasi-experimental design, 19 participants with velocardiofacial syndrome, who underwent primary cleft palate repair by the Isfahan cleft care team, were included through convenience sampling. Perceptual and instrumental outcomes were assessed pre-and post-operatively. Statistical analysis encompassed paired t-tests and the non-parametric Wilcoxon signed-rank test (p < 0.05). RESULTS The study identified no statistically significant differences between pre-and post-surgical speech outcome parameters and nasalance scores. Nonetheless, a significant distinction emerged in the velopharyngeal closure ratio based on fluoroscopic evaluation (p = 0.038). CONCLUSION The efficacy of the SIVV technique in treating velopharyngeal dysfunction in velocardiofacial syndrome patients is inconclusive, demanding further research. Post-surgical speech outcomes are influenced by surgical technique, hypotonia, apraxia of speech, and surgery timing. Notably, an elevated velopharyngeal valve closure ratio, though anatomically indicative, does not exclusively predict surgical success.
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Affiliation(s)
- Sarah Esmailzade Moghimi
- Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Faculty of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Rezaei
- Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Sadeghi
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Awat Feizi
- Department of Biostatistics, Faculty of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Derakhshandeh
- Craniofacial and Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Ma J, Zhang M, Yang D, Zhai K, Yu L, Hu C, Dong W, Huang Y. Three-dimensional finite element analysis on stress distribution after different palatoplasty and levator veli palatini muscle reconstruction. Clin Oral Investig 2024; 28:221. [PMID: 38499908 DOI: 10.1007/s00784-024-05583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To establish a three-dimensional finite element model of the upper palate, pharyngeal cavity, and levator veli palatini muscle in patients with unilateral complete cleft palate, simulate two surgical procedures that the two-flap method and Furlow reverse double Z method, observe the stress distribution of the upper palate soft tissue and changes in pharyngeal cavity area after different surgical methods, and verify the accuracy of the model by reconstructing and measuring the levator veli palatini muscle. MATERIALS AND METHODS Mimics, Geomagic, Ansys, and Hypermesh were applied to establish three-dimensional finite element models of the pharyngeal cavity, upper palate, and levator veli palatini muscle in patients with unilateral complete cleft palate. The parameters including length, angle, and cross-sectional area of the levator veli palatini muscle etc. were measured in Mimics, and two surgical procedures that two-flap method and Furlow reverse double Z method were simulated in Ansys, and the area of pharyngeal cavity was measured by hypermesh. RESULTS A three-dimensional finite element model of the upper palate, pharyngeal cavity, and bilateral levator veli palatini muscle was established in patients with unilateral complete cleft palate ; The concept of horizontal projection characteristics of the palatal dome was applied to the finite element simulation of cleft palate surgery, vividly simulating the displacement and elastic stretching of the two flap method and Furlow reverse double Z method during the surgical process; The areas with the highest stress in the two-flap method and Furlow reverse double Z method both occur in the hard soft palate junction area; In resting state, as measured, the two flap method can narrow the pharyngeal cavity area by 50.9%, while the Furlow reverse double Z method can narrow the pharyngeal cavity area by 65.4%; The measurement results of the levator veli palatini muscle showed no significant difference compared to previous studies, confirming the accuracy of the model. CONCLUSIONS The finite element method was used to establish a model to simulate the surgical procedure, which is effective and reliable. The area with the highest postoperative stress for both methods is the hard soft palate junction area, and the stress of the Furlow reverse double Z method is lower than that of the two-flap method. The anatomical conditions of pharyngeal cavity of Furlow reverse double Z method are better than that of two-flap method in the resting state. CLINICAL RELEVANCE This article uses three-dimensional finite element method to simulate the commonly used two-flap method and Furlow reverse double Z method in clinical cleft palate surgery, and analyzes the stress distribution characteristics and changes in pharyngeal cavity area of the two surgical methods, in order to provide a theoretical basis for the surgeon to choose the surgical method and reduce the occurrence of complications.
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Affiliation(s)
- Jian Ma
- The General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Meng Zhang
- Stomatology College of Ningxia Medical University, Yinchuan, China
- Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian Hospital affiliated to Xuzhou Medical University, Suqian, China
| | - Denglan Yang
- Stomatology College of Ningxia Medical University, Yinchuan, China
| | - Kun Zhai
- The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lili Yu
- The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Chen Hu
- The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wen Dong
- The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yongqing Huang
- The General Hospital of Ningxia Medical University, Yinchuan, China.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Schaar Johansson M, Becker M, Eriksson M, Stiernman M, Klintö K. Surgical treatment of velopharyngeal dysfunction: Incidence and associated factors in the Swedish cleft palate population. J Plast Reconstr Aesthet Surg 2024; 90:240-248. [PMID: 38387421 DOI: 10.1016/j.bjps.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/30/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Speech in children with cleft palate can be affected by velopharyngeal dysfunction, which persists after primary palate repair. The incidence of surgery to correct velopharyngeal dysfunction in this patient group has previously been reported as 2.6-37%. We aimed to investigate the incidence of velopharyngeal dysfunction surgery in Swedish children with cleft palate and to examine potential associations of independent variables with this incidence. METHODS In this cohort study, we analysed data from the Swedish cleft lip and palate quality registry for 1093 children with cleft palate with or without cleft lip. Kaplan-Meier analysis was used to estimate the risk of having velopharyngeal dysfunction surgery. Multivariable Cox proportional hazards models were used to estimate the associated effect of cleft subtype, additional diagnoses, gender, and age at and number of stages for primary palate repair on the primary outcome. RESULTS The risk of having velopharyngeal dysfunction surgery was 25.6%. Complete primary palate repair after the age of 18 months or in more than one stage was associated with a higher risk, but it could not be determined which of these was the more significant factor. Cleft soft palate was associated with a significantly lower risk than other cleft subtypes. CONCLUSIONS Primary palate repair at a higher age or in more than one stage may increase the risk of having velopharyngeal dysfunction surgery. Further analysis of potential unknown confounding factors and the association between the incidence of velopharyngeal dysfunction and surgery to correct this condition is needed.
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Affiliation(s)
- Malin Schaar Johansson
- Division of Speech Language Pathology, Phoniatrics and Audiology, Department of Clinical Sciences in Lund, Lund University, Sweden; Division of Speech Language Pathology, Department of Otorhinolaryngology, Skåne University Hospital, Malmö, Sweden.
| | - Magnus Becker
- Division of Surgery, Department of Clinical Sciences in Malmö, Lund University, Sweden; Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Mia Stiernman
- Division of Surgery, Department of Clinical Sciences in Malmö, Lund University, Sweden; Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Kristina Klintö
- Division of Speech Language Pathology, Phoniatrics and Audiology, Department of Clinical Sciences in Lund, Lund University, Sweden; Division of Speech Language Pathology, Department of Otorhinolaryngology, Skåne University Hospital, Malmö, Sweden
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15
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Swanson D, Struyk G, Ba'th F, Chinnadurai S, Roby BB. The Incidence of Velopharyngeal Insufficiency in Stickler Syndrome. Cleft Palate Craniofac J 2024; 61:231-234. [PMID: 36443936 DOI: 10.1177/10556656221140675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE Stickler Syndrome (SS) is an inherited collagenopathy characterized by heterogenous orofacial, ocular, auditory, and skeletal abnormalities. The orofacial manifestations are variable and some patients present with cleft palate and velopharyngeal insufficiency (VPI). The incidence of VPI in SS is poorly studied and no studies have compared the incidence of VPI between Type I (COL2A1) and Type II (COL11A1) SS. The objective of this study is to compare the incidence of VPI between SS subtypes and discuss the surgical techniques used to treat them. DESIGN Single-institution, retrospective chart review. SETTING Tertiary pediatric hospital. PATIENTS/PARTICIPANTS Forty-three children were diagnosed with SS between January 2003 and December 2018. Genetic testing results, genetics notes, craniofacial clinic notes, and operative reports were reviewed. Patients without genetic testing or craniofacial/otolaryngologic evaluation were excluded. Thirty-one patients met criteria and were included. MAIN OUTCOME MEASURE Primary outcome was VPI incidence. RESULTS There were 18 patients with Type I SS and 13 with Type II SS. Five (16%) patients had VPI, 2 (11%) with Type I SS compared to 3 (23%) with Type II SS (P > .05). All patients with VPI underwent surgery with either sphincter pharyngoplasty (3) or pharyngeal flap (2). Two patients with Type II SS underwent revision sphincter pharyngoplasty, with one conversion to pharyngeal flap. CONCLUSION VPI is common for patients with SS. In this study, there was no significant difference in the incidence of VPI between SS subtypes. Future studies are needed to confirm these findings, which could be important for patient counseling and treatment planning.
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Affiliation(s)
- Daniel Swanson
- Georgetown University School of Medicine, Washington, DC, USA
| | - Griffin Struyk
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Fadlullah Ba'th
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sivakumar Chinnadurai
- Children's Minnesota ENT and Facial Plastic Surgery, Minneapolis, MN, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Brianne B Roby
- Children's Minnesota ENT and Facial Plastic Surgery, Minneapolis, MN, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
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Long BD, Petersson RS. Primary Cleft Palate Repair. Facial Plast Surg Clin North Am 2024; 32:55-62. [PMID: 37981416 DOI: 10.1016/j.fsc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
There are several factors to consider when planning cleft palate repair. It is important to review the patient's associated comorbidities, as they impact decisions on perioperative management and family counseling. Many comorbidities change the risk of postoperative airway obstruction, velopharyngeal insufficiency, or fistula formation. It is also critical to determine the type of cleft palate to be addressed, as this influences the decision on which technique is most appropriate for optimal patient outcome. Common surgical techniques for palatoplasty are reviewed in detail and outcomes are discussed as it relates to various techniques. Intraoperative photographs are included to detail the procedures.
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Affiliation(s)
- Barry Daniel Long
- Department of Otolaryngology/Head and Neck Surgery, Virginia Commonwealth University SOM, Richmond, VA, USA
| | - Rajanya Shah Petersson
- Department of Otolaryngology/Head and Neck Surgery, Virginia Commonwealth University SOM, Richmond, VA, USA; Department of Otolaryngology/Head and Neck Surgery, Children's Hospital of Richmond at VCU, Richmond, VA, USA.
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Huang Z, Bo Z, Li J, Zheng Q, Shi B, Zeng N. Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty. J Craniomaxillofac Surg 2024; 52:234-239. [PMID: 38161074 DOI: 10.1016/j.jcms.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/23/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.
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Affiliation(s)
- Zhongping Huang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Zhenyan Bo
- West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ni Zeng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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18
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Tran T, Perry J, Blemker S, Mason K. Simulation of Velopharyngeal Biomechanics Identifies Differences in Sphincter Pharyngoplasty Outcomes: A Matched Case-Control Study. Cleft Palate Craniofac J 2024; 61:339-349. [PMID: 35996316 PMCID: PMC9943793 DOI: 10.1177/10556656221122634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to develop a framework for 3D subject-specific computational models capable of simulating velopharyngeal biomechanics for anatomic changes that occur following pharyngoplasty and to gain insight into biomechanical factors that may lead to different speech/surgical outcomes. Patient-specific models for two, matched participants with differing speech/surgical outcomes were developed: one with a successful pharyngoplasty outcome and one with a failed pharyngoplasty outcome. Surgical scenarios were simulated to model pharyngoplasty location, identify LVP muscle biomechanics, and identify an optimal pharyngoplasty location for each participant. These simulations illustrate the potential for optimizing pharyngoplasties based on patient-specific geometry.
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Affiliation(s)
- Thanh Tran
- Department of Biomedical Engineering, University of Virginia
| | - Jamie Perry
- Department of Communication Sciences & Disorders, Eastern Carolina University
| | - Silvia Blemker
- Department of Biomedical Engineering, University of Virginia
| | - Kazlin Mason
- Department of Human Services, University of Virginia
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Kamal Lashin M, Kadry W, Al-Byale RR, Beheiri G. A novel technique predicting velopharyngeal insufficiency risk in newborns following primary cleft repair. A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty. J Craniomaxillofac Surg 2024; 52:188-195. [PMID: 38195298 DOI: 10.1016/j.jcms.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 08/01/2023] [Accepted: 11/23/2023] [Indexed: 01/11/2024] Open
Abstract
The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.
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Affiliation(s)
| | - Walaa Kadry
- Faculty of Oral and Dental Medicine, Cairo University, Egypt.
| | | | - Galal Beheiri
- Faculty of Oral and Dental Medicine, Cairo University, Egypt
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20
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Raposo-Amaral CA, Monte TM, Raposo-Amaral CE. Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps. Plast Reconstr Surg 2024; 153:411e-414e. [PMID: 37053444 DOI: 10.1097/prs.0000000000010551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
SUMMARY The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.
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Affiliation(s)
- Cesar Augusto Raposo-Amaral
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
- Department of Neurology, University of Campinas
| | - Thais Miguel Monte
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
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Boynuyoğun E, Çırak A, Atak F, Tığrak TK, Çalış M, Günaydın RÖ, Karaosmanoğlu A, Süslü AE, Kayıkçı MEK, Özgür F. Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy. J Plast Reconstr Aesthet Surg 2024; 88:397-406. [PMID: 38086325 DOI: 10.1016/j.bjps.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 01/02/2024]
Abstract
The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.
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Affiliation(s)
- Etkin Boynuyoğun
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey.
| | - Alaz Çırak
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Fırat Atak
- Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Tuğçe Karahan Tığrak
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Ankara, Turkey
| | - Mert Çalış
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Rıza Önder Günaydın
- Hacettepe University Faculty of Medicine, Department of Otorhinolaryngology, Ankara, Turkey
| | - Ayça Karaosmanoğlu
- Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Ahmet Emre Süslü
- Hacettepe University Faculty of Medicine, Department of Otorhinolaryngology, Ankara, Turkey
| | - Maviş Emel Kulak Kayıkçı
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Ankara, Turkey
| | - Figen Özgür
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
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Lignieres A, Anderson B, Alimi O, Cepeda A, Seitz A, Obinero CG, Teichgraeber JF, Nguyen PD, Greives MR. Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate? Plast Reconstr Surg 2024; 153:139e-145e. [PMID: 37053453 DOI: 10.1097/prs.0000000000010531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
SUMMARY Velopharyngeal insufficiency (VPI) is a complication following primary palatoplasty that can lead to hypernasality of the voice and other speech problems. The conversion Furlow palatoplasty for VPI can be performed with the addition of buccal flaps to provide additional tissue for palatal repair. In this study, the authors aimed to determine the effectiveness of buccal flaps with conversion Furlow palatoplasty in secondary management of VPI. A retrospective review of patients undergoing surgical repair of VPI between 2016 and 2020 was performed. Patients underwent either conversion Furlow palatoplasty alone (FA) or conversion Furlow palatoplasty with buccal flaps (FB) for VPI after primary straight-line repair of the palate. The authors reviewed medical records to collect demographics, operative information, and preoperative and postoperative speech scores. Of the 77 patients in the study, 16 (21%) had a revision that incorporated buccal flaps. The median age at cleft palate revision surgery was 8.97 years in the FA group and 7.96 years in the FB group ( P = 0.337). In the FA group, four patients (7%) developed a postoperative fistula, compared with zero patients in the FB group. The average time to follow-up after revision surgery was 3.4 years (range, 7 months to 5.9 years). Both cohorts demonstrated a decrease in hypernasality and total parameter scores postoperatively. The use of buccal flaps in revision Furlow palatoplasty could decrease the risk for postoperative complications. The use of data from a larger patient population from multiple institutions is warranted to determine true significance. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Austin Lignieres
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Brady Anderson
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Oluwatofe Alimi
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Alfredo Cepeda
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Allison Seitz
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Chioma G Obinero
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - John F Teichgraeber
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Phuong D Nguyen
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Matthew R Greives
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
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Chin MG, Roca Y, Huang KX, Moghadam S, LaGuardia JS, Bedar M, Wilson LF, Lee JC. Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate. J Plast Reconstr Aesthet Surg 2024; 88:24-32. [PMID: 37950988 DOI: 10.1016/j.bjps.2023.10.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA). DESIGN Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n = 166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified. INTERVENTIONS The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty. MAIN OUTCOME MEASURES Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA. RESULTS Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p < 0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4 ± 2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p = 0.03). CONCLUSIONS Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.
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Affiliation(s)
- Madeline G Chin
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Yvonne Roca
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Shahrzad Moghadam
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Jonnby S LaGuardia
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Libby F Wilson
- Craniofacial/Cleft Palate Program, Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States.
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Cho DY, Taylor JA. Discussion: Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate? Plast Reconstr Surg 2024; 153:146e-147e. [PMID: 38127450 DOI: 10.1097/prs.0000000000010796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
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Geisman MM, Skolnick GB, Grames LM, Naidoo SD, Snyder-Warwick AK, Patel KB. Impact of a Palatal Fistula After Cleft Palate Repair on Velopharyngeal Closure. Cleft Palate Craniofac J 2024; 61:61-67. [PMID: 35912430 DOI: 10.1177/10556656221116534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency. METHODS A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction. RESULTS Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤P ≤ .975). CONCLUSIONS A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction.
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Affiliation(s)
- Mackenzie M Geisman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lynn M Grames
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Hofman L, van Dongen JA, van Rees RCM, Jenniskens K, Haverkamp SJ, Beentjes YS, van der Molen ABM, Paes EC. Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis. Clin Oral Investig 2023; 28:58. [PMID: 38157017 DOI: 10.1007/s00784-023-05391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
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.
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Affiliation(s)
- Lieke Hofman
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands.
| | - Joris A van Dongen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | | | - Kevin Jenniskens
- Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sarah J Haverkamp
- Speech and Language Therapy, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Yente S Beentjes
- Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Aebele B Mink van der Molen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Emma C Paes
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
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Dong Z, Xie Y, Yang J, Fu Y, Li J. Clinical efficacy of Hogan posterior pharyngeal flap in repairing velopharyngeal insufficiency secondary to cleft palate in older patients. Hua Xi Kou Qiang Yi Xue Za Zhi 2023; 41:713-718. [PMID: 38597038 PMCID: PMC10722449 DOI: 10.7518/hxkq.2023.2023155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/07/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVES The clinical effects and surgical procedures of Hogan posterior pharyngeal flap in the treatment of the older patients with velopharyngeal insufficiency (VPI) after cleft palate repair were investigated. METHODS A total of 33 patients (aged 10-35 years; average of 20.4 years) with VPI secondary to cleft palate were included. They underwent Hogan posterior pharyngeal flap to improve velopharyngeal closure function. The clinical efficacy of the ope-ration was evaluated with Chinese speech clarity measurement and nasopharyngeal fiberscope (NPF), and the velopharyngeal closure was graded. The average follow-up time was 13.3 months. RESULTS The wounds of all patients were healed by first intention, and speech assessment showed that the consonant articulation increased and the rate of hypernasality and nasal emission decreased significantly (P<0.05). NPF examination showed that the postoperative velopharyngeal closure function significantly improved, 30 cases (91%) were gradeⅠ, and 3 cases (9%) were grade Ⅱ. CONCLUSIONS Hogan posterior pharyngeal flap for VPI secondary to cleft palate can significantly improve velopharyngeal closure.
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Affiliation(s)
- Zhe Dong
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, Dept. of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Ying Xie
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, Dept. of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Jiegang Yang
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, Dept. of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Yuchuan Fu
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, Dept. of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Jian Li
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, Dept. of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, China
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28
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De Virgilio A, Bellini E, Pace GM, Costantino A, Festa BM, Iandelli A, Russo E, Sampieri C, Peretti G, Spriano G, Marchi F. Functional outcomes of soft palate reconstruction after oncologic surgery: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:5177-5191. [PMID: 37620732 DOI: 10.1007/s00405-023-08191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The aim of this study is to analyze functional outcomes of soft palate reconstruction after oncologic surgery. METHODS This study was conducted in conformity with the PRISMA statement. A single arm meta-analysis was performed for feeding tube dependence (FTD) (primary outcome), velopharyngeal insufficiency (VPI) and hypernasality (HN) (secondary outcomes) incidences. RESULTS A total of 510 patients (males: 77.75%, n = 353/454) with a median age of 58 years (n = 480/510; 95% CI 57.0-61.0) who underwent soft palate surgical resection with primary reconstruction were included. Overall, the cumulative FTD rate was 1.55% (n = 28/510; 95% CI 0.24-3.96%), the VPI rate was 22.18% (n = 119/379; 95% CI 12.99-33.02%), and the HN rate was 33.01% (n = 88/234; 95% CI 19.03-46.61%). CONCLUSIONS Soft palate reconstruction results in a low incidence of FTD, and most patients resume a full oral diet. Both obturators, primary closure, local and free flaps seem good reconstructive options. Nevertheless, more specific postoperative functional deficiencies like VPI and HN owns higher incidences, potentially affecting the quality of the swallowing and speaking function and the patient's quality of life.
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Affiliation(s)
- Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Elisa Bellini
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Gian Marco Pace
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Andrea Iandelli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Elena Russo
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Claudio Sampieri
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
- Functional Unit of Head and Neck Tumors, Hospital Clínic, Barcelona, Spain
- Otorhinolaryngology Department, Hospital Clínic, Barcelona, Spain
| | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Filippo Marchi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
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Alanazi A, Merati A. Epidural Abscess After Injection Pharyngoplasty: A Case Report. Laryngoscope 2023; 133:3409-3411. [PMID: 37042543 DOI: 10.1002/lary.30693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 02/23/2023] [Accepted: 03/25/2023] [Indexed: 04/13/2023]
Abstract
VPI occurs when the seal between the oral and nasal cavities does not doesn't close completely. One of the treatment options is an injection pharyngoplasty (IP). We are presenting a life threating -threatening case of epidural abscess after in- office injection pharyngoplasty IP. Laryngoscope, 133:3409-3411, 2023.
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Affiliation(s)
- Abdullah Alanazi
- Otolaryngology-Head and Neck Surgery Department, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Albert Merati
- Otolaryngology-Head and Neck Surgery Department, University of Washington Medical Center, Seattle, Washington, U.S.A
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30
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Reed CA, Birch A, Coward T. A custom nasal obturator for velopharyngeal dysfunction: A dental technique. J Prosthet Dent 2023; 130:940-943. [PMID: 35501186 DOI: 10.1016/j.prosdent.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
Removable nasal obturators provide a treatment option for a range of patients presenting with velopharyngeal dysfunction without eliminating the possibility for future surgery, speech therapy, or the provision of other devices. The presented technique describes the fabrication of a 1-piece silicone nasal obturator to reduce hypernasality and nasal airflow errors without causing significant hyponasality. The obturator has minimal visibility and minimal risk of inhalation.
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Affiliation(s)
- Caroline A Reed
- Principal Maxillofacial Prosthetist, Academic Centre of Reconstructive Science, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom.
| | - Alison Birch
- Speech and Language Therapist, Evelina London Cleft Service, South Wing, St Thomas' Hospital. Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Trevor Coward
- Professor/Consultant in Maxillofacial Craniofacial Rehabilitation, Academic Centre of Reconstructive Science, King's College London, London, United Kingdom
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31
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Ha JH, Lee H, Kwon SM, Joo H, Lin G, Kim DY, Kim S, Hwang JY, Chung JH, Kong HJ. Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates. J Craniofac Surg 2023; 34:2369-2375. [PMID: 37815288 PMCID: PMC10597411 DOI: 10.1097/scs.0000000000009560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 05/16/2023] [Indexed: 10/11/2023] Open
Abstract
Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.
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Affiliation(s)
- Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Biomedical Research Institute, Seoul National University Hospital
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul
| | - Haeyun Lee
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Production Engineering Research Team, SAMSUNG SDI, Yongin-si, Gyeonggi-do Province
| | - Seok Min Kwon
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine
| | - Hyunjin Joo
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
| | - Guang Lin
- Department of Aesthetic and Plastic Surgery, The First Affiliated Hospital ZHEJIANG University School of Medicine, Hangzhou, China
| | - Deok-Yeol Kim
- Department of Plastic Surgery, CHA Bundang Medical Center, and CHA Institute of Aesthetic Medicine, Seongnam-si, Gyeonggi-do Province
| | - Sukwha Kim
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Department of Plastic Surgery, CHA Bundang Medical Center, and CHA Institute of Aesthetic Medicine, Seongnam-si, Gyeonggi-do Province
| | - Jae Youn Hwang
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu
- Interdisciplinary Studies of Artificial Intelligence, Daegu Gyeongbuk Institute of Science and Technology, Daegu
| | - Jee-Hyeok Chung
- Division of Pediatric Plastic Surgery, Seoul National University Children’s Hospital
| | - Hyoun-Joong Kong
- Medical Big Data Research Center, Seoul National University College of Medicine, Seoul
- Department of Transdisciplinary Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul, Korea
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32
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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33
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Perry JL, Williams JL, Snodgrass TD, Sitzman TJ. VPI Management in SATB2 Syndrome: Use of MRI to Evaluate Anatomy and Physiology in Non-Cleft VPI. Cleft Palate Craniofac J 2023; 60:1499-1504. [PMID: 35695193 PMCID: PMC10183239 DOI: 10.1177/10556656221106888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This clinical case study describes the velopharyngeal anatomy and physiology in a patient who presented with SATB2-associated syndrome (SAS) and velopharyngeal insufficiency (VPI) in the absence of an overt cleft palate. The clinical presentation, treatment, outcome, and the contribution of anatomical findings from MRI to surgical treatment planning for this rare genetic disorder, SAS, are described. This case study contributes to our current understanding of the anatomy and physiology of the velopharyngeal mechanism in an individual born with SAS and non-cleft VPI. It also details the changes following bilateral buccal myomucosal flaps in this patient.
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Affiliation(s)
- Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Jessica L Williams
- Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
- Department of Speech and Hearing Science, Arizona State University, Tempe, AZ, USA
| | - Taylor D Snodgrass
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Thomas J Sitzman
- Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
- Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
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Ku YC, Al-Malak M, Mulvihill L, Deleonibus A, Maasarani S, Bassiri Gharb B, Rampazzo A. Tissue adjuncts in primary cleft palate reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2023; 86:300-314. [PMID: 37797378 DOI: 10.1016/j.bjps.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/13/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty. METHODS A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables. RESULTS A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03). CONCLUSIONS Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.
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Affiliation(s)
- Ying C Ku
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mazen Al-Malak
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lianne Mulvihill
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony Deleonibus
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samantha Maasarani
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bahar Bassiri Gharb
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Antonio Rampazzo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Camargo Y, Kellogg B, Kollara L. Pharyngeal Flap Versus Sphincter Pharyngoplasty for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome: Preliminary Findings From a Systematic Review. J Craniofac Surg 2023; 34:1994-1998. [PMID: 37431935 DOI: 10.1097/scs.0000000000009531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
The purpose of this study was to examine and compare surgical and speech outcomes of the posterior pharyngeal flap and sphincter pharyngoplasty following surgical management of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome (22q11.2DS). This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist and guidelines. Selected studies were chosen using a 3-step screening process. The 2 primary outcomes of interest were speech improvement and surgical complications. Preliminary findings based on included studies suggest a slightly higher rate of postoperative complications with the posterior pharyngeal flap in patients with 22q11.2DS but a lower percentage of patients needing additional surgery compared with the sphincter pharyngoplasty group. The most reported postoperative complication was obstructive sleep apnea. Results from this study provide some insight into speech and surgical outcomes following pharyngeal flap and sphincter pharyngoplasty in patients with 22q11.2DS. However, these results should be interpreted with caution due to inconsistencies in speech methodology and lack of detail regarding surgical technique in the current literature. There is a significant need for standardization of speech assessments and outcomes to help optimize surgical management of velopharyngeal insufficiency in individuals with 22q11.2DS.
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Affiliation(s)
- Yitzella Camargo
- School of Communication Sciences and Disorders, College of Health Professions and Sciences, University of Central Florida
| | - Brian Kellogg
- Division of Plastic & Craniofacial Surgery, Department of Surgery, Nemours Children's Hospital
| | - Lakshmi Kollara
- School of Communication Sciences and Disorders, College of Health Professions and Sciences, University of Central Florida
- Biionix Cluster, College of Medicine, University of Central Florida, Orlando, FL
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Pattisapu P, Kinter S, Bly RA, Dahl JP, Perkins JA, Wang X, Sie KCY. Sphincter Pharyngoplasty for Velopharyngeal Dysfunction: Impact of 22q11.2 Deletion Syndrome. Laryngoscope 2023; 133:2813-2820. [PMID: 36695155 DOI: 10.1002/lary.30579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Patients with 22q11.2 deletion syndrome (22q11DelS) often present with velopharyngeal dysfunction (VPD). VPD in patients with 22q11DelS is multifactorial beyond velopharyngeal insufficiency (VPI) alone, and differences in surgical outcomes are poorly understood. Our objective was to determine whether patients with 22q11DelS have an increased risk for persistent VPI after sphincter pharyngoplasty compared to patients without 22q11DelS. METHODS We completed a retrospective cohort study of patients with 22q11DelS undergoing sphincter pharyngoplasty between 1995 and 2019 using a VPD clinic database. Patients with 22q11DelS were compared to a cohort of 2:1 frequency-matched (age, degree of velopharyngeal closure) patients without 22q11DelS. Variables included patient characteristics, surgical history, perceptual speech evaluation, and degree of closure on nasopharyngoscopic evaluations. Primary outcomes included postoperative VPI severity and hypernasality. Speech and nasopharyngoscopic characteristics were compared using Fisher's exact test. Postoperative VPI severity and hypernasality were compared between groups via relative risks (RR) from mixed effects Poisson regression models, with random effects of age and velopharyngeal closure. RESULTS 134 patients (51 22q11DelS, 83 matched) were included, with mean age of 7.3 years (standard deviation 3.0) and 50% male. Cohorts had similar preoperative speech characteristics and nasopharyngoscopic findings. Patients with 22q11DelS had similar postoperative VP function as patients without 22q11DelS (RR 0.85, CI 0.46-1.57 for VPI severity, RR 0.83, CI 0.45-1.53 for hypernasality). Even after adjusting by preoperative variables, no differences were seen between both groups. CONCLUSION Matched for age and pre-operative velopharyngeal closure, patients with and without 22q11DelS and VPI had similar benefits after sphincter pharyngoplasty. LEVEL OF EVIDENCE Non-randomized controlled cohort study, 3 Laryngoscope, 133:2813-2820, 2023.
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Affiliation(s)
- Prasanth Pattisapu
- Department of Otolaryngology-Head & Neck Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
- Center for Surgical Outcomes Research and Center for Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sara Kinter
- Childhood Communication Center, Seattle Children's Hospital, Seattle, Washington, USA
- Division of Craniofacial Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior & Development, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonathan A Perkins
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Xing Wang
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Y Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
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Okhiria Å, Persson C, Johansson MB, Hakelius M, Nowinski D. Longitudinal data on speech outcomes in internationally adopted children compared with non-adopted children with cleft lip and palate. Int J Lang Commun Disord 2023; 58:1440-1453. [PMID: 36929536 DOI: 10.1111/1460-6984.12869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND At the beginning of the 21st century, international adoptions of children with cleft lip and/or palate increased dramatically in Sweden. Many children arrived partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. To date, the speech development of internationally adopted (IA) children has been described up to age 7-8 years, but later development remains unstudied. AIMS To investigate speech development between ages 5 and 10 years in children born with cleft lip and palate (CLP) adopted from China and to compare them with non-adopted (NA) children with CLP. A secondary aim was to compare the frequencies of secondary palatal surgery and number of visits to a speech and language pathologist (SLP) between the groups. METHODS & PROCEDURES In a longitudinal study, 23 IA children from China were included and matched with 23 NA children born in Sweden. Experienced SLPs blindly reassessed audio recordings from routine follow-ups at ages 5 and 10 years. Velopharyngeal function (VPF) was assessed with the composite score for velopharyngeal competence (VPC-Sum) for single words and rated on a three-point scale (VPC-Rate) in sentence repetition. Target sounds in words and sentences were phonetically transcribed. Per cent correct consonants (PCC) were calculated at word and sentence levels. For in-depth analyses, articulation errors were divided into cleft speech characteristics (CSCs), developmental speech characteristics (DSCs) and s-errors. Information on secondary palatal surgery and number of visits to an SLP was collected. OUTCOMES & RESULTS VPF differed significantly between the groups at both ages when assessed with VPC-Sum, but not with VPC-Rate. Regardless of the method for assessing VPF, a similar proportion in both groups had incompetent VPF but fewer IA than NA children had competent VPF at both ages. IA children had lower PCC at both ages at both word and sentence levels. More IA children had CSCs, DSCs and s-errors at age 5 years, and CSCs and s-errors at age 10. The development of PCC was significant in both groups between ages 5 and 10 years. The proportion of children receiving secondary palatal surgery did not differ significantly between the groups, nor did number of SLP visits. CONCLUSIONS & IMPLICATIONS CSCs were more persistent in IA children than in NA children at age 10 years. Interventions should target both cleft and DSCs, be comprehensive and continue past the pre-school years. WHAT THIS PAPER ADDS What is already known on this subject At the beginning of the 21st century, IA children with cleft lip and/or palate arrived in Sweden partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. Studies up to age 7-8 years show that adopted children, compared with NA peers, have poorer articulation skills, demonstrate both cleft-related and developmental articulation errors, and are more likely to have velopharyngeal incompetence. Several studies also report that adopted children more often require secondary palatal surgery due to fistulas, dehiscence or velopharyngeal incompetence compared with NA peers. What this paper adds to existing knowledge This longitudinal study provides additional knowledge based on longer follow-ups than previous studies. It shows that the proportion of children assessed to have incompetent VPF was similar among IA and NA children. It was no significant difference between the groups regarding the proportion that received secondary palatal surgery. However, fewer IA children were assessed to have a competent VPF. Developmental articulation errors have ceased in most IA and all NA children at age 10 years, but significantly more adopted children than NA children still have cleft-related articulation errors. What are the potential or actual clinical implications of this work? Speech and language therapy should target both cleft-related and developmental articulation errors. When needed, treatment must be initiated early, comprehensive, and continued past the pre-school years, not least for adopted children.
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Affiliation(s)
- Åsa Okhiria
- Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Christina Persson
- Institute of Neuroscience and Physiology, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monica Blom Johansson
- Department of Public Health and Caring Sciences, Speech and Language Pathology, Uppsala University, Uppsala, Sweden
| | - Malin Hakelius
- Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Daniel Nowinski
- Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
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Sakran KA, Yin J, Yang R, Alkebsi K, Elayah SA, Al-Rokhami RK, Holkom MA, Liu Y, Wang Y, Yang C, Shi B, Huang H. Evaluation of late cleft palate repair by a modified technique without relaxing incisions. J Stomatol Oral Maxillofac Surg 2023; 124:101403. [PMID: 36717021 DOI: 10.1016/j.jormas.2023.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/09/2023] [Accepted: 01/26/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the postoperative outcomes together with analyzing the associated influencing factors following a late cleft palate repair by the Sommerlad-Furlow modified technique (S-F). MATERIALS AND METHODS In a retrospective cohort, 320 consecutive patients with cleft palate, who received S-F technique between 2011 and 2017, were reviewed. The patients were divided into three age groups, less than one year (143), one to two years (113), and greater than 2 years (64). The postoperative outcomes included wound healing (complete/fistula) and velopharyngeal function (VPF). RESULTS The overall cleft width was 10 ± 3.07 mm. The overall rates of complete wound healing and proper velopharyngeal function were 96.6% and 81.56%, respectively. No significant difference was found between the age groups regarding wound healing, with an overall fistula rate of 3.4%. The VPF was significantly varied among the age groups (P<0.001). In context, the rates of velopharyngeal insufficiency (VPI) were 9.8%, 14.2%, and 45.4% among patients repaired at ˂1, 1-2, and >2 years old, respectively. The cleft type was the most potential factor associated with fistula. The age at repair was identified as the most implicating factor for VPI. CONCLUSIONS The S-F technique had achieved low fistula rate and satisfactory speech outcome, especially in early repair group and even in the wide cleft palate. The older age at repair and severe cleft type had a major impact on the postoperative outcomes.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Jiayi Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Renjie Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Remsh Khaled Al-Rokhami
- Department of Orthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Mohammed Ali Holkom
- Department of Oral and Maxillofacial Surgery, School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Yingmeng Liu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chao Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China.
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Lou Q, Wang X, Chen Y, Wang G, Jiang L, Liu Q. Subjective and Objective Evaluation of Speech in Adult Patients With Repaired Cleft Palate. J Craniofac Surg 2023; 34:e551-e556. [PMID: 36949035 DOI: 10.1097/scs.0000000000009301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/28/2022] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE To explore the speech outcomes of adult patients with repaired cleft palate through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with complete velopharyngeal closure (VPC) and velopharyngeal insufficiency (VPI) patients. PARTICIPANTS AND INTERVENTION Subjective evaluation indicators included speech intelligibility, nasality and consonant missing rate, for objective acoustic analysis, we used speech sample normalization and objective acoustic parameters included normalized vowel formants, voice onset time and the analysis of 3-dimensional spectrogram and spectrum, were carried out on speech samples produced by 3 groups of speakers: (a) speakers with velopharyngeal competence after palatorrhaphy (n=38); (b) speakers with velopharyngeal incompetence after palatorrhaphy (n=70), (c) adult patients with cleft palate (n=65) and (d) typical speakers (n=30). RESULTS There was a highly negative correlation between VPC grade and speech intelligibility (ρ=-0.933), and a highly positive correlation between VPC and nasality (ρ=0.813). In subjective evaluation, the speech level of VPI patients was significantly lower than that of VPC patients and normal adults. Although the nasality and consonant loss rate of VPC patients were significantly higher than that of normal adults, the speech intelligibility of VPC patients was not significantly different from that of normal adults. In acoustic analysis, patients with VPI still performed poorly compared with patients with VPC. CONCLUSIONS The speech function of adult cleft palate patients is affected by abnormal palatal structure and bad pronunciation habits. In subjective evaluation, there was no significant difference in speech level between VPC patients and normal adults, whereas there was significant difference between VPI patients and normal adults. The acoustic parameters were different between the 2 groups after cleft palate repair. The condition of palatopharyngeal closure after cleft palate can affect the patient's speech.
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Affiliation(s)
- Qun Lou
- Department of Oral and Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, Manufacturing bureau road, Shanghai, China
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Inostroza-Allende F, Torres Cavallo S, Palomares-Aguilera M, Giugliano-Villarroel C, Villarruel A, Benegas J, Selvaggio M, Sammartino F. International Collaboration for the Prosthetic and Surgical Intervention of Velopharyngeal Insufficiency. J Craniofac Surg 2023; 34:e549-e551. [PMID: 37503830 DOI: 10.1097/scs.0000000000009571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Interdisciplinary teamwork is essential for the rehabilitation of patients with cleft lip and palate, and therefore, the application of treatment techniques for velopharyngeal insufficiency, both surgical and prosthetic, depends on the experience of each rehabilitation team. For this reason, the following study consisting of the cooperation between interdisciplinary cleft lip and palate teams from Chile and Argentina, which succeeded in correcting velopharyngeal insufficiency in an adolescent, initially using a pharyngeal bulb prosthesis and speech therapy, and finally through pharyngeal flap surgery, is presented. This shows that international cooperation is a valuable tool for training, implementation, and follow-up of different treatment techniques for teams in formation.
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Affiliation(s)
| | | | - Mirta Palomares-Aguilera
- Gantz Foundation-Cleft Children's Hospital
- Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
- Smile Train-South American Medical Advisory Council-SAMAC
| | | | | | - Jorge Benegas
- Dr. Humberto Notti Pediatric Hospital, Mendoza, Argentina
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Antoneli MZ, Fukushiro AP, Yamashita RP, Ozawa TO, Alonso N, Tonello C. Speech Outcomes Audit for Unilateral Cleft lip and Palate After 2-Stage Palate Repair: Preliminary Results. J Craniofac Surg 2023; 34:1772-1775. [PMID: 37555517 DOI: 10.1097/scs.0000000000009594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/15/2023] [Indexed: 08/10/2023] Open
Abstract
Primary cleft lip and palate surgeries can interfere with speech status, facial appearance, maxillary growth, and psychosocial and academic development. Therefore, different surgical protocols and techniques have been proposed, and adequate velopharyngeal function and speech is the main goal for the treatment success. The present study aimed to report preliminary speech results of the 2-stage palate repair of children with unilateral cleft lip and palate. One hundred seventy nonsyndromic patients with unilateral cleft lip and palate were included in this report, 35% males and 65% females, submitted to the 2-stage palatoplasty protocol, composed by lip, nasal ala, and hard palate repair at 3 to 6 m (stage 1) and soft palate repair at 12 to 18 m (stage 2). The target age range for speech recording was 5 to 10 years, and the speech material included repetition of Brazilian Portuguese sentences. These samples were obtained over 5 years and assessed by 3 of 14 experienced speech pathologists. When discordant, the majority rate was adopted. Average velopharyngeal dysfunction (VPD) rates were 19,5%, varying according to the soft palate technique, with better results when the Sommerlad technique was performed (VPD=11%), followed by Braithwaite (VPD=15%) and then Von Langenbeck (VPD=25%). Passive errors were observed in 32% and active errors in 25%. Speech results reflect the outcomes of an interdisciplinary team's work, where facial growth and nasolabial appearance must also be considered. Further analysis and a wider casuistic are recommended. Hence outcomes audit needs to be a permanent process, providing solid and updated evidence for optimal cleft care.
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Affiliation(s)
- Melissa Zattoni Antoneli
- Department of Speech and Hearing, Hospital for Rehabilitation of Craniofacial Anomalies. University of São Paulo
| | - Ana Paula Fukushiro
- Hospital for Rehabilitation of Craniofacial Anomalies and Bauru School of Dentistry. University of São Paulo
| | - Renata Paciello Yamashita
- Laboratory of Physiology. Hospital for Rehabilitation of Craniofacial Anomalies. University of São Paulo
| | - Terumi Okada Ozawa
- Department of Orthodontics, Hospital for Rehabilitation of Craniofacial Anomalies. University of São Paulo
| | - Nivaldo Alonso
- Hospital for Rehabilitation of Craniofacial Anomalies and Hospital of Clinics of Medicine Faculty, University of São Paulo
| | - Cristiano Tonello
- Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
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Jeon S, Choi KB, Kim HW, Park HY, Kim S, Chung JH. Is There a Relationship between Palatal Asymmetry and Speech in Children with Isolated Cleft Palate after Double-Opposing Z-Plasty? Plast Reconstr Surg 2023; 152:307e-314e. [PMID: 36735819 DOI: 10.1097/prs.0000000000010272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although some cleft palates show asymmetric palatal shelf length and/or width intraoperatively, the relationship between palate asymmetry and speech outcomes has not been fully investigated. METHODS This study retrospectively reviewed 234 patients who underwent double-opposing Z-plasty (DOZ) for isolated cleft palate (Veau class I and II). Speech outcomes were analyzed to evaluate the association with width and length discrepancy of the palatal shelves using multiple logistic regression adjusting for patient age. RESULTS The mean age at repair was 14.2 ± 5.26 months. The mean palatal shelf width and length differences were 0.87 ± 0.97 mm and 1.63 ± 1.61 mm, respectively. The mean age at initial and follow-up assessment was 37.6 ± 5.70 months ( n = 234) and 66.2 ± 8.81 months ( n = 120), respectively. Multivariate logistic regression analysis of initial speech outcomes showed odds ratios in width discrepancy of 1.67 ( P = 0.0703), 1.59 ( P = 0.0104), and 2.01 ( P = 0.0051) for nasal emission, hypernasality, and compensatory articulation, respectively. Additional analysis including follow-up outcomes also revealed that width discrepancy of the palatal shelves had higher odds ratios for nasal emission, hypernasality, and compensatory articulation (OR, 1.49, P = 0.0406; OR, 1.36; P = 0.0660; and OR, 1.65; P = 0.0170, respectively). There was no association between length discrepancy and all speech abnormalities. CONCLUSIONS Greater discrepancies in palatal shelf width, rather than in length, were associated with poorer speech outcomes after DOZ. The authors suggest that DOZ is effective for longitudinally asymmetric cleft palates. CLIINCAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Sungmi Jeon
- From the Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital
- Department of Plastic and Reconstructive Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center
| | | | | | | | - Sukwha Kim
- Department of Plastic Surgery, CHA Bundang Medical Center
- Medical Big Data Research Center, Seoul National University College of Medicine
| | - Jee Hyeok Chung
- From the Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital
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Charters E, Pelham C, Novakovic D, Madill C, Clark J. Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review. Int J Speech Lang Pathol 2023; 25:540-548. [PMID: 35975948 DOI: 10.1080/17549507.2022.2104927] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Following transoral robotic surgery (TORS) for oropharyngeal carcinoma (OPC), velopharyngeal incompetence (VPI) is a known consequence that may contribute to swallowing and speech disorders. As the incidence of OPC increases affecting a younger demographic, a better understanding of VPI is required to support speech and swallowing rehabilitation. METHOD A scoping review was conducted using Arskey & O'Malley's framework. Studies were identified from five databases between 2007 and 2020. The methodological quality was measured with the RevMan Risk of Bias Tool by two independent evaluators. RESULT A total of seven studies met the inclusion criterion. There was a combined total of 306 participants, their average age was 59.2 years. A high risk of bias and degree of heterogeneity across all seven cohort studies was observed. Validated and instrumental evaluations of VPI were present in two papers, with the majority only reporting the presence or absence of VPI. The incidence of VPI reported in each study ranged from 0 to 53%, (median 3.5%). CONCLUSION There are few high-quality studies and considerable heterogeneity in the terminology, inclusion criteria and measurement of VPI. Instrumentation, to date, has been rarely used but is necessary for a normed and validated approach to VPI. Based on this review, there is considerable need for larger studies which instrumentally and longitudinally assess VPI as a consequence of TORS, in order to guide patient education and management prior to, and following their surgery.
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Affiliation(s)
- Emma Charters
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Claire Pelham
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Daniel Novakovic
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
| | - Cate Madill
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jonathan Clark
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
- Sydney Head and Neck Cancer Institute, Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, Australia
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, Australia
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Haydon N, Semple H, Ho K, Boorer C. Does pharyngoplasty work? Outcomes of 100 consecutive operations over 10 years. ANZ J Surg 2023; 93:1944-1949. [PMID: 37283293 DOI: 10.1111/ans.18563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Velopharyngeal insufficiency is a commonly encountered problem in Cleft Surgery, with pharyngoplasty being the mainstay of surgical management. In this study we aim to investigate the indications and outcomes of a single institution's experience and compare to international literature. METHODS A retrospective review was performed looking at over 100 consecutive primary pharyngoplasty operations for velopharyngeal dysfunction over a 10-year period at a single institution. Aetiology, peri-operative course and speech outcomes for the cohort between January 2010 through January 2020 were assessed. A comprehensive literature review was performed for comparison and analysis of the studies' data. RESULTS Ninety-seven consecutive patients were included in the study on which 103 operations were performed. Average age at time of surgery was 7.25 years old. Approximately 37% of the patients had a diagnosed syndrome, sequence or chromosomal abnormality. Ninety-seven of the 103 operations were primary pharyngoplasties, 4 were revision pharyngoplasties and 2 return to theatre procedures. Regarding speech outcomes, 51% of the patients that had formal speech assessments were found to have a significant improvement, 42% moderate improvement and 7% had no improvement. 93% of the patients that underwent pharyngoplasty in this study had significant or moderate improvement in speech outcomes. These speech outcomes and post-operative complications such as obstructive sleep apnoea are analysed. CONCLUSION This study demonstrates that pharyngoplasty is a safe procedure for velopharyngeal insufficiency with a good overall success rate. The major outcomes assessed including complications & safety, revision rate and speech outcomes are comparative to previous international studies.
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Affiliation(s)
- Nicholas Haydon
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Harriet Semple
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Kevin Ho
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Catherine Boorer
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
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Rossell-Perry P. Flap Necrosis Associated With Furlow's Palatoplasty. J Craniofac Surg 2023; 34:1301-1303. [PMID: 37101326 DOI: 10.1097/scs.0000000000009323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/09/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Numerous authors have reported their outcomes after using Furlow's palatoplasty for cleft palate repair. However, little attention has been given to the operative complications associated with this technique. The present study was carried out to present cases and analyze the various factors influencing the development of this complication accompanying Furlow's palatoplasty. MATERIALS AND METHODS This is a case report study of patients with cleft palate admitted to our center due to sequelae after primary cleft palate repair using Furlow palatoplasty between 2003 and 2021. Patient information was identified from the Smile Train cleft charity organization, parents' reports, and hospital records (intake forms and operating room registries). RESULTS Five patients were identified as having secondary cleft palate with palatal flap necrosis and associated with Furlow palatoplasty during patient evaluation at our center between 2003 and 2021. The observed prevalence was 1.54%. CONCLUSIONS Palatal flap necrosis is a rare but serious complication after primary Furlow's palatoplasty. The occurrence of this complication can be reduced by careful preoperative planning, and prevention is possible.
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Affiliation(s)
- Percy Rossell-Perry
- Research Professor Health of Science Faculty School of Human Medicine, Peruvian University Union (UpeU) Lima, Peru
- South American Medical (SAMAC) and Research and Innovation (STRIAC) Advisory Councils, Smile Train Foundation, New York City, NY
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Lee SK, Nam SM, Cha HG, Jung SA, Choi CY, Park ES. Overlapping Intravelar Veloplasty Improves the Speech Outcomes in Submucous Cleft Palate. Ann Plast Surg 2023; 90:451-455. [PMID: 37115949 DOI: 10.1097/sap.0000000000003538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND Submucous cleft palate (SMCP) is a subgroup of cleft palate that can present as velopharyngeal insufficiency due to muscle displacement. The pharyngeal flap and Furlow palatoplasty have been introduced to correct SMCP patient with velopharyngeal insufficiency. However, pharyngeal flap and Furlow palatoplasty can occur various complications. We consider the overlapping intravelar veloplasty (IVVP) can overcome these complications. Therefore, we present the speech outcomes of overlapping IVVP for the treatment of patients with SMCP. METHODS We retrospectively reviewed 12 patients with SMCP underwent overlapping IVVP between April 2016 and October 2018. The patients who underwent speech evaluation, nasometry, and nasoendoscopy before and after surgery and who were followed up for >18 months were enrolled in this study. RESULTS The average age of the patients was 5 years (range, 3-11 years) and the postoperative follow-up period ranged from 18 to 24 months (mean, 20 months). The preoperative perceptual speech evaluation was moderate and the postoperative evaluation was normal ( P < 0.01). The preoperative and postoperative nasalance scores obtained using a nasometer were 37.00 and 12.50, respectively, ( P < 0.01). Preoperative and postoperative velopharyngeal movements were grades 3 and 0, respectively, ( P < 0.01). CONCLUSIONS Our study showed that overlapping IVVP could provide successful correction of velopharyngeal insufficiency in patients with SMCP, including relatively old patients.
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Affiliation(s)
- Seo Koo Lee
- From the Department of Plastic and Reconstructive Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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48
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Willadsen E, Jørgensen LD, Alaluusua S, Pedersen NH, Nielsen JB, Hölttä E, Hide Ø, Hayden C, Havstam C, Hammarström IL, Davies J, Boers M, Andersen HS, Aukner R, Jackson Morris D, Nielsen SF, Semb G, Lohmander A, Persson C. Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: Speech proficiency at 10 years of age. Int J Lang Commun Disord 2023; 58:892-909. [PMID: 36541222 DOI: 10.1111/1460-6984.12830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/21/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND & AIM To assess consonant proficiency and velopharyngeal function in 10-year-old children born with unilateral cleft lip and palate (UCLP) within the Scandcleft project. METHODS & PROCEDURES Three parallel group, randomized, clinical trials were undertaken as an international multicentre study by nine cleft teams in five countries. Three different surgical protocols for primary palate repair (Arm B-Lip and soft palate closure at 3-4 months, hard palate closure at 36 months, Arm C-Lip closure at 3-4 months, hard and soft palate closure at 12 months, and Arm D-Lip closure at 3-4 months combined with a single-layer closure of the hard palate using a vomer flap, soft palate closure at 12 months) were tested against a common procedure (Arm A-Lip and soft palate closure at 3-4 months followed by hard palate closure at 12 months) in the total cohort of 431 children born with a non-syndromic UCLP. Speech audio and video recordings of 399 children were available and perceptually analysed. Percentage of consonants correct (PCC) from a naming test, an overall rating of velopharyngeal competence (VPC) (VPC-Rate), and a composite measure (VPC-Sum) were reported. OUTCOMES & RESULTS The mean levels of consonant proficiency (PCC score) in the trial arms were 86-92% and between 58% and 83% of the children had VPC (VPC-Sum). Only 50-73% of the participants had a consonant proficiency level with their peers. Girls performed better throughout. Long delay of the hard palate repair (Arm B) indicated lower PCC and simultaneous hard and soft palate closure higher (Arm C). However, the proportion of participants with primary VPC (not including velopharyngeal surgeries) was highest in Arm B (68%) and lowest in Arm C (47%). CONCLUSIONS & IMPLICATIONS The speech outcome in terms of PCC and VPC was low across the trials. The different protocols had their pros and cons and there is no obvious evidence to recommend any of the protocols as superior. Aspects other than primary surgical method, such as time after velopharyngeal surgery, surgical experience, hearing level, language difficulties and speech therapy, need to be thoroughly reviewed for a better understanding of what has affected speech outcome at 10 years. WHAT THIS PAPER ADDS What is already known on the subject Speech outcomes at 10 years of age in children treated for UCLP are sparse and contradictory. Previous studies have examined speech outcomes and the relationship with surgical intervention in 5-year-olds. What this study adds to the existing knowledge Speech outcomes based on standardized assessment in a large group of 10-year-old children born with UCLP and surgically treated according to different protocols are presented. While speech therapy had been provided, a large proportion of the children across treatment protocols still needed further speech therapy. What are the potential or actual clinical implications of this work? Aspects other than surgery and speech function might add to the understanding of what affects speech outcome. Effective speech therapy should be available for children in addition to primary surgical repair of the cleft and secondary surgeries if needed.
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Affiliation(s)
- E Willadsen
- Department of Nordic Studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | - L D Jørgensen
- Copenhagen Cleft Palate Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - S Alaluusua
- Cleft Palate and Craniofacial Center, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - E Hölttä
- Cleft Palate and Craniofacial Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Ø Hide
- Department of Speech and Language Disorders, Statped sørøst, Oslo, Norway
| | - C Hayden
- The Royal Hospital for Sick Children, Belfast, UK
| | - C Havstam
- Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - I L Hammarström
- Division of Speech and Language Pathology, Linköping University, Linköping, Sweden
| | - J Davies
- Greater Manchester Cleft Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - M Boers
- Copenhagen Cleft Palate Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - H S Andersen
- Copenhagen Cleft Palate Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - R Aukner
- Department of Speech and Language Disorders, Statped sørøst, Oslo, Norway
| | - D Jackson Morris
- Department of Nordic Studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | - S F Nielsen
- Copenhagen Business School, Center for Statistics, Copenhagen, Denmark
| | - G Semb
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - A Lohmander
- Division of Speech and Language Pathology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Speech and Language Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - C Persson
- Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Smiljanić I, Knežević P, Milić M, Tarle M, Lauš P, Jurišić I. IS SURGICAL TREATMENT OF VELOPHARYNGEAL INSUFFICIENCY BY MYOMUCOSAL POSTERIOR PHARYNGEAL FLAP A CONTRAINDICATION FOR NASAL INTUBATION? A NARRATIVE REVIEW. Acta Clin Croat 2023; 62:91-98. [PMID: 38746620 PMCID: PMC11090225 DOI: 10.20471/acc.2023.62.s1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Velopharyngeal insufficiency is a disorder where the soft palate directs the air through the nose. It is often present in patients with previous cleft or short palate, but also in many other conditions. Symptoms are primarily to be found in speech, with very distinct nasal sound. After clinical evaluation and nasal endoscopy, surgery is considered. Several surgical techniques are in use, with posterior pharyngeal flap pharyngoplasty being most widely used. This method leaves the base of the posterior pharyngeal flap attached to the posterior pharyngeal wall, with two lateral ports on each side of the flap. Permanent nasopharyngeal obstruction is a very challenging pathology for anesthesiologists in case of mandatory nasal intubation since it is a relative contraindication for nasal intubation. Patients with previous palatoplasty will regularly appear in our routine anesthetic practice, in all surgical segments. The high risk of damage to the flap with possible bleeding can put the anesthesiologist in a very unpleasant situation if not aware of the permanent effect of this surgery. During preanesthetic assessment, if there is information on a previous pharyngoplasty, one should consider alternative options for nasotracheal intubation. All nasal insertion procedures must be either avoided or carried out with great caution, under fiberoptic visual control.
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Affiliation(s)
- Iva Smiljanić
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, Dubrava University Hospital, Zagreb, Croatia
| | - Predrag Knežević
- Department of Maxillofacial and Oral Surgery, Dubrava University Hospital, Zagreb, Croatia
| | - Morena Milić
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, Dubrava University Hospital, Zagreb, Croatia
- Dubrovnik University, Dubrovnik, Croatia
| | - Marko Tarle
- Department of Maxillofacial and Oral Surgery, Dubrava University Hospital, Zagreb, Croatia
| | - Perislav Lauš
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, Dubrava University Hospital, Zagreb, Croatia
| | - Ivo Jurišić
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, Dubrava University Hospital, Zagreb, Croatia
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50
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Nam SM, Kim YB, Park KC, Park ES, Choi CY, Cha HG, Jung SA. Speech Outcomes of Treatment for Velopharyngeal Insufficiency: Combined Use of an Overlapping Intravelar Veloplasty and Dynamic Sphincter Pharyngoplasty. Ann Plast Surg 2022; 88:518-523. [PMID: 34711724 DOI: 10.1097/sap.0000000000003038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Velopharyngeal insufficiency involving a large velopharyngeal gap and poor lateral wall movement is referred to as a "black hole" and remains a challenging problem for cleft surgeons. The effect of the pharyngeal flap on this form of velopharyngeal insufficiency is still debatable because a wide pharyngeal flap is associated with a high incidence of airway obstruction. The present study aimed to evaluate the speech outcomes of combined overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency. METHODS Between March 2016 and June 2019, 15 patients with velopharyngeal insufficiency were treated with a combination of overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty. Preoperative speech evaluation was performed on the basis of perceptual speech evaluation, nasometry, and nasoendoscopy. Postoperative speech evaluation using the same approach as that used preoperatively was performed after completion of speech therapy. RESULTS All 15 patients achieved satisfactory velopharyngeal port closure and speech phonation after completion of speech therapy. No additional procedures were performed to improve velopharyngeal port closure and speech production. The preoperative and postoperative results of perceptual speech evaluation, nasometry, and nasoendoscopy evaluation were significantly different (P < 0.01). CONCLUSION Combined treatment with overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty can correct the velopharyngeal insufficiency "black hole" with highly reliable results and minimal risk of airway obstruction.
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Affiliation(s)
- Seung Min Nam
- From the Department of Plastic and Reconstructive Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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