Speech outcomes following buccal fat pad interposition in palatal repair: A clinical outcome analysis

Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (β = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (β = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

Early palate repair is recommended to minimize the development of disordered speech. We studied the speech outcome of late palate repair in 131 patients. The success of late palate repair is questioned because of the persistence of learned, compensatory misarticulations that are difficult to correct in spite of the establishment of correct palatal anatomy and a competent velopharyngeal mechanism. The objective of this study is to highlight the speech results following late primary repair of the palate. Retrospective analysis of speech outcomes in 131 patients with cleft lip and palate who underwent primary palate repair after the age of 10 years between November 2000 and December 2004. None of the patients had received supervised institution-based speech therapy. However, all patients were counseled and oriented and demonstrated the correct place and manner of articulation for the phonemes misarticulated by them. Preoperative and 6- to 12-month postoperative speech samples were assessed within the parameters of articulation, hypernasality, nasal air emission, and speech intelligibility. The analysis indicated improvement in all speech parameters leading to an overall improvement in postoperative intelligibility for most patients. Although definite improvement occurs in all parameters of speech following late primary palate repair, residual speech problems persist in most patients, requiring further evaluation and appropriate treatment.

Early palate repair is recommended to minimize the development of disordered speech. We studied the speech outcome of late palate repair in 131 patients. The success of late palate repair is questioned because of the persistence of learned, compensatory misarticulations that are difficult to correct in spite of the establishment of correct palatal anatomy and a competent velopharyngeal mechanism. The objective of this study is to highlight the speech results following late primary repair of the palate.Retrospective analysis of speech outcomes in 131 patients with cleft lip and palate who underwent primary palate repair after the age of 10 years between November 2000 and December 2004. None of the patients had received supervised institution-based speech therapy. However, all patients were counseled and oriented and demonstrated the correct place and manner of articulation for the phonemes misarticulated by them. Preoperative and 6- to 12-month postoperative speech samples were assessed within the parameters of articulation, hypernasality, nasal air emission, and speech intelligibility.The analysis indicated improvement in all speech parameters leading to an overall improvement in postoperative intelligibility for most patients.Although definite improvement occurs in all parameters of speech following late primary palate repair, residual speech problems persist in most patients, requiring further evaluation and appropriate treatment.

Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth. A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis. Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm. The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

To compare speech outcome and self-reported speech and communicative ability (SOK) in young adults treated with one-stage (OS) or two-stage (TS) palatal repair. Furthermore, to compare with normative data on individuals without cleft lip and palate and to study the relationship between patients' and experts' judgments. A cross-sectional group comparison study with long-term follow-up. Participants: Patients born with unilateral cleft lip and palate treated at 2 cleft centers; 17 with OS at 14 months and 25 with TS, soft palate repair at 7 months and hard palate repair at 6.2 years. Pharyngeal flap surgery was performed in 53% (OS) and 24% (TS) of patients. Speech characteristics were blindly assessed by speech and language pathologist from audio recordings, SOK at 19 years of age. No group differences were found. Although the occurrence of nasality symptoms was low in both groups, only 60% (OS)/65% (TS) were assessed with competent velopharyngeal function (VPC). Articulation proficiency (percentage of consonants correct [PCC]) was 91%/97%, the /s/-sound specifically 87%/91%. Good intelligibility was found in 91%/87%. Patient opinion was in agreement with norms and significantly associated with intelligibility (rs = 0.436, P < .01), PCC (rs = -0.534, P < .01), and correct /s/ (rs = -0.354, P < .05). No differences in speech outcome were related to operation method. The low prevalence of VPC was not clearly reflected in nasality symptoms. Patient opinion was related to articulation and intelligibility. A higher burden of care in terms of pharyngeal flap surgery was seen after the OS technique.

This was a study of patients with cleft palate who for various reasons have their first hospital visit for palatal repair at an older age in developing countries. The aims of this study were to investigate the incidence of postoperative velopharyngeal insufficiency in Chinese patients with late palatal repair and to determine the relative importance of age at palatoplasty, cleft type, surgical technique, and experience for clinical outcomes. A cohort of 224 patients who underwent primary palate repair were studied retrospectively. Speech outcomes were evaluated based on the severity of hypernasality and nasal emission. The percentage of cases that required a second operation was recorded. The related factors were analyzed, and a logistic regression model was applied. The mean age at palatoplasty was 5.6 (SD, 4.6) years (age range, 2-24 years of age); 29.9% of the cases required a second operation. Age at palatoplasty was the only significant contributing factor for the percentage of patients who needed a second surgery. Each additional year in age at palatoplasty was associated with a 10.8% increase in odds of requiring a second surgery (P = 0.002; odds ratio, 1.108; confidence interval, 1.038-1.182). However, cleft type, surgical technique, and surgeon's experience did not influence clinical outcomes. Primary palate repair at older than 2 years resulted in acceptable clinical speech outcomes in our patient population, there was an increase in the incidence of postoperative velopharyngeal insufficiency with increasing age at the time of palatoplasty. There was no correlation with cleft type, surgical technique, or surgeon's experience.

As the performance of late primary palatoplasty for skeletally mature patients remains controversial, there is little data available regarding speech outcomes for this patient population. The purpose of this study therefore is to identify and evaluate the impact of speech outcomes following late palate repair on skeletally mature patients. A retrospective study was performed on 19 consecutive skeletally mature patients who underwent late primary palate repair between 2010 and 2018. Speech assessment was performed preoperatively, between 3 and 6 months postoperatively, and then after 6 months postoperatively. Levels for hypernasality, oral pressure, and audible nasal air emission were scored and recorded.Patients were stratified by age, gender, presence of postoperative fistula, and Veau cleft type, in order to determine the impact of each variable on final speech outcomes. The Kruskal-Wallis test was used to compare the preoperative speech assessment with the postoperative speech outcomes, and the Mann-Whitney test was used to analyze the impact of the above variables on final speech outcomes. Our data showed overall postoperative speech improvement for all tested variables. Patients without postoperative fistula presented better results in oral pressure than those patients with postoperative fistula (P < 0.05). None of the other tested variables presented a significant negative impact on speech outcomes. Late primary palatoplasty significantly improves speech outcomes for skeletally mature patients. Fistula has a negative impact on oral pressure.

Background: The management of patients with cleft lip and palate is complex, where the treatment outcome is judged on the balance between aesthetics, speech, and maxillary growth. Up to now, there is no generally accepted treatment protocol. Every center must find the best-suited protocol treatment for their population. Methods: A systematic review through literature search was conducted for English-language studies in PubMed. This search was conducted in September 2011 using EndNote X3 with keywords: Two-stage Palate Repair and Maxillary Growth and Two-stage Palate Repair and Speech Outcome. Both retrospective and prospective studies on maxillary growth and speech outcome in patient with cleft lip and palate after two-stage palate repair published from 2001 to 2012 were included. Result: From the reviewed of 37 articles, only 14 articles fit the inclusions criteria, three articles discussed the outcome of maxillary growth and speech outcome, eight articles only discussed the maxillary growth and the rest of articles only discussed the speech outcome. Conclusion:From this review we found that most of the two-stage palate repair results in better maxillary growth, but only few of them results in good speech outcome. We will perform further study based on this review to discover a new protocol for the management of palate repair in our center.

Early Placement of Ventilation Tubes in Infants with Cleft Lip and Palate: A Systematic Review

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing. A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale. A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups. There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

To assess consonant proficiency and velopharyngeal function in 10-year-old children born with unilateral cleft lip and palate (UCLP) within the Scandcleft project. 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 3-4months, hard palate closure at 36months, Arm C-Lip closure at 3-4months, hard and soft palate closure at 12months, and Arm D-Lip closure at 3-4months combined with a single-layer closure of the hard palate using a vomer flap, soft palate closure at 12months) were tested against a common procedure (Arm A-Lip and soft palate closure at 3-4months followed by hard palate closure at 12months) 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. 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%). 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 10years. What is already known on the subject Speech outcomes at 10years 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.

Some cleft clinics use a two-stage method to correct the cleft palate, which helps avoid reduced maximum growth after early hard palate surgery and impaired speech development after late soft palate repair.. This study sought to evaluate the effects of early vs late palatoplasty on speech and maximum growth results. The following databases were searched: Cochrane Library, Science Direct, Pubmed, and NCBI. The primary objective of this study was to determine whether unilateral, non-syndromic cleft lip, alveolus, and palate patients who underwent early or late hard palate surgery before or after 18 months of age had an impact on speech and maxillary development. Things like case studies, reviews, editorials, textbooks, and studies conducted on animals weren't included. The following systematic observations consist of eight studies. Most studies had methodological quality that ranged from fair to good. This review discusses the experience of cleft centers using a variety of one and two stage palatoplasty procedures and timing, and shows inconsistent results regarding maximal progression. The seemingly inconsistent results of the studies included in this observation of speech outcomes suggest that there is insufficient evidence to conclude whether one- or two-stage palatoplasty has a significant effect on maximal development for a variety of reasons. The review provides inconclusive evidence on the impact of hard palate repair timing on facial growth and speech outcomes in unilateral cleft lip and palate patients, highlighting the need for further controlled studies.

ObjectiveTo design a technique of palate repair with predictable Velo Pharyngeal (VP) closure and normal speech - 'Suspension Palatoplasty' in speaking unrepaired Cleft Palate (CP) patients. To evaluate the results of patients with CP operated using the technique of 'Suspension palatoplasty' from 2014 -2018 in terms of surgical complications and speech outcomes.DesignAn ambi-spective longitudinal clinical study.SettingComprehensive cleft care clinic in a private trust hospital.Patients/ ParticipantsPatients above 6 years of age with isolated CP, cleft lip and palate (CLP), operated using 'Suspension Palatoplasty' technique between 2014 and 2018 were included with minimum follow up period of 5 years. Subjective speech evaluation was done by two speech therapists and analysed.InterventionAuthor designed the technique of 'Suspension Palatoplasty' which aims to suspend the soft palate repaired by 'Hybrid Palatoplasty' technique, close to the nasopharynx using narrow pharyngeal flap with the pedicle based superiorly at adenoids, for an acceptable VP closure.Main Outcome MeasuresSpeech outcome and surgical complications were assessed.ResultsOut of 94 cases operated with age ranging from 6 to 45 years, 59 (62.8%) had normal speech, 12 (12.8%) had articulation errors but with no Velo-Pharyngeal Insufficiency (VPI) and 23 patients (24.4%) had hypernasality/ nasal emission (Suspected VPI). None of them had difficulty in breathing but one patient had snoring.Conclusion'Suspension Palatoplasty' is a simple primary operation with excellent speech outcomes with no obstructive sequelae in patients with speaking unrepaired cleft palate.

Speech production and age at palatal repair were investigated in 80 cleft palate children. Children whose palates were repaired prior to the onset of speech production demonstrated significantly better speech than those whose palates were repaired between 12 and 27 months of age. The supposition that earlier palatal repair results in more normal speech development was, in fact, demonstrated in these cases. Rather than using chronologic age alone as the deciding factor in determining timing of initial palatal repair, the stage of each child's phonemic development should be considered if maximum speech potential is to be achieved and if speech development is to parallel normal noncleft peers. Determining this stage of development through early speech and language evaluations, beginning at 6 months of age, thus becomes an essential component in the habilitation of children with cleft palate. Continued research is needed to ensure against giving the obtainment of early speech normalcy disproportionate emphasis over craniofacial growth considerations. To this end, continued cooperative research between surgeons and speech pathologists is imperative in order to base these important decisions on substantiated findings.

Repair of cleft palate after 6 years of age is controversial in regard to the surgical procedure and the speech outcome. Primary repair alone may not be considered sufficient to achieve intelligible speech. The authors consider addition of pharyngeal flap at the time of primary repair to be a significant factor in improving speech. Prospectively maintained data of all cleft palate patients operated from 2013 to 2017 (5 years) was analyzed to identify patients older than 6 years. Complete cleft palate, incomplete cleft palate, and cleft of the soft palate were further stratified according to different Randall types. They were divided into 2 main types: primary palate repair only and primary palate repair with pharyngeal flap. Speech was assessed preoperatively and 12 months postoperatively by Pittsburgh weighted speech scale. A total of 139 patients were analyzed. There were 78 males and 61 females. Their ages ranged from 6 to 60 years (mean age, 12.5 years). The overall preoperative speech score in palate repair-only group was 12.15, whereas the postoperative score was 7.32. In patients who underwent primary pharyngeal flap along with palate repair, the preoperative speech score was 11.3, and the postoperative score was 3.76. In select group of patients who report late for palate repair, addition of pharyngeal flap along with the primary palate repair improves the speech outcome in all Randall groups.