2-stage Palate Research Articles

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution

Introduction Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. Methods Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). Results Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). Conclusion This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Speech Outcomes Audit for Unilateral Cleft lip and Palate After 2-Stage Palate Repair: Preliminary Results.

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.

Growth Outcomes Audit for Unilateral Cleft Lip and Palate (UCLP) After 2-stage Palate Repair.

To assess the impact of 1 and 2-stage palatoplasty protocol on the dental arch relationships in unilateral cleft lip and palate (UCLP) in a single center. Our study consisted of 349 individuals divided into 2 groups according to the palatoplasty protocol. Two-stage group comprised 169 subjects with UCLP (mean age: 6.9y, 110 male and 59 female) who underwent lip, nasal ala, and anterior palate repair with vomer flap from 3 to 6 months (first surgery stage). Soft palate repair occurred from 12 to 18 months (second surgery stage). The one-stage group comprised 180 subjects with UCLP (mean age: 7.2y, 108 male and 72 female) who underwent 1-stage palatoplasty. Dental models were evaluated by 3 experienced orthodontists applying Goslon Yardstick and the 5-year-old index (FYOI). The influence of the palatoplasty technique and surgeon factor on the interarch relationship was evaluated. The weighted Kappa was used to assess intraexaminer and interexaminer agreements for comparisons of dental arch relationships. Intergroup comparisons were conducted using the χ 2 test ( P <0.05). The intraexaminer reliability was very good (0.81 to 0.98) and interexaminer reliability varied from satisfactory to very good (0.56 to 0.83). The mean occlusal index of the 2-stage and 1-stage groups was 2.77 and 3.03, respectively. The variability of the mean index between surgeons varied from 2.38 to 3.2 in the 2-stage group and 2.91 to 3.2 in the 1-stage group. There were significant differences in the frequency of Goslon 5 index ( P =0.002) between groups, with the 2-stage group presenting less cases (1.18%) than the group 1-stage (11.11%). The interarch relationship was similar for both palate repair protocols. Two-stage palatoplasty showed a decreased prevalence of Goslon index 5.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair.

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.

Oronasal Fistula Risk After Palate Repair.

To assess risk factors for oronasal fistula, including 2-stage palate repair. Retrospective analysis. Tertiary children's hospital. Patients with non-submucosal cleft palate whose entire cleft repair was completed at the study hospital between 2005 and 2013 with postsurgical follow-up. Hierarchical binary logistic regression assessed predictive value of variables for fistula. Variables tested for inclusion were 2 stage repair, Veau classification, sex, age at surgery 1, age at surgery 2, surgeon volume, surgeon, insurance status, socioeconomic status, and syndrome. Variables were added to the model in order of significance and retained if significant at a .05 level. Postoperative fistula. Of 584 palate repairs, 505 (87%) had follow-up, with an overall fistula rate of 10.1% (n = 51). Among single-stage repairs (n = 211), the fistula rate was 6.7%; it was 12.6% in 2-stage repairs (n = 294, P = .03). In the final model utilizing both single-stage and 2-stage patient data, significant predictors of fistula were 2-stage repair (odds ratio [OR]: 2.5, P = .012), surgeon volume, and surgeon. When examining only single-stage patients, higher surgeon volume was protective against fistula. In the model examining 2-stage patients, surgeon and age at hard palate repair were significant; older age at hard palate closure was protective for fistula, with an OR of 0.82 (P = .046) for each additional 6 months in age at repair. Two-stage surgery, surgeon, and surgeon volume were significant predictors of fistula occurrence in all children, and older age at hard palate repair was protective in those with 2-stage repair.

Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair.

To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden. Retrospective cohort with follow-up of 4 to 19 years. Academic, tertiary children's hospital. Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9. Cleft palate surgery, completed in either a single-stage or 2-stage repair. Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews. A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients (P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI (P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures. Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

Speech and Audiology Outcomes Following Single-stage Versus Early 2-stage Cleft Palate Repair

Speech and Audiology Outcomes Following Single-stage Versus Early 2-stage Cleft Palate Repair

On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair.

The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development. Systematic review. Various primary cleft and craniofacial centers in the world. Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery. Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports. The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty. The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate-hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor. Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.

WITHDRAWN-Administrative Duplicate Publication: Voice Quality in Adults Treated for Unilateral Cleft Lip and Palate: Long-term Follow-up After 1- or 2-Stage Palate Repair.

Morén, S., Lindestad, P. Å., Holmström, M., & Mani, M. (2018). Voice Quality in Adults Treated for Unilateral Cleft Lip and Palate: Long-term Follow-up After 1- or 2-Stage Palate Repair. The Cleft Palate-Craniofacial Journal, 55(5), 758-768. DOI: 10.1177/1055665618754946 Article withdrawn by publisher. Due to an administrative error, this article was accidentally published in Volume 55 Issue 5 as well as Volume 55 Issue 8 of publishing year 2018 with different DOIs and different page numbers. The incorrect version of the article with DOI: 10.1177/1055665618754946 has been replaced with this correction notice. The correct and citable version of the article remains: Morén, S., Lindestad, P. Å., Holmström, M., & Mani, M. (2018). Voice Quality in Adults Treated for Unilateral Cleft Lip and Palate: Long-Term Follow-Up After One- or Two-Stage Palate Repair. The Cleft Palate-Craniofacial Journal, 55(8), 1103-1114. DOI: 10.1177/1055665618764521.

Electromyographic Activity of the Masseter and Temporal Muscles in Patients With Nonsyndromic Complete Unilateral Cleft Lip and Palate: 2-Stage Versus 1-Stage Palate Repair.

To assess the electromyographic activity of the masseter and temporal muscles in cleft patients who underwent 1-stage palate repair versus 2-stage palate repair. Thirty-two patients with nonsyndromic complete unilateral cleft lip and palate operated by 2 different protocols for palate repair, 1-stage (group 1, n = 16) versus 2-stage with delayed hard palate closure (group 2, n = 16) were available in the retrospective longitudinal study. Standardized electromyographic records of the masseter and anterior portion of temporal muscles were obtained with 2 repetitions during mastication and rest. No statistically significant (all P > 0.05) differences were observed in the electromyographic data between the groups 1 and 2. There were similar electromyographic activity of masseter and temporal muscles during mastication and at rest after 1- and 2-stage palate closure.

Facial and Nasolabial Aesthetics of Complete UCLP Submitted to 2-Stage Palate Repair With Vomer Flap.

To evaluate the aesthetics of nasolabial appearance and facial profile of children with unilateral cleft lip and palate (UCLP) submitted to 2-stage palate repair with vomerine flap. Retrospective. Single center. Forty patients with UCLP, mean age of 7.81 years of both sexes, rehabilitated at a single center by 1 plastic surgeon. Lip and anterior palate repair with nasal alar repositioning was performed at 3 to 6 months of age by Millard technique and vomer flap, respectively. Posterior palate was repaired at 18 months by Von Langenbeck technique. Four cropped digital facial photographs of each patient were evaluated by 3 orthodontists to score the nasolabial aesthetics and profile. Frequencies of each score as well means and medians were calculated. Kappa test was used for evaluating inter- and intrarater reproducibility. The nasal form and deviation was scored as good/very good in 70%, fair in 22.5%, and poor in 7.5% of the sample. The nasal-subnasal aesthetic was considered good/very good in 55%, fair in 30%, and poor in 15% of the sample. The lip vermilion border and the white part of surgical scar aesthetics were good/very good in 77.5% and 80%, fair in 17.5% for both categories, and poor in 5% and 2.5% of the cases, respectively. In all, 67.5% showed convex facial profile, 20% was straight, and 12.5% was concave profile. Two-stage palatoplasty presented an adequate aesthetical results for the majority of patients with UCLP in the mixed dentition.

Voice Quality in Adults Treated for Unilateral Cleft Lip and Palate: Long-Term Follow-Up After One- or Two-Stage Palate Repair.

The aim of the current study was to assess voice quality among adults treated for unilateral cleft lip and palate (UCLP), after one- or two-stage palate closure, and compare it to a noncleft control group. Cross-sectional study of patients with UCLP with long-term follow-up and noncleft controls. Patients with UCLP born between 1960 and 1987, treated at Uppsala University Hospital, Sweden, were examined (n = 73) at a mean of 35 years after primary surgery. Forty-seven (64%) patients had been treated with 1-stage palate closure and 26 with 2-stage closure (36%). The noncleft control group consisted of 63 age-matched volunteers. Ratings of perceptual voice characteristics from blinded voice recordings with Swedish Voice Evaluation Approach method. Acoustic voice analysis including pitch and spectral measures. Among the patients, the mean values for the 12 evaluated variables on a visual analog scale (0 = no abnormality, 100 = maximal abnormality) ranged between 0.1 and 17, and the mean for all was 6 mm. Voice variables were similar between patients and controls, except the total mean of all the perceptual voice variables, as well as "vocal fry"; both slightly lower among patients ( P = .018 and P = .009). There was no difference in any variable between patients treated with 1-stage and 2-stage palate closure. No clear relationship was found between velopharyngeal insufficiency and dysphonia. The voice characteristics among adults treated for UCLP in childhood are not different from those of individuals without cleft.

Voice Quality in Adults Treated for Unilateral Cleft Lip and Palate: Long-term Follow-up After 1- or 2-Stage Palate Repair.

The aim of the current study was to assess voice quality among adults treated for unilateral cleft lip and palate (UCLP), after 1- or 2-stage palate closure, and compare it to a noncleft control group. Cross-sectional study in UCLP patients with long-term follow-up and noncleft controls. UCLP patients born 1960-1987, treated at Uppsala University Hospital, Sweden, were examined (n = 73) at a mean of 35 years after primary surgery. Forty-seven patients (64%) had been treated with 1-stage palate closure and 26 with 2-stage closure (36%). The noncleft control group consisted of 63 age-matched volunteers. Ratings of perceptual voice characteristics from blinded voice recordings with Swedish Voice Evaluation Approach (SVEA) method. Acoustic voice analysis including pitch and spectral measures. Among the patients, the mean values for the 12 evaluated variables on a VAS scale (0 = no abnormality, 100 = maximal abnormality) ranged between 1 and 22 and the mean for all was 6 mm. Voice variables were similar between patients and controls except the total mean of all the perceptual voice variables, as well as "vocal fry"-both slightly lower among patients ( P = .018 and P = .009). There was no difference in any variable between patients treated with 1-stage and 2-stage palate closure. No clear relationship was found between VPI and dysphonia. The voice characteristics among adults treated for UCLP in childhood are not different from those of individuals without cleft.

The effect of 1-stage versus 2-stage palate repair on facial growth in patients with cleft lip and palate: a review

The purpose of this review was to evaluate the effect of 1-stage versus 2-stage palate repair with delayed hard palate closure on facial growth in patients with cleft lip and palate. A literature survey from the PubMed database from January 1966 to December 2007 used the medical subject headings terms 'facial growth', 'cleft lip and palate', 'cephalometry', and '1-stage palate repair' in combination with '2-stage palate repair' or 'delayed hard palate closure'. The Cleft Palate-Craniofacial Journal from 1964 to November 2007 was hand searched. Controlled studies written in English were selected. Two reviewers selected and extracted the data independently and assessed the quality of the studies. On the basis of this search only nine studies were included in this review. All studies were retrospective and non-randomized. Six studies were cross-sectional, and three were longitudinal. Heterogeneity and methodological deficiencies in the studies prevented conclusions regarding stage of palate repair and facial growth. Further well-designed controlled studies and long-term studies are needed, and researchers should focus on the variation in hard palate repair timing before 3 years of age and consider patient speech.

A Longitudinal Cephalometric Study From Age 5 to 18 Years on Individuals With Complete Bilateral Cleft Lip and Palate

Development of the facial profile between the age of 5 years and the end of pubertal growth in patients with complete bilateral cleft lip and palate was studied by means of cephalometric radiographs obtained at the age of 5, 10, and 15 years as well as at the end of the growth period. All 29 patients had been treated according to the same plan and operated on by the same surgeon.Values for the ANB angle are typically very high in 5-year-old children and then decrease to values corresponding to those of the general population by the end of the pubertal growth period. Vertical development maintains the initial pattern; no compensatory vertical excess was observed. Owing to the wide range in all measurements, age-related mean values in a patient sample are of little consequence for individuals but can point out tendencies.The multidisciplinary concept of maintaining the initially protrusive position of the premaxilla by means of a passive plate at the newborn and infant stage, as well as using surgical procedures with limited retrusive effect, proved to be correct in the long run: At the young adult stage, the ANB angle remained positive for almost all patients except for those with multiple-tooth agenesis in the upper arch. A potential benefit of 2-stage palate repair is seen in the neutral vertical development of the patients examined. This hypothesis is supported by comparing with other studies from the literature.

Active versus passive cleft-type speech characteristics.

Cleft palate speech is generally described in terms of nasal resonance, nasal emission and compensatory articulations. A longitudinal study of children at different stages of surgical treatment revealed a distinction between passive and active cleft-type speech characteristics whereby passive characteristics were thought to be the product of structural abnormality or dysfunction and active characteristics were specific articulatory gestures replacing intended consonants. Passive and active patterns of articulation are described and defined in the context of three longitudinal studies of subjects who were at various stages of two different surgical regimes: five bilateral cleft lip and palate (BCLP) subjects aged 1;6-4;6, 12 mixed unilateral cleft lip and palate (UCLP) and BCLP subjects aged 4;6-7;6 and nine mixed UCLP and BCLP subjects aged 9;0-11;0. Reference is also made to data from 12 mixed cleft-type subjects aged 13;0 who had been treated with different surgical timing regimes. Comparison is made between the incidence of active versus passive processes in relation to oral structure. At age 4;6 speech samples taken from BCLP subjects who had been treated with 1-stage versus 2-stage palate repair all evidenced both active and passive processes. The lack of differentiation in speech results irrespective of their current surgical status, i.e. completely repaired palates versus residual cleft of the hard palate, was unexpected. Cleft-type processes in completely repaired subjects might be accounted for by the inevitable anterior defect following repair of a bilateral cleft. Older subjects with structural defects also evidenced more cleft-type processes. The relevance of distinguishing between active and passive processes is underlined by consideration of the effects of structural changes following surgery. The effect of surgery on seven subjects' speech is discussed using the active/passive distinction. Active cleft-type characteristics did not change as a direct result of surgery, whereas passive characteristics were largely eliminated following surgery. A specific distinction is made between active and passive nasal fricatives, with the implication that active nasal fricatives may not be affected by surgical intervention, whereas passive nasal fricatives may be eliminated by surgery. Accurate distinction between active and passive patterns of articulation may serve to identify those cleft-type speech error patterns most likely to respond to surgical intervention. Indications from this study are that active cleft-type characteristics require destabilization in a course of speech and language therapy before the potential benefits of surgery can be properly assessed. An analytical protocol for the interpretation of speech samples is presented and some therapy strategies are proposed for active and passive processes.

Speech patterns found in children treated with 2-stage versus 1-stage palate repair: preliminary findings from a longitudinal study

Speech patterns found in children treated with 2-stage versus 1-stage palate repair: preliminary findings from a longitudinal study