Primary Palatoplasty Research Articles

Assessment of speech nasality in children with Robin Sequence.

To report the outcomes of primary palatoplasty in Robin Sequence (RS); to verify the relationship between modalities of assessment of nasality; to compare nasality between techniques at palatoplasty. This study involved the identification of hypernasality in four modalities: live assessment with 4-point scale; live assessment with cul-de-sac test; multiple listeners' ratings of recorded phrase; nasometric assessment. Live ratings of speech nasality and nasalance scores were retrieved from charts, while a recorded phrase was rated by listeners for occurrence of hypernasality. Agreement between the modalities was established as well as association between nasality, nasal turbulence and age at surgery and at assessment. Fisher's exact test was used to compare findings between surgical techniques. Agreement between nasalance, live assessment with 4-point scale, live assessment with cul-de-sac, and multiple listeners' ratings of recorded samples ranged between reasonable (0.32) and perfect (1.00). Percentage occurrence of hypernasality varied largely between assessment modalities. Mean occurrence of hypernasality was lower for the group submitted to Furlow technique (26%) than the group that received von Langenbeck technique (53%). Only findings obtained live were statistically significant (scale: p=0.012; cul-de-sac: p<0.001). Listeners identified nasal turbulence for 22 (32%) samples out of the 69 recordings, and an association was found between hypernasality and nasal turbulence. Lower occurrence of hypernasality was identified for patients with RS in Furlow group. Identification of hypernasality varied largely among the four assessment modalities.

Clinical Outcomes of Primary Palatal Surgery in Children with Nonsyndromic Cleft Palate with and without Lip.

This study presents clinical outcomes of primary cleft palate surgery, including rate of oronasal fistula development, rate of velopharyngeal insufficiency (VPI) requiring secondary surgery, and speech outcomes. We examined the effect of cleft type on the clinical outcomes. Retrospective analysis was performed using clinical records of all patients who received a primary palatoplasty at the Cleft Palate Clinic at Seoul Asan Medical Center, South Korea, between 2007 and 2012. The study included 292 patients with nonsyndromic overt cleft palate (±cleft lip). The results revealed that the rate of oronasal fistula was 7.9% and the incidence of VPI based on the rate of secondary palatal surgery was 19.2%. The results showed that 50.3% of all the patients had received speech therapy and 28.8% and 51.4% demonstrated significant hypernasality and articulatory deficits, respectively. The results of the rate of VPI and speech outcomes were significantly different in terms of cleft type. Except for the rate of oronasal fistula, patients with cleft palate generally exhibited better clinical outcomes compared to those with bilateral or unilateral cleft lip and palate. This study suggests that several factors, including cleft type, should be identified and comprehensively considered to establish an optimal treatment regimen for patients with cleft palate.

Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function

The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function. This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation. All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001). ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.

Long term speech outcomes following late cleft palate repair using the modified Furlow technique

ObjectivesPublished reports and previous studies from our institution have reported worse overall speech results, including significantly higher rates of persistent articulation errors, in patients undergoing palatoplasty at age >18 months. This study further investigates the effects of late repair on long term speech outcomes. MethodsA retrospective review was performed of non-syndromic patients undergoing primary palatoplasty at age >18 months between 1980 and 2006 at our institution. Longitudinal speech results were compared based on reason for late repair and age at repair. ResultsForty-one patients were greater than 18 months of age at the time of palatoplasty, and 24 fit criteria for longitudinal data analysis. There was a statistically significant improvement in nasality scores at Time Point 1 for international adoptees compared to the non-adopted population (p=0.04). Patients with submucosal clefts were found to have significantly less severe nasal emission scores at Time Point 1 compared to those with overt clefts (p=0.04), but not at Time Point 2. There were no significant differences between scores if repair was performed between 18 and 36 months or >36 months, nor any difference in incidence of articulation errors between subgroups of patients with late repair at either Time Point. ConclusionOur experience demonstrates that cleft palate repair after 18 months of age is associated with a significantly increased incidence of articulation errors associated with VPI, irrespective of reason for late repair, highlighting the persistence of learned compensatory behaviors in speech and the importance of proceeding with early repair.

Incidence of palatal fistula formation after primary palatoplasty in northern Finland.

The purpose of this retrospective study was to determine the incidence of palatal fistulas after primary cleft palate repair. The study included 136 patients who were treated at the Oulu University Hospital cleft lip and palate center between 1998 and 2011. All patients were treated by the same surgeons with 1-stage palatoplasty closing the hard and soft palate concurrently. The overall frequency of postoperative fistula was 9.6% of patients. Patients with cleft lip and palate (20.0%) were more likely to develop postoperative palatal fistulas than patients with cleft palate (6.6%). Surgical technique and cleft severity were not significant factors for the development of palatal fistulas. The majority of patients undergoing primary palatal repair do not develop palatal fistulas.

Transverse Mucoperiosteal Flap Inset by Rotation for Cleft Palate Repair

Cleft palate is a relatively common deformity with various techniques described for its repair. Most techniques address the hard palate portion of the cleft with bilateral mucoperiosteal flaps transposed to the midline. This results in superimposed, linear closure layers directly over the cleft and may predispose the repair to oronasal fistula formation. This report details an alternative technique of flap rotation with an outcome analysis. A retrospective chart analysis was performed of all patients having undergone primary palatoplasty for cleft palate. Demographics and cleft Veau type were recorded. Postoperative speech outcomes were assessed by standardized speech evaluation performed by 2 speech language pathologists. The presence and location of oronasal fistulae was assessed and recorded by the surgeon and speech language pathologists in follow-up evaluations. The study revealed an overall incidence of velopharyngeal insufficiency of 5.7% using this surgical technique. It also revealed a fistula rate of 8.6%. Secondary surgery has been successful in those patients in which it was indicated. Eleven (31%) patients were diagnosed with Robin sequence. This technique demonstrates excellent early outcomes in a difficult subset of cleft patients including a high proportion of those with Pierre Robin sequence. The technique addresses the inherent disadvantages to a linear closure over the bony cleft. The variability in its design provides the surgeon another option for correction of this deformity.

Intraoperative High-Dose Epinephrine Infiltration in Cleft Palate Repair

Local infiltration of epinephrine before surgical procedures is a well-accepted technique to promote vasoconstriction. Typically, the dose of epinephrine is limited by the co-administration of local anesthetic as well as the risk for arrhythmogenesis and hemodynamic changes. In addition, some controversy exists regarding the acceptable dose of epinephrine given to children. This retrospective review examines the use and safety of "high-dose" epinephrine in palatoplasty at our cleft-craniofacial center. A retrospective review of epinephrine use in primary palatoplasty at a tertiary children's hospital from 2003 to 2007 was performed. Operative and anesthetic records were reviewed for hypertension (systolic blood pressure, >120 or diastolic blood pressure, >70) and tachycardia (>190 beats per min) as defined by the American Heart Association guidelines, as well as dysrhythmias, intraoperative complications, and postoperative complications. A total of 102 patients who underwent consecutive primary palatoplasties performed by a single surgeon were identified. After the induction of anesthesia and before incision, the patients received an initial epinephrine infiltration (without local anesthetic) up to a maximum 10 μg/kg. The average total dose of epinephrine administered during palatoplasty was 12.8 μg/kg (range, 3.2-75.0 μg/kg). Doses up to a maximum of 10 μg/kg were administered as needed at 30-minute intervals. No instances of clinically unstable tachycardia or hypertension occurred. A total of 21.6% of the patients (22/102) experienced an instance of hypertension, and only 13.7% of these (14/102) were related to epinephrine administration. One (1%) postoperative fistula was identified. Locally infiltrated high-dose epinephrine during palatoplasty can be safely used as a means of vasoconstriction. Doses reaching a maximum of 10 μg/kg, administered as needed at 30-minute intervals, do not seem to be a significant risk for hemodynamic instability, intraoperative complications, or postoperative complications.

Diagnosis and management of velopharyngeal insufficiency following cleft palate repair

Background: Cleft lip and palate repair seeks to restore normal form, improve feeding and achieve normal speech, which requires velopharyngeal competence. The absence of this ability, termed velopharyngeal insufficiency (VPI), is seen in a wide range of patients following primary cleft palate repair. This review article focuses on patient assessment and the surgical management of VPI. Recent trends and future directions in management are also presented. After reading, one should be able to describe the various treatment approaches for a patient with suspected VPI. Materials and Methods: A PubMed search was conducted using the following search terms: VPI, velopharygneal incompetence, VPI, velopharynx, velopharyngeal port, velopharyngeal mechanism, veloplasty, intravelar veloplasty and hypernasal speech. Relevant manuscripts were identified by abstract review and additional articles selected based on bibliography review. Articles were restricted to those in the English language. A total of 88 articles were selected for further review. Conclusions: VPI is a common complication following primary palatoplasty. The decision to operate, as well as the selection of operative procedure, depends on a multimodal patient assessment, including speech evaluation and imaging studies of the pharyngeal mechanism. A thorough understanding of velopharyngeal anatomy and physiology is crucial to understanding the deficits in patients with VPI as well as the myriad methods of surgical correction. While many techniques are available, there are no conclusive data to guide procedure choice and newer techniques of imaging and treating patients with VPI continue to evolve.

An Adult Case of Unilateral Cleft Lip and Palate Treated by Primary Palatoplasty, Alveolar Bone Grafting and Secondary Repair of Cleft Lip and Nose

An Adult Case of Unilateral Cleft Lip and Palate Treated by Primary Palatoplasty, Alveolar Bone Grafting and Secondary Repair of Cleft Lip and Nose

Buccinator myomucosal flap in cleft palate repair: Revisited

Objective: To present various ways of transfer and result of buccinator myomucosal flap (BMMF) in primary and secondary repair of palatal cleft and palate fistula. Design: This study has been designed on the basis of a clinical experience and literature search. Route of single or two BMMF(s) transfer was either lateral or posterior to the greater palatine neurovascular bundle. The flap has been used to repair defect in nasal layer, oral layer, or in combined nasal as well as oral layer of the palate. Materials and Methods: More than 160 palatoplasties have undergone palate repair with the use of BMMFs between 1999 and 2011. The analysis includes 98 palate repair. Unilateral flap was used most commonly in primary repair of nasal side of wide unilateral cleft palate (CP); whereas, two flaps were used mostly in primary repair of wide bilateral CP and in secondary palate repair for large fistula. Results: The fistula rate; in primary palatoplasty patients was 4.8% and in secondary palatoplasty patients, it was 8.3%. Good speech has been achieved in primary palatoplasty patients. After secondary palatoplasty also patients had good speech following therapy. Conclusion: The presented technique has been effective in anatomical and functional repair of wide palatal defects primary as well as secondary. The literature has been reviewed along with.

Frequency of pharyngoplasty after primary repair of cleft palate in northern Finland

One measure of primary cleft palate repair success is the subsequent need for secondary pharyngoplasty due to velopharyngeal insufficiency. This study aimed to assess primary palatoplasty outcomes and frequency of secondary pharyngoplasty. A total of 138 patients underwent palatoplasty between 1998 and 2011. All patients were treated with 1-stage palatoplasty closing the hard and soft palate concurrently. Overall frequency of pharyngoplasty after palatoplasty was 21% of patients. The rate of secondary surgery was significantly higher for girls (27%) than for boys (13%). Patients with cleft lip and palate were more likely to require secondary pharyngoplasty (24%) than the patients with soft and hard cleft palate (20%). Surgical technique and cleft severity were significant factors for secondary surgery. Pharyngoplasty was least common in patients whose palatal clefts were treated at 9 to 12 months of age. The majority of patients undergoing primary palatal repair do not need secondary pharyngoplasty.

A prospective, randomized, double-blind clinical trial study to evaluate a method for uvular repair during primary palatoplasty

The purpose of this study was to evaluate the efficacy of a new technique for uvular repair in patients with cleft palate. This is a prospective, randomized, double blind controlled trial study with Ethical Committee approval between two groups of 30 patients each with cleft palate who were operated on using the conventional and proposed method of uvular repair from 2005–2007. Data was from the Outreach Surgical Center Program, Lima, Peru. Two groups of 30 patients each with cleft palate were operated on using the new technique by the Outreach Surgical Center Program Lima since 2007. Data collection was accomplished by physical exam to evaluate the appearance of the constructed uvula, as well as the presence or absence of a fistula and by a speech therapist. This comparative study did not find a statistically significant association between the conventional and the proposed method for uvular repair or the presence of postoperative hypernasal speech determined at 1–5 years of age during follow-up (p = 0.640). This study observed no increase in the rate of fistulas and/or VPI between these two groups so it was concluded that the use of the proposed method for uvular reconstruction does not affect the closure of the velopharyngeal sphincter and, thus, the development of VPI is not increased.

Prospective Analysis of Presurgical Risk Factors for Outcomes in Primary Palatoplasty

The authors present a single surgeon's series of primary palatoplasty over a 10-year period in order to determine which presurgical factors might influence postoperative fistula rate and speech outcome. Data were prospectively acquired for all patients undergoing primary palatoplasty between January of 2000 and January of 2010. Standard demographic data were captured together with classification of cleft type and severity (as defined by palate length and cleft width). Outcome data were assessed in terms of fistula rate and the requirement for secondary speech surgery for velopharyngeal insufficiency. There were 485 primary procedures; 276 patients were male. Mean age at primary surgery was 20.4 months. Clefts were classified according to Kernahan and Stark (cleft palate, n = 260; cleft lip/palate, n = 225) and Veau class (I, n = 85; II, n = 175; III, n = 165; and IV, n = 60). Palate length was assessed according to Randall's classification (I, n = 81; II, n = 319; III, n = 58; IV, n = 2). Mean palate width was 7.7 mm (range, 0 to 19 mm). Cleft lip/palate was associated with wider mean cleft width and a higher incidence of shorter palates than cleft palate. Velopharyngeal insufficiency was more frequent in cleft lip/palate than in cleft palate. Male sex, greater cleft width, and shorter palate length were independent predictors of velopharyngeal insufficiency. Distributions of sex, cleft width, and palate length vary among the differing cleft types and may explain some of the variation in outcomes among centers and protocols. These data should be recorded to facilitate valid comparisons among future studies. Risk, III.

Velopharyngeal Function of Patients With Cleft Palate After Primary Palatoplasty

The aim of this study was to investigate the relevance of sex, age, and cleft type to velopharyngeal function after primary Sommerlad palatoplasty so as to improve velopharyngeal function after the procedure. Records of 503 patients with nonsyndromic cleft palate after primary Sommerlad palatoplasty were included in the retrospective study. Relevance between their velopharyngeal function and sex, age, and cleft type was analyzed. Statistical analysis was performed using SPSS 13.0 (SPSS Inc., Chicago, IL). There were no significant differences of velopharyngeal competence (VPC) rates between different sexes (P = 0.635). Specifically, VPC rates were significantly higher in younger-than-2-years groups than in older age groups (P < 0.05) and significantly lower in 6-years-or-older group (P < 0.05). No differences were found among 2- to 6-year-old groups (P > 0.05). The VPC rates were significantly lower in the bilateral complete cleft palate and the unilateral complete cleft palate than in the incomplete cleft palate before 2 years old (P < 0.05), whereas there were no significant differences totally (P = 0.875). Results showed that the disparity of the VPC rate among different cleft types would decrease with age. Moreover, results of multivariate logistic regression also indicated that operation age and cleft type are factors influencing velopharyngeal function. Primary palatoplasty should be completed before 2 years old, and the postoperative velopharygeal function will greatly decreases after 6 years old. The influence of cleft type on velopharyngeal function is limited to young patients. For those who have missed the best surgical timing, appropriate delay of operation age is reasonable, especially for patients with complete cleft palate. For patients 4 to 6 years old, the first choice is still simple palatoplasty no matter which cleft type they are classified into.

唇・顎・口蓋裂患者に対する初回ロ蓋形成手術の遠隔成績

唇・顎・口蓋裂患者に対する初回ロ蓋形成手術の遠隔成績

Profile Evaluation of Patients with Cleft Lip and Palate Undergoing Surgery at a Reference Center in Rio de Janeiro, Brazil

In Brazil, the classic timeline for operating on cleft lip and palate is three months old for cheiloplasty and is 12 to 18 months old for palatoplasty. As from Brazilian treatment centers are usually located in major cities, patients living in more remote areas are often unable to receive treatment at the ideal ages. Data were analyzed retrospectively on 45 patients with cleft lip and/or palate, consecutively operated at the Reference Center, Rio de Janeiro Federal University, Brazil. Particularly noteworthy among these data are gender, clinical presentation, operations performed, age of surgery, and the distance between their homes and the hospital. The average age of patients undergoing primary cheiloplasty was 9.4 months, with primary palatoplasties performed at an average age of 7.2 years. As 67% of these patients lived in other towns, they encountered difficulties in seeking and continuing specialized care. Despite attempts to decentralize cleft palate care in Brazil, suitable conditions are not yet noted for following the treatment protocols in a full and adequate manner.

Fraca pressão aérea intraoral na fala após correção cirúrgica da fissura palatina

INTRODUCAO: Diversas alteracoes anatomicas e funcionais sao observadas nos individuos portadores de fissuras labiopalatinas, dentre elas anormalidades estruturais da musculatura orofaringea, que podem causar prejuizo da funcao velofaringea e, consequentemente, de funcoes como succao, degluticao e fala. O presente estudo teve por objetivo avaliar a presenca de fraca pressao aerea intraoral na fala de individuos com fissura palatina submetidos a palatoplastia primaria em tempo adequado e tardiamente, e comparar se o momento do procedimento cirurgico pode acarretar maior ocorrencia do disturbio. A hipotese e de que os individuos submetidos a palatoplastia primaria tardiamente apresentam maior ocorrencia de fraca pressao aerea intraoral em comparacao aqueles que realizaram a palatoplastia primaria no momento adequado. METODO: Participaram do estudo 37 individuos de ambos os sexos, com diagnostico de fissura de palato associada ou nao a fissura de labio, divididos em dois grupos: 1) grupo precoce (GP), composto por 22 pacientes submetidos a palatoplastia primaria ate o 2o ano de vida; e 2) grupo tardio (GT), composto por 15 pacientes submetidos a palatoplastia primaria tardiamente, apos o periodo de aquisicao dos sons da fala. Todos os participantes foram submetidos a rotina de avaliacao fonoaudiologica com intervalo de, no minimo, 3 meses de pos-operatorio. Dentre os parâmetros avaliados encontra-se a analise da fraca pressao aerea intraoral, que foi a variavel considerada para este estudo. RESULTADOS: A analise dos dados possibilitou observar maior frequencia de fraca pressao aerea intraoral no GT (33%) em comparacao ao GP (18%). Entretanto, tal diferenca nao foi estatisticamente significante (P = 0,44). CONCLUSOES: A hipotese do estudo foi rejeitada. A presenca de fraca pressao aerea intraoral foi observada na fala dos dois grupos estudados, nao sendo a idade na ocasiao da palatoplastia primaria um fator determinante.

Speech Outcome after Palatal Repair in Nonsyndromic versus Syndromic Robin Sequence

The authors' purpose was to document speech outcome after cleft palate repair in patients with syndromic versus nonsyndromic Robin sequence. Results of secondary correction of velopharyngeal insufficiency using a superiorly based pharyngeal flap or double-opposing Z-palatoplasty are also reported. Charts of patients with Robin sequence and cleft palate between 1980 and 2007 were reviewed. Data collected included date of birth, sex, syndrome/association, cleft palatal type (Veau I or II), age at palatoplasty, incidence of palatal fistula, postoperative speech assessment, videofluoroscopic results, need for secondary operation for velopharyngeal insufficiency, and type of secondary operation (pharyngeal flap or double-opposing Z-palatoplasty). The authors identified 140 patients with Robin sequence who had palatal closure. Postoperative speech evaluation was available for 96 patients (69 percent). A syndrome or association was identified in 42 patients (30 percent). Primary palatoplasty was successful in 74 patients (77 percent); speech was characterized as competent and competent to borderline competent. The authors found a significantly higher incidence of velopharyngeal insufficiency following palatal repair for syndromic (38 percent) than nonsyndromic Robin sequence (16 percent). (p = 0.039). In patients with velopharyngeal insufficiency, competent or borderline competent speech was determined after double-opposing Z-palatoplasty (two of five patients) or pharyngeal flap (eight of 10 patients). The rate of velopharyngeal insufficiency in syndromic Robin sequence is significantly greater than in nonsyndromic Robin sequence. The authors prefer pharyngeal flap for velopharyngeal insufficiency in patients with Robin sequence, whether syndromic or nonsyndromic, without retrognathism or signs/symptoms of obstructive sleep apnea.

Poster 06: Case Series Utilizing Acellular Collagen Reinforcement in Full Primary Palatoplasty Cases for the Last 5 Years

Primary closure of the soft palate by 12-18 months of age has been shown to be instrumental in proper speech development and function. Several techniques have been discussed regarding primary soft palate cleft repair. Tension leading to necrosis and fistula formation at the hard/soft palate raphe after primary repair is not an unusual complication. A technique involving a two-layer closure of the posterior hard palate and three-layer closure of the soft palate has been the gold standard for cleft repair.

AlloDerm Revision for Failed Pharyngoplasty

Velopharyngeal insufficiency (VPI) occurs in more than 20% of patients with a cleft palate after primary palatoplasty. Surgical treatment focuses on pharyngoplasty to narrow the nasopharyngeal space and to decrease the distance needed for palatal closure. Persistent VPI after pharyngoplasty affects more than 20% of patients.From September 2007 to December 2009, 16 children (10 boys and 6 girls) with a mean age of 9.5 years (4-15 years) underwent surgical revision using an AlloDerm sling for persistent VPI after at least 1 previous failed pharyngoplasty. Ten children had previous sphincter pharyngoplasties, and 6 had previous pharyngeal flaps. Surgical technique involves creation of a submucosal tunnel through the limbs of the previous pharyngoplasty or pharyngeal flap. A strip of AlloDerm is threaded circumferentially, and the port is adjusted to the desired aperture.All patients underwent preoperative and postoperative analysis of VPI, including oral pharyngeal and perceptual speech examination by speech pathology with a mean follow-up of 441 days. Acoustic nasometry was used to objectively compare preoperative and postoperative nasalance values. A significant improvement in perceptual resonance was seen in 93.8% of patients, and 87.5% of patients improved to normal or mild resonance (P < 0.001). There was a significant mean reduction of nasalance using the MacKay-Kummer Simplified Nasometric Assessment Procedure test (P < 0.001). Two patients developed postoperative flap dehiscence, with one being revised ultimately to have normal speech resonance.Revision pharyngoplasty using an AlloDerm sling can safely and effectively improve speech in patients with persistent VPI after failed pharyngoplasty. Long-term follow-up studies are ongoing.