Residual Velopharyngeal Insufficiency Research Articles

Speech Outcome Audit for Cleft Lip and Palate Patient Population Correlated With Veau Cleft Type, Surgical Repair Technique, and Patient Age

Objective: The objective of this study is to determine speech outcome differences for specific palate repair techniques and correlate these data with patient age at the time of operation. Methods: A retrospective study was conducted on a cohort of consecutive nonsyndromic patients who underwent cleft lip and/or palate repair at the authors' hospital between 2010 and 2020. Only those patients who participated in at least 4 years of follow-up accompanied by audio-video recording were included. The patient cohort was divided into 2 age groups, between 1 year and 2 years of age versus older than 2 years of age. Standardized perceptual speech evaluations and nasopharyngoscopy were performed by the authors' team to detect the presence of velopharyngeal insufficiency. Results: A total of 481 patients were initially evaluated, and 323 of these patients met all inclusion criteria and were subsequently selected for this study. One hundred seventy-two patients (n = 172) underwent palatal surgery using the Bardach 2-flap palatoplasty technique, 47 patients (n = 47) underwent repair through the von Langenbeck palatoplasty technique, 78 patients (n = 78) underwent repair through Veau-Wardill-Killner palatoplasty technique, and 26 patients (n = 26) underwent repair through double-opposing Z-plasty palatoplasty. The rate of residual velopharyngeal insufficiency was statistically similar among all palatoplasty techniques. A comparison between these two age groups revealed that patients younger than 2 years of age showed higher speech outcome success. Conclusion: High rates of speech success are achieved for patients younger than 2 years of age. Speech outcomes success is maximized by proper technique selection in relation to cleft type.

Outcomes of Primary Furlow Double-Opposing Z-plasty for the Treatment of Symptomatic Submucous Cleft Palate.

Submucous cleft palate (SMCP) requires surgical repair if symptomatic. The Furlow double-opposing Z-plasty is the preferred method in Helsinki cleft center. To assess the efficacy and complications of Furlow Z-plasty in the treatment of symptomatic SMCP. This retrospective study reviewed documentation of 40 consecutive patients with symptomatic SMCP who underwent primary Furlow Z-plasty by 2 high-volume cleft surgeons at a single center between 2008 and 2017. Patients underwent perceptual and instrumental evaluation of velopharyngeal function (VPF) by speech pathologists preoperatively and postoperatively. The median age at Furlow Z-plasty was 4.8 years (SD 2.6, range 3.1-13.6). The overall success rate, including postoperative competent or borderline competent VPF, was 83%, and 10% required secondary surgery for residual velopharyngeal insufficiency. The success rate was 85% in nonsyndromic, and 67% in syndromic patients with no significant difference ( P =0.279). Complications arose in only 2 (5%) patients. No children were found to have obstructive sleep apnea postoperatively. Furlow primary Z-plasty is a safe and effective operation for symptomatic SMCP with a success rate of 83% with only 5% rate of complications.

How Early Can We Predict the Need for VPI Surgery?

This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years. Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics. Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

Pharyngoplasty versus buccinator myomucosal flap in the management of velopharyngeal-insufficiency coronal pattern of closure

Background Velopharyngeal insufficiency (VPI) is an anatomical or structural defect that hinders sufficient velopharyngeal closure, as visualized on nasoendoscopy. Aim The aim of this work was to compare the result of sphincter pharygoplasty versus buccinator myomucosal flap in management of VPI cases with coronal pattern of closure in order to select the proper operation for managing these cases. Patients and methods This study included 20 patients in our institute with residual VPI after primary repair of cleft palate with age range between 3 and 12 years. Randomly, patients with coronal pattern of closure were categorized into two groups: (A) 10 patients underwent sphincteroplasty and (B) 10 patients underwent buccinator myomucosal flap. Preoperatively and 2 months after operation, every patient was evaluated by auditory perceptual assessment, flexible nasopharyngoscopy, and nasometry. The results were documented, tabulated, and statistically analyzed. Results There were statistically significant improvements of auditory perceptual assessment in obligatory speech disorders and intelligibility of speech, nasometeric evaluation in oral and nasal sentences in both groups. Additionally, there were significant improvements of nasoendoscopic evaluations in the degree of velar movement, presence or absence and size of persistent gap in both groups, and in the degree of lateral pharyngeal wall movements in group A. Conclusion Sphincterpharyngoplasty or buccinator myomucosal flap have satisfactory results in treatment of VPI patients with coronal pattern of closure with no statistically significant difference between both groups.

Palatal Re-Repair With Z-Plasty in Treatment of Velopharyngeal Insufficiency of Syndromic and Nonsyndromic Patients With Cleft Palate.

Velopharyngeal insufficiency (VPI) often results from palatal shortening or insufficient levator function after cleft palate repair. To assess the efficacy of palatal re-repair with Z-plasty in treatment of VPI for patients with isolated cleft palate (ICP). This retrospective analysis comprised 130 consecutive patients who had ICP with VPI that required Z-plasty as secondary surgery between 2008 and 2017. Pre- and post-operative evaluation of velopharyngeal function was done perceptually and instrumentally by Nasometer. Median patient age at Z-plasty was 6.8 years (range 3.0-20.1). Of the 130 patients, preoperatively VPI was severe in 73 (56%), mild-to-moderate in 55 (42%), and borderline in 2 (2%). Postoperatively, 105 (81%) of patients achieved adequate (normal or borderline) velopharyngeal competence and 16 (12%) required second operation for residual VPI. The success rate was 84% in nonsyndromic patients, 79% in nonsyndromic Pierre Robin sequence patients, and 58% in syndromic patients. In syndromic children, the speech outcome was significantly worse than in nonsyndromic children (P = 0.014). Complications included wound healing problems in 3 patients (2%), mild infection in 1 patient (1%), postoperative bleeding in 1 (1%), and postoperative fistula in 2 (2%). Palatal re-repair with Z-plasty is a safe operation for VPI correction in patients with ICP with a success rate of 81%. In syndromic patients, the procedure did not seem to work as well as in nonsyndromic patients.

Palatal Re-Repair With Double-Opposing Z-Plasty in Treatment of Velopharyngeal Insufficiency of Patients With Unilateral Cleft Lip and Palate.

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair that is often related to palatal shortening and insufficient levator reconstruction. For VPI correction in our cleft center, palatal re-repair with double-opposing Z-plasty is the standard operation. To assess the efficacy of double-opposing Z-plasty in treatment of VPI after primary surgery for unilateral cleft lip and palate (UCLP). This retrospective analysis comprised 109 consecutive UCLP patients born between 1997 and 2014 with VPI that required re-operation, and were operated on by 2 highvolume cleft surgeons, followed by perceptual and instrumental (Nasometer) evaluation of velopharyngeal competence (VPC). Preoperatively, VPI was severe in 96% (105 of 109) and mild-to-moderate in 4% (4 of 109). Median age at surgery was 5.6 years (range 2.8-21.9). Postoperatively, 84% of patients achieved adequate VPC: 65% (71 of 109) were competent and 19% (21 of 109) borderline competent. Postoperative adequate VPC was 89% (70 of 79) in nonsyndromic Finnish patients, 50% (4 of 8) in syndromic patients, and 82% (18 of 22) in adoption children. Compared to Finnish nonsyndromic patients, patients with syndrome had more residual VPI (P = 0.003), but no statistically significant difference existed for adoption patients (P = 0.251). Complications of the double-opposing Z-plasty included hemorrhage, postoperative mild airway obstruction, and wound-healing problems, each arising in 2 (1.8%) patients. Fourteen (13%) patients needed a second VPI operation. Double-opposing Z-plasty seems to be a good and safe treatment option for VPI in patients with previously repaired UCLP with a success rate of 84%.

Optimizing speech outcomes for cleft palate.

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate. The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics. According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

Management of velopharyngeal insufficiency by modified Furlow palatoplasty with pharyngeal flap: a retrospective outcome review

The surgical approach for the correction of residual velopharyngeal insufficiency requiring secondary surgery at Chang Gung Memorial Hospital is the modified Furlow palatoplasty with pharyngeal flap (mFP-PF). The aim of this study was to describe the mFP-PF technique and to determine the results obtained with regard to improvements in velopharyngeal function in patients undergoing this surgery. This retrospective analysis included 58 non-syndromic patients treated during the period 1992–2015 who complained of hypernasal speech after primary cleft palate repair and failed postoperative speech therapy. All of them underwent mFP-PF surgery. Preoperative and postoperative perceptual speech assessment results were obtained. The male to female ratio in the study group was 1.2:1, and the mean patient age at the time of surgery was 8.27 years. The patients underwent nasoendoscopic examination and the velar closing ratio was categorized as 0.1–0.4 in 53.4% and 0.5–0.7 in 46.6%. The assessment of speech after mFP-PF showed statistically significant changes for all perceptual speech outcomes. The incidence of repeat surgery was 3.4%. This study revealed that 96.6% of patients did not require second surgery for velopharyngeal insufficiency. Further studies on obstructive sleep apnoea in post-mFP-PF patients and improvements to the surgical technique should be considered.

Influência do retalho faríngeo sobre a nasalidade e a nasalância na produção de sons nasais em indivíduos com fissura labiopalatina

To verify the influence of pharyngeal flap surgery on the management of velopharyngeal insufficiency on nasality and speech nasalance on nasal sound production in individuals with cleft lip and palate. Prospective study in 159 individuals with repaired cleft palate ± lip, of both genders, aged 6 to 57 years old. All the participants presented residual velopharyngeal insufficiency and were submitted to pharyngeal flap surgery. Perceptual speech evaluation and nasometric assessment were performed before and after (14 months on average) the pharyngeal flap surgery. Hyponasality was rated as absent or present, and nasalance scores were determined by means of nasometer using nasal stimuli, with a cutoff score of 43% used as the lowest limit of normality. Nasality and nasalance were compared before and after surgery (p < 0.05). On the basis of correlation between both the methods used, perceptual hyponasality was observed in 14% of the individuals, whereas nasalance scores indicating hyponasality (< 43%) were obtained in 25% of the patients after surgery. Pharyngeal flap surgery influenced the production of nasal sounds, causing hyponasality in a significant proportion of individuals. The presence of this speech symptom can also be an indicator of upper airway obstruction caused by pharyngeal flap, which should be investigated objectively and prudently postoperatively.

Redo double-opposing Z-plasty is effective for correction of marginal velopharyngeal insufficiency

Double-opposing Z-plasty (DOZ) of the Furlow method has been successfully used for the correction of marginal velopharyngeal insufficiency (VPI) by reconstructing the levator muscle and lengthening the soft palate. For a recurrent or residual marginal VPI, it was questioned whether redo DOZ could be applied to correct the problem and minimize surgical morbidity. This study reported the outcome of the redo DOZ. The DOZ procedure was the method of choice for marginal VPI in the authors' center. To evaluate the effectiveness of the redo operation, patients with cleft palate with or without cleft lip treated from 2005 to 2014 were reviewed. Inclusion criteria were non-syndromic patients who underwent the second DOZ for the correction of marginal VPI. Clinical information, speech assessment, and nasopharyngoscopic findings were reviewed. The velopharyngeal function was improved from marginal to adequate in all 13 patients either subjectively or objectively. The resonance became normal in nine patients after the surgery, and the change was statistically significant. Preoperative audible nasal emission improved in four out of five patients. Complications were minor or transient including one patient with snoring. No patient complained of airway or sleep problems. Although the levator muscle sling might be disturbed by the redo DOZ procedure, the surgery was effective in correcting the residual VPI with low morbidity.

Acoustic analysis of voice in children with cleft palate and velopharyngeal insufficiency

BackgroundAcoustic analysis of voice can provide instrumental data concerning vocal abnormalities. These findings can be used for monitoring clinical course in cases of voice disorders. Cleft palate severely affects the structure of the vocal tract. Hence, voice quality can also be also affected. ObjectiveTo study whether the main acoustic parameters of voice, including fundamental frequency, shimmer and jitter are significantly different in patients with a repaired cleft palate, as compared with normal children without speech, language and voice disorders. Materials and methodsFourteen patients with repaired unilateral cleft lip and palate and persistent or residual velopharyngeal insufficiency (VPI) were studied. A control group was assembled with healthy volunteer subjects matched by age and gender. Hypernasality and nasal emission were perceptually assessed in patients with VPI. Size of the gap as assessed by videonasopharyngoscopy was classified in patients with VPI. Acoustic analysis of voice including Fundamental frequency (F0), shimmer and jitter were compared between patients with VPI and control subjects. ResultsF0 was significantly higher in male patients as compared with male controls. Shimmer was significantly higher in patients with VPI regardless of gender. Moreover, patients with moderate VPI showed a significantly higher shimmer perturbation, regardless of gender. ConclusionAlthough future research regarding voice disorders in patients with VPI is needed, at the present time it seems reasonable to include strategies for voice therapy in the speech and language pathology intervention plan for patients with VPI.

Effects of preoperative speech therapy on the speech intelligibility of patients with velopharyngeal incompetence

EnAbstract Background Improved articulatory placement through speech therapy may eliminate compensatory errors, improve velopharyngeal function, minimize perception of hypernasality, and improve speech intelligibility. Aim The aim of this work was to study the effect of preoperative speech therapy on the speech intelligibility in patients with residual velopharyngeal insufficiency in order to provide a better speech outcome in such patients. Patients and methods This study included 41 patients diagnosed with residual velopharyngeal insufficiency after cleft palate repair. Patients were divided into two groups: group I included 22 patients scheduled to undergo speech therapy 6 months preoperatively, and group II included 19 patients who did not receive preoperative speech therapy. Both groups underwent speech therapy for 6 months postoperatively. Evaluation was carried out through auditory perceptual assessment (APA) including the type and degree of open nasality, consonant precision, compensatory articulatory mechanisms (glottal articulation and pharyngealization of fricatives), audible nasal emission of air, and overall intelligibility of speech. All these elements are graded along a five-point scale in which 0 is normal and 4 is severe affection. Documentation of APA is performed by high fidelity speech and voice audio recording and endoscopy. Formal speech intelligibility testing was carried out using the Arabic Speech Intelligibility test, which is designed to provide an estimation of the overall speech intelligibility of children by providing a total score in percentage. Nasometry was performed for all patients using a Kay nasometer, which provides the ‘nasalance score’. Results On comparing the APA assessment of group I after 6 months of speech therapy postoperatively with the preoperative data, a highly significant decrease with regard to all parameters was revealed; however, in group II, the same comparison revealed a highly significant decrease as regards the degree of open nasality and nasal emission of air and a significant difference in terms of glottal articulation, pharyngealization of fricatives, and overall speech intelligibility. On comparing the two groups postoperatively, a significant difference in glottal articulation, pharyngealization of fricatives, and overall speech intelligibility, being more improved in group I, was revealed. Nasometry showed a significant difference between the postoperative results after speech therapy compared with the preoperative results, with a nonsignificant difference between the two groups postoperatively. In group I, the results of the Arabic Speech Intelligibility test showed a highly significant decrease in the number of patients with unintelligible speech and poor speech intelligibility, a significant decrease in number of patients with fair speech intelligibility, and a highly significant increase in the number of patients with good and excellent speech intelligibility. In group II, there was a significant decrease in the number of patients with unintelligible speech and poor speech intelligibility and a significant increase in the number of patients with fair, good, and excellent speech intelligibility. Conclusion and recommendations Speech therapy before surgery for residual velopharyngeal insufficiency can improve the results of postoperative therapy, with a better speech intelligibility outcome. Therefore, it is recommended to schedule a speech therapy program before secondary repair of the velopharyngeal valve in order to attain better speech intelligibility.

Adaptive averaging applied to dynamic imaging of the soft palate

Achieving sufficient temporal and spatial resolution with adequate signal-to-noise ratio (SNR) in dynamic soft palate imaging is challenging. Triggered acquisitions require repeated reproducible speech samples, and while real-time imaging is more reliable, it may lack SNR. Adaptive averaging was implemented to improve SNR in nongated imaging during repetition of a speech task. Similar images were identified using localized cross-correlation before averaging. Adaptive averaging was applied to the soft palate region of images from six volunteers and one patient acquired with various sequences. In volunteers, soft palate SNR increased by 53 ± 17% with four averages. The additional SNR was used to enable reduced slice thickness in two example subjects. Adaptive averaging was also compared to pseudotriggered images in one example and, in another, it was applied to an unrepeated speech task. In a patient with a repaired cleft palate, the technique was used to demonstrate residual velopharyngeal insufficiency. This initial work demonstrates that increased temporal or spatial resolution may be traded for reduced SNR, which can be recovered using adaptive averaging. This will be a valuable tool in assessing velopharyngeal function, particularly in pediatric patients where cooperation may make gated studies difficult or when their head sizes require increased spatial resolution while maintaining temporal resolution.

Repair of submucous cleft palate with Furlow palatoplasty

ObjectiveSubmucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI. MethodsThis prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy. ResultsSignificant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory. ConclusionsFurlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

Velopharyngeal function after two different types of pharyngoplasty

To evaluate velopharyngeal function after two different types of pharyngoplasty: pharyngeal flap (PF) and sphincter pharyngoplasty (SP). Two groups of patients operated on with pharyngeal flaps or sphincter pharyngoplasty were studied prospectively. The study was carried out at the cleft palate clinic of the Hospital Gea Gonzalez in Mexico City. Fifty-eight cleft palate patients were studied. All patients had undergone palatal repair and showed residual velopharyngeal insufficiency. Twenty-five patients were operated on using a pharyngeal flap. Twenty-three patients were operated on using a sphincter pharyngoplasty. Pharyngeal muscle function was evaluated using selective electromyography (EMG) and simultaneous videonasopharyngoscopy (VNP). The superior constrictor muscle was approached directly. The levator veli palatini was included in the central pharyngeal flap. The palatopharyngeus were included in the lateral and superiorly-based surgical flaps inserted on the posterior pharyngeal wall. All patients showed a complete velopharyngeal closure after surgery. None of the patients showed muscle activity on the central pharyngeal flaps. None of the patients showed muscle activity on the lateral flaps of the sphincter pharyngoplasties. All the patients showed strong muscle activity of the superior constrictor. It is concluded that lateral pharyngeal flaps in cases of sphincter pharyngoplasty and the central pharyngeal flap in cases of pharyngeal flap, show absence of intrinsic activity during speech. The participation of these structures when velopharyngeal closure occurs during speech is rather passive. These flaps, central or lateral, increase tissue volume on specific areas; their movements are produced by the underlying superior constrictor.

Buccinator sandwich pushback: a new technique for treatment of secondary velopharyngeal incompetence.

A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.

Pressure-flow measurements for selected oral sound segments produced by normal children and adolescents: a basis for clinical testing.

Despite advances in surgery, a significant number of patients who undergo cleft palate repair have residual velopharyngeal insufficiency. Maxillary advancement may also result in velopharyngeal openings during speech. Instrumental approaches providing objective measures of palatal function assisting in the accurate diagnosis of these patients include pressure-flow measurements of velopharyngeal valving during speech. There is little information to guide clinicians in interpreting pressure-flow data when testing pediatric patients, however. The primary purpose of this study was to develop a method for categorizing pressure-flow data used in the diagnosis of children and adolescents with suspected velopharyngeal insufficiency. This prospective study involved 56 male and female subjects 5 to 18 years of age. Subjects had normal speech and resonance at the time of testing, no history of speech therapy, no upper respiratory infections or allergies at the time of testing, and no orofacial anomalies. Subjects repeated oral syllables and the word "hamper" after an examiner. Mean pressures, airflows, and velopharyngeal orifice areas were obtained for each utterance produced by each subject. A discriminate function analysis was performed to determine whether data could be grouped by age, gender, or utterance type. Results indicated significant differences in data for age groups 5 to 8 years, 9 to 13 years, and 14 to 18 years. There were no significant differences between data for male subjects versus female subjects or for different utterance types. Pressures generally decreased, whereas airflows and orifice areas increased with age. Results for 14 to 18 year olds were like those for adults. Using these data, a categorization scheme for velopharyngeal function was proposed for use in clinical testing.

Results with Furlow palatoplasty in management of velopharyngeal insufficiency.

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

Linguistic development in cleft palate patients with and without compensatory articulation disorder

Introduction: Cleft palate patients frequently show compensatory articulation disorder (CAD). CAD severely affects speech intelligibility and requires a prolonged period of speech intervention. CAD has been considered a phonologic disorder. Thus, it seems necessary to explore the relationship between CAD and language development. Objective: To study the relationship between language development and the presence of CAD in cleft palate patients. Materials and Methods: Cleft palate children with residual velopharyngeal insufficiency (VPI) after palatal closure, with and without CAD were studied. Only patients with an age ranging from 3 to 8 years were included in the study group. Twenty-nine cleft palate patients with residual VPI and CAD were included in the first group (active). The second group was assembled with 29 cleft palate patients with residual VPI without CAD, matched by age and sex (control). For evaluating language development, all patients were analyzed using the Situational–Discourse–Semantic (SDS) Model [13]. This Model is a valuable tool for conducting naturalistic observation and descriptive assessment of language development. The SDS Model provides a detailed description of three contexts (situational, discourse, and semantic) in ten levels of cognitive and linguistic organization. Results: In all contexts considered by the model of cognitive and linguistic organization used for this study, i.e. SDS, a Fischer exact test demonstrated that patients with CAD showed a significantly higher frequency of language delay as compared with patients without CAD. None of the patients present with CAD showed an adequate level of language development. The degree of language delay was greater in the situational context as compared to the semantic and discourse contexts. Conclusions: Cleft palate patients present with CAD, demonstrated a significantly higher frequency of delay in language development as compared with cleft palate patients present with VPI without CAD. From the results of this paper, it seems that a detailed evaluation of all aspects of cognitive and linguistic organization should be performed in cleft palate patients, especially in patients present with CAD. Moreover, it seems that speech intervention in cleft palate patients with CAD should address not only the articulation process, but also specific aspects of language development.

Velopharyngeal Motion after Sphincter Pharyngoplasty: A Videonasopharyngoscopic and Electromyographic Study

Sphincter pharyngoplasty is a surgical procedure for managing velopharyngeal insufficiency after palatal closure. This procedure is intended to create an active diaphragm for velopharyngeal closure. The purpose of this study was to evaluate velopharyngeal motion after sphincter pharyngoplasty, by using selective electromyography and simultaneous videonasopharyngoscopy. Twenty-five patients who were subjected to sphincter pharyngoplasty from 1985 to 1996 were reviewed. All conditions were evaluated by using electromyography with simultaneous videonasopharyngoscopy. The following velopharyngeal muscles were examined: superior constrictor pharyngeus, palatopharyngeus, and levator veli palatini. The palatopharyngeus was included in the superiorly based surgical flaps inserted at the posterior pharyngeal wall. Twentythree patients (92 percent) showed complete velopharyngeal closure. The two patients with residual velopharyngeal insufficiency showed a defect size of 20 and 25 percent. None of the patients showed electromyographic activity at the superiorly based flaps, indicating absence of activity of the palatopharyngeus muscles. However, all patients showed normal electromyographic activity at the superior constrictor pharyngeus and the levator veli palatini. Videonasopharyngoscopy demonstrated that lateral pharyngeal wall movements, which ranged from 25 to 40 percent, were related to strong electromyographic activity at the superior constrictor pharyngeus. It is concluded that the superiorly based pharyngeal flaps of the sphincter pharyngoplasty do not seem to create an active diaphragm for velopharyngeal closure. Moreover, the observed sphinctering seems to be passive, caused by the contraction of the superior constrictor pharyngeus. (Plast. Reconstr. Surg. 104: 905, 1999.)