Journal Article•
Abnormal anatomy of the muscles of palatopharyngeal closure in cleft palates: anatomical and surgical considerations based on the autopsies of 18 unoperated cleft palates.
About: This article is published in Plastic and Reconstructive Surgery.The article was published on 1970-11-01 and is currently open access. It has received 93 citations till now.
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TL;DR: The attached vomer/levator muscle complex may be a more important predictor of surgical success than the anatomic extent of cleft, and age at repair was more critical for HSCP and BCLP patients.
Abstract: Objective: The goal of this study was to determine the relative importance of surgical technique, age at repair, and cleft type for velopharyngeal function. Design: This was a retrospective study of patients operated on by two surgeons using different techniques (von Langenbeck and Veau-Wardill-Kilner [VY]) at Children's Hospital, Boston, MA. Patients: we included 228 patients who were at least 4 years of age at the time of review. Patients with identifiable syndromes, nonsyndromic Robin sequence, central nervous system disorders, communicatively significant hearing loss, and inadequate speech data were excluded. Main Outcome Measure: Need for a pharyngeal flap was the measure of outcome. Results: Pharyngeal flap was necessary in 14% of von Langenbeck and 15% of VY repaired patients. There was a significant linear association (p = .025) between age at repair and velopharyngeal insufficiency (VPI). Patients with an attached vomer, soft cleft palate (SCP), and unilateral cleft lip/palate (UCLP) had...
173 citations
TL;DR: The findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults are applied to analyze current controversies in velopharyngeal function and cleft palate surgery.
Abstract: The purpose of this investigation was to apply the findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults to analyze current controversies in velopharyngeal function and cleft palate surgery. The levator veli palatini was observed to form a muscular sling, suspending the velum from the cranial base. Its fibers occupied the middle 50 percent of the velum, lying in transverse orientation and without significant overlap across the midline. It is well placed to function as the prime mover in the velar component of velopharyngeal closure. The velar component of the palatopharyngeus consisted of two heads clasping the levator and inserting into the latter just short of the midline. Its pharyngeal component inserted into the superior constrictor in the lateral and posterior pharyngeal walls. Together, these two muscles formed a sphincter around the velopharyngeal port, suggesting that both muscles are involved in the pharyngeal component of velopharyngeal closure. Based on the premise that the goal of palatoplasty is to restore normal anatomy, the intravelar veloplasty has a sound basis, and theoretically improves both velar and pharyngeal wall function because it corrects the dysmorphology of both the levator and palatopharyngeus. Although the Furlow palatoplasty also reorients these velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus across the midline is morphologically abnormal. In addition, the use of large Z-plasty flaps in wide clefts may cause excessive lateral tension, increasing the risk of fistula formation and causing an impairment of velar stretch capacity. The raising of a vertical pharyngeal flap divides the fibers of the superior constrictor and has the potential to impair pharyngeal wall function. The sphincter pharyngoplasty interferes less with pharyngeal wall anatomy. The potential for an obstructive outcome seems to be related to the use of wide, long flaps and a tight, overlapping type of flap inset. In addition, the level of flap inset is important: an inset at the level of the uvula has the greatest risk of causing obstruction, whereas a higher inset at the level of attempted velopharyngeal closure seems to provide the best opportunity for achieving velopharyngeal competence while avoiding hyponasality and obstruction.
136 citations
TL;DR: It is indicated that cleft palate children have a limited ability to open the eustachian tube actively by swallowing, as evidenced by an inability to equilibrate applied positive or negative pressures.
Abstract: The cleft palate population has a high prevalence of chronic otitis media with effusion (OME). The present study attempts to relate this pathology to a functional obstruction of the eustachian tube...
116 citations
TL;DR: In this paper, the authors examined the paratubal muscles of 15 fresh human adult cadaveric head specimens, paying particular attention to their cranial base anatomy and concluded that the salpingopharyngeus muscle is probably functionally the least important of all the muscles.
Abstract: The aims of this anatomic investigation were to examine the levator veli palatini, tensor veli palatini, and salpingopharyngeus muscles in relation to normal eustachian tube function and to analyze the clinical implications of these data for tubal physiology in cleft palate individuals. Detailed dissections under 3.2x loupe magnification were conducted on the paratubal muscles of 15 fresh human adult cadaveric head specimens, paying particular attention to their cranial base anatomy. Each half of the cadaveric heads was examined separately, giving a sample size of 30. The cranial base origin of the levator veli palatini was the junction of the cartilaginous and bony parts of the eustachian tube. Contrary to statements in the existing literature, it had no origin from the quadrate area of the petrous temporal bone. In its path toward the velum, it was related inferiorly and lay almost parallel to the tube. The tensor veli palatini originated from the scaphoid fossa of the sphenoid bone and the tube. In contrast to previous descriptions, it was found to consist of a single sheet of muscle with no bilaminar structure. Its axis was oblique to that of the tube. The salpingopharyngeus was a slender muscle attached to the posteroinferior aspect of the pharyngeal end of the tube. It inserted into the palatopharyngeus inferiorly. These morphologic characteristics and anatomic relationships suggest that (1) the levator veli palatini opens the eustachian tube by isotonic contraction that results in displacement of the medial tubal cartilage and the tubal membrane, (2) the tensor veli palatini opens the tube directly by traction on the lateral tubal membrane and indirectly by rotation of the medial tubal cartilage by means of traction on the lateral tubal cartilage, (3) because of its consistently small size, the salpingopharyngeus is probably functionally the least important of the paratubal muscles, (4) the levator veli palatini is unable to cause tubal dilatation in cleft palate because it can only contract isometrically, and (5) tensor veli palatini function is probably unaffected by clefting. However, its mechanism of action may be disrupted iatrogenically by complete hamular fracture or division of its tendon.
102 citations
TL;DR: It is indicated that most children with cleft palates eventually recover normal eustachian tube function after palatoplasty, but for the majority of children, this does not occur for many years.
Abstract: Eustachian tube dysfunction is a nearly universal complication of cleft palate, resulting in chronic ear disease and conductive hearing loss Cleft palate repair is thought to result in recovery of eustachian tube function, but the length of time between repair and recovery of eustachian tube function is not known Furthermore, the efficacy of tympanostomy tubes in the treatment of eustachian tube dysfunction and hearing sequelae has not been examined in a systematic way To answer these questions, we performed a retrospective study that used serial audiometric data and tympanometry on 81 patients with cleft palates (162 ears), with follow-up ranging from 1 to 173 years Average time to recovery of eustachian tube function was 60 years (range, 10 to 103 years) after cleft palate surgery For children followed up for at least 6 years (longest follow-up, 173 years), 70% (67 of 85) had normal eustachian tube function at their last follow-up visit Ears treated with Armstrong tympanostomy tubes required an average of 31 tubes per ear until recovery of eustachian tube function, whereas ears treated with Goode T tubes required only 11 tubes per ear (p 20 dB) before tympanostomy tube placement, whereas only 75% of ears demonstrated this loss after tube placement Furthermore, more than 90% of ears maintained normal thresholds after recovery of eustachian tube function These data indicate that most children with cleft palates eventually recover normal eustachian tube function after palatoplasty, but for the majority of children, this does not occur for many years(ABSTRACT TRUNCATED AT 250 WORDS)
99 citations