Velopharyngeal function in nonsyndromic cleft palate: relevance of surgical technique, age at repair, and cleft type.
01 Mar 1998-The Cleft Palate-Craniofacial Journal (Cleft Palate Craniofac J)-Vol. 35, Iss: 2, pp 95-100
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...
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TL;DR: A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches.
Abstract: Objective: State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems. Method: The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a bet...
303 citations
TL;DR: The senior surgeon's 29-year palatoplasty experience with respect to incidence of fistula and VPI was assessed, and the incidence of palatal fistula was low and Velopharyngeal insufficiency was associated with increasing age at pal atoplasty and with the Veau hierarchy.
Abstract: The primary objective of cleft palate repair is velopharyngeal competence without fistula. The reported incidence of fistula and velopharyngeal insufficiency (VPI) is variable. Our purpose was to assess the senior surgeon's 29-year palatoplasty experience with respect to incidence of fistula and VPI. Our hypotheses were that VPI is related to (1) age at palatoplasty, (2) cleft palate type, and (3) VPI and palatal fistula incidence decrease with the surgeon's experience. We reviewed the records of all children with cleft palate treated by the senior author between 1976 and 2004. Cleft palate was categorized according to Veau. Palatoplasty was performed on 449 patients, using a 2-flap technique with muscular retropositioning. The mean age at palatoplasty was 11.6 +/- 4.9 months (range, 7.0-46.4 months). The incidence of palatal fistula was 2.9%, and velopharyngeal sufficiency was found in 85.1% of patients. We found a significant association between age at palatoplasty and VPI (P = 0.009, odds ratio, 1.06 [95% confidence interval, 1.02-1.10]). Velopharyngeal insufficiency was also associated with the Veau hierarchy (P = 0.001). Incidence of VPI was independent of surgeon experience (P = 0.2). In conclusion, the incidence of palatal fistula was low. Velopharyngeal insufficiency was associated with increasing age at palatoplasty and with the Veau hierarchy.
131 citations
TL;DR: The two-flap palatoplasty is a reliable technique that has yielded excellent surgical and speech outcomes and is an integral part of the multidisciplinary approach to achieve good speech outcome.
Abstract: Background:The two-flap palatoplasty was described more than 30 years ago, but there are few reports of long-term results using this technique. There are also very few long-term series of a single method of palatoplasty from a single surgeon.Methods:The authors reviewed the technique of the two-flap
129 citations
TL;DR: Overall, Furlow palatoplasty yielded outstanding speech results, with rates of velopharyngeal dysfunction that seem to improve upon those reported for other techniques, although there was a trend toward better outcome in those undergoing palatal repair before 6 months of age and toward poorer outcome in Those with Veau class I and II clefts.
Abstract: Although the optimal technique of cleft-palate repair remains controversial, several small series have suggested that superior speech results may be obtained with the Furlow double-opposing Z-plasty. To examine speech outcome in a large series of Furlow palatoplasties performed at a single center, we retrospectively reviewed the records of 390 cleft-palate patients who underwent Furlow palatoplasty at The Children's Hospital of Philadelphia from 1979 to 1992. Speech outcome at 5 years of age or greater was available for 181 nonsyndromic patients and was scored using the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence. No or mild hypernasality was noted in 93.4 percent of patients, with 88.4 percent demonstrating no or inaudible nasal escape and 97.2 percent demonstrating no errors in articulation associated with velopharyngeal incompetence. Secondary pharyngeal flap surgery was required in just 7.2 percent of patients. Age at palatoplasty, cleft type, and experience of the operating surgeon had no significant effect on speech results, although there was a trend toward better outcome in those undergoing palatal repair before 6 months of age and toward poorer outcome in those with Veau class I and II clefts. Overall, Furlow palatoplasty yielded outstanding speech results, with rates of velopharyngeal dysfunction that seem to improve upon those reported for other techniques.
127 citations
TL;DR: The findings suggested that children who were less lexically advanced and younger at the time of palatal surgery exhibited better articulation and resonance outcomes at 3 years of age.
Abstract: Objective: To examine the impact of age and lexical status at the time of primary palatal surgery on speech outcome of preschoolers with cleft palate. Participants: Forty children (33 to 42 months) with nonsyndromic cleft palate participated in the study. Twenty children (Group 1) were less lexically advanced and younger (mean age = 11 months) and 20 children (Group 2) were more lexically advanced and older (mean age = 15 months) when palatal surgery was performed. Main Outcome Measures: Samples of the children's spontaneous speech were compared on 11 speech production measures (e.g., size of consonant inventory, total consonants correct, % correct for manner of articulation categories, compensatory articulation usage, etc.). Next, listeners rated a 30-second sample of each child's connected speech for articulation proficiency and hypernasality, separately, using direct magnitude estimation (DME). Results: Group differences were noted for 4 of the 11 speech production measures. Children in Gr...
127 citations
Cites background from "Velopharyngeal function in nonsyndr..."
...…Ysunza et al., 1998), less CA usage (Dorf and Curtin, 1982, 1990; Ysunza et al., 1998), more normal resonance (Evans and Renfrew, 1974; Rohrich et al., 1996; Hardin-Jones and Jones, 2005), and/or less need of secondary surgery (Cleveland and Falk, 1970; Randall et al., 1983; Marrinan et al., 1998)....
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...…speech (Holdsworth, 1954; Jolleys, 1954; Peet, 1961; Cleveland and Falk, 1970; Evans and Renfrew, 1974; Dorf and Curtin, 1982, 1990; Randall et al., 1983; O’Gara and Logemann, 1988; O’Gara et al., 1994; Rohrich et al., 1996; Marrinan et al., 1998; Ysunza et al., 1998; Hardin-Jones and Jones, 2005)....
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...…1988; Copeland, 1990; Rohrich and Byrd, 1990; Haapanen and Rantala, 1992; O’Gara et al., 1994; Denk and Magee, 1996; Rohrich et al., 1996, 2000; Marrinan et al., 1998; Ysunza et al., 1998; Kirschner et al., 2000; Sandberg et al., 2002; Rohrich and Gosman, 2004; Hardin-Jones and Jones, 2005)....
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References
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TL;DR: In this paper, the role and limitations of retrospective investigations of factors possibly associated with the occurrence of a disease are discussed and their relationship to forward-type studies emphasized, and examples of situations in which misleading associations could arise through the use of inappropriate control groups are presented.
Abstract: The role and limitations of retrospective investigations of factors possibly associated with the occurrence of a disease are discussed and their relationship to forward-type studies emphasized. Examples of situations in which misleading associations could arise through the use of inappropriate control groups are presented. The possibility of misleading associations may be minimized by controlling or matching on factors which could produce such associations; the statistical analysis will then be modified. Statistical methodology is presented for analyzing retrospective study data, including chi-square measures of statistical significance of the observed association between the disease and the factor under study, and measures for interpreting the association in terms of an increased relative risk of disease. An extension of the chi-square test to the situation where data are subclassified by factors controlled in the analysis is given. A summary relative risk formula, R, is presented and discussed in connection with the problem of weighting the individual subcategory relative risks according to their importance or their precision. Alternative relative-risk formulas, R I , R2, Ra, and R4/ which require the calculation of subcategory-adjusted proportions ot the study factor among diseased persons and controls for the computation of relative risks, are discussed. While these latter formulas may be useful in many instances, they may be biased or inconsistent and are not, in fact, overages of the relative risks observed in the separate subcategories. Only the relative-risk formula, R, of those presented, can be viewed as such an average. The relationship of the matched-sample method to the subclassification approach is indicated. The statistical methodolo~y presented is illustrated with examples from a study of women with epidermoid and undifferentiated pulmonary ccrclnomc.e-J. Nat. Cancer Inst, 22: 719748, 1959.
14,433 citations
"Velopharyngeal function in nonsyndr..." refers methods in this paper
...The age at repair was coded into clinically relevant age groups (8 to 10 months, 11 to 13 months, 14 to 16 months, and 16 months and older) and the resulting ordinal measure of the proportion of patients needing a pharyngeal flap in each period was tested for a significant linear association over time (Mantel and Haenzel, 1959)....
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Journal Article•
TL;DR: A sample of 1,600 cephalometric radiographs of 538 males with complete unilateral cleft lip and palate was contributed by a total of 15 Centers around the world for the purpose of determining the effects on facial growth of manipulative and surgical treatment.
Abstract: A sample of 1,600 cephalometric radiographs of 538 males with complete unilateral cleft lip and palate was contributed by a total of 15 Centers around the world for the purpose of determining the effects on facial growth of manipulative and surgical treatment. All radiographs were traced, digitized, and analyzed in the Craniofacial Center of The Hospital For Sick Children. A series of seven papers presents the findings. The first paper describes the sample and methodology, surveys the entire sample for differences from the noncleft population, and establishes the range of variability within the sample attributable to variations in treatment. Notable differences between cleft and noncleft samples were in the maxillary complex and mandibular posture. Differences within the cleft sample attributable to the treatment received were also in the maxillary complex and mandibular posture.
416 citations
TL;DR: The supposition that earlier palatal repair results in more normal speech development was demonstrated and the stage of each child's phonemic development should be considered if maximum speech potential is to be achieved and if speech development is to parallel normal noncleft peers.
Abstract: Speech production and age at palatal repair were investigated in 80 cleft palate children. Children whose palates were repaired prior to the onset of speech production demonstrated significantly better speech than those whose palates were repaired between 12 and 27 months of age. The supposition that earlier palatal repair results in more normal speech development was, in fact, demonstrated in these cases. Rather than using chronologic age alone as the deciding factor in determining timing of initial palatal repair, the stage of each child's phonemic development should be considered if maximum speech potential is to be achieved and if speech development is to parallel normal noncleft peers. Determining this stage of development through early speech and language evaluations, beginning at 6 months of age, thus becomes an essential component in the habilitation of children with cleft palate. Continued research is needed to ensure against giving the obtainment of early speech normalcy disproportionate emphasis over craniofacial growth considerations. To this end, continued cooperative research between surgeons and speech pathologists is imperative in order to base these important decisions on substantiated findings.
258 citations