Speech Outcomes of 10-year-old Children after Early Palatoplasty Using Presurgical Orthodontics at 6 Months of Age.

OBJECTIVE: We aimed to assess whether patients who underwent early palatoplasty have normal speech. METHODS: 19 patients with unilateral cleft lip and palate were enrolled in this study. At 6 months of age, we performed simultaneous lip, maxilla, and palate repair using presurgical orthodontics. Speech development was assessed by evaluating velopharyngeal function (VPF) and development of articulation for 10 years. RESULTS: No articulation disorders were observed after 4 years of age. Although palatalized articulation was evidently temporary in 3 cases before 4 years of age, all patients recovered without any speech training. Normal VPF rates were as follows: at 4 and 7 years of age 78.9% (n = 15), 10 years of age 73.7% (n = 4). 10 patients temporarily presented with mild VPI after 5 years of age although they had a normal VPF until 4 years of age. CONCLUSION: Early palatoplasty after narrowing the cleft palate using presurgical orthodontics is beneficial for development of articulation. The rate of normal VPF did not decrease over the years.

Effect of One-Stage versus Two-Stage Palatoplasty on Hypernasality and Fistula Formation in Children with Complete Unilateral Cleft Lip and Palate: A Randomized Controlled Trial.

BACKGROUND: Is one-stage or two-stage palatoplasty more effective for preventing fistula formation and hypernasality in patients with complete unilateral cleft lip and palate? METHODS: This parallel blocked randomized controlled trial included 100 patients with nonsyndromic complete unilateral cleft lip and palate with a repaired cleft lip, divided into two equal groups. Group A had one-stage palatoplasty patients at age 12 to 13 months while group B had two-stage palatoplasty patients with soft palatoplasty at age 12 to 13 months and hard palatoplasty at age 24 to 25 months. Presence of a fistula was tested clinically at 3 years and speech was tested using nasometry and perceptual analyses at 6 years. Group C consisted of noncleft controls (n = 20, age 6 years) for speech using nasometry. Fistula rates, hypernasality ratings, and nasalance scores were compared between groups A and B. Nasometry recordings of groups A and B were compared with control group C. RESULTS: There was no difference in fistula rates between groups A and B (p = 0.409; 95 percent CI, 0.365 to 11.9). Mean nasalance scores of group A showed higher nasalance than group B (p = 0.006; 95 percent CI, 1.16 to 6.53). Perceptual analysis showed no difference between groups A and B (p = 0.837 and p = 1.000). Group A showed higher mean nasalance than group C (p = 0.837 and p = 1.000), whereas group B showed no difference (p = 0.088; 95 percent CI, -0.14 to 2.02). CONCLUSIONS: There was no difference in fistula rates between groups. Nasalance was slightly higher in patients in the one-stage palatoplasty group than two-stage palatoplasty group, but the difference was not clinically significant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Puntos de aproximación de pilares en amigdalectomía pediátrica / Pillars´ approach suture points in pediatric tonsillectomy / Pontos de abordagem dos pilares na tonsilectomia pediátrica

INTRODUCCIÓN: A lo largo de los años, varias técnicas de amigdalectomía han sido desarrolladas y modificadas con el fin de reducir su morbimortalidad. Diversos estudios han comparado estas técnicas, no habiendo consenso en cuanto al método con mejores resultados. El objetivo de nuestro trabajo es describir la técnica personal de amigdalectomía y analizar la frecuencia de sangrado y el desarrollo de insuficiencia velopalatina post-quirúrgica en la cirugía con aproximación de pilares. MATERIAL Y MÉTODO: Estudio descriptivo, prospectivo. Se incluyeron pacientes operados de amigdalectomía con amigdalotomo de Daniels, de 3 a 15 años, en el período comprendido desde febrero de 2017 a febrero de 2018, en el sistema de salud Malvinas Argentinas. Se interrogó por sintomatología de sangrado e insuficiencia velopalatina mediante una encuesta de elaboración propia a la semana y al mes post-quirúrgico...

INTRODUCTION: Throughout the years, several tonsillectomy techniques have been developed and modified in order to reduce their morbidity and mortality. Several studies have compared these techniques, and there is no consensus regarding the method with better results. The objective of our study is to describe the personal technique of tonsillectomy and analyze the frequency of bleeding and development of post-surgical velopalatine insufficiency in surgery with abutment approach. MATERIAL AND METHOD: Descriptive, prospective study. We included patients undergoing tonsillectomy with Daniels, from between 3 and 15 years old, from February 2017 to February 2018, in the Malvinas Argentinas hospital. They were interrogated for symptomatology of bleeding and velopalatine insufficiency by through of a self-developed questionnaire one week and one month after surgery…

INTRODUÇÃO: Ao longo dos anos, várias técnicas de amigdalectomia foram desenvolvidas e modificadas para reduzir sua morbidade e mortalidade. Diversos estudos compararam essas técnicas, não havendo consenso em relação ao método com melhores resultados. O objetivo do nosso trabalho é descrever a técnica pessoal de amigdalectomia e analisar a frequência de sangramento e o desenvolvimento de insuficiência velopalatina pós-cirúrgica em cirurgia com abordagem de abutment. MATERIAL E MÉTODO: Estudo descritivo, prospectivo. Foram incluídos pacientes submetidos à tonsilotomia com tonsilectomia de Daniels, de 3 a 15 anos, no período de fevereiro de 2017 a fevereiro de 2018, no sistema de saúde Malvinas Argentinas. Foi interrogado por sintomatologia de hemorragia e insuficiência velopalatine por meio de um questionário autodevelado durante a semana e o mês pós-cirúrgico...

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 4. Speech outcomes in 5-year-olds - velopharyngeal competency and hypernasality.

BACKGROUND AND AIM: Adequate velopharyngeal function and speech are main goals in the treatment of cleft palate. The objective was to investigate if there were differences in velopharyngeal competency (VPC) and hypernasality at age 5 years in children with unilateral cleft lip and palate (UCLP) operated on with different surgical methods for primary palatal repair. A secondary aim was to estimate burden of care in terms of received additional secondary surgeries and speech therapy. DESIGN: Three parallel group, randomised clinical trials were undertaken as an international multicentre study by 10 cleft teams in five countries: Denmark, Finland, Sweden, Norway, and the UK. METHODS: Three different surgical protocols for primary palatal repair were tested against a common procedure in the total cohort of 448 children born with a non-syndromic UCLP. Speech audio and video recordings of 391 children (136 girls, 255 boys) were available and perceptually analysed. The main outcome measures were VPC and hypernasality from blinded assessments. RESULTS: There were no statistically significant differences between the prevalences in the arms in any of the trials. VPC: Trial 1, A: 58%, B: 61%; Trial 2, A: 57%, C: 54%; Trial 3, A: 35%, D: 51%. No hypernasality: Trial 1, A: 54%, B: 44%; Trial 2, A: 47%, C: 51%; Trial 3, A: 34%, D: 49%. CONCLUSIONS: No differences were found regarding VPC and hypernasality at age 5 years after different methods for primary palatal repair. The burden of care in terms of secondary pharyngeal surgeries, number of fistulae, and speech therapy visits differed. TRIAL REGISTRATION: ISRCTN29932826.

Technical details of rotation palatoplasty in patients with Veau 1 cleft palate.

In cleft palate repair, elongation of the cleft toward the posterior is critically important to prevent velopharyngeal insufficiency. The purpose of many cleft palate repair techniques has been to ensure this elongation. Rotational palatoplasty is a recent cleft palate repair technique. In this technique, the soft palate is transformed into a rotational flap to allow the palate to elongate in patients with a cleft palate. This technique, which is used in all types of cleft palate and velopharyngeal insufficiency, is easy to use, practical, and efficient, especially in patients with a Veau 1 cleft palate. The aim of this study was to explain the technical details of the rotation palatoplasty technique in Veau 1 cleft palate with the aid of figures.

[Functional soft-palate reconstruction with radial forearm free flaps]. / Funktionelle Weichgaumen-rekonstruktion mit Radialislappen.

Oropharyngeal cancer of the soft palate is a therapeutic challenge. This is due to crucial importance of velopharyngeal competence for articulation and swallowing. Patient counseling must present the whole therapeutic spectrum in order to receive informed consent. Basically, in primary therapy of oropharyngeal cancer multimodal concepts have to be considered including surgical resection and radiochemotherapy. With regard to the occasional difficulties predicting the functional outcome after primary therapy the ladder of reconstructive options has to be discussed a priori. Among numerous pedicled flaps the radial forearm free flap nowadays belongs definitely in the surgical armoury, which offers almost ideal reconstructive possibilities after extensive resections. This implies some additional aspects in pre- and postoperative workup that are reviewed in this article.

Speech outcome after early repair of cleft soft palate using Furlow technique.

OBJECTIVE: The earlier closure of palatal cleft is the better the speech outcome and the less compensatory articulation errors, however dissection on the hard palate may interfere with facial growth. In Furlow palatoplasty, dissection on the hard palate is not needed and surgery is usually limited to the soft palate, so the technique has no deleterious effect on the facial growth. The aim of this study was to assess the efficacy of Furlow palatoplasty technique on the speech of young infants with cleft soft palate. METHODS: Twenty-one infants with cleft soft palate were included in this study, their ages ranged from 3 to 6 months. Their clefts were repaired using Furlow technique. The patients were followed up for at least 4 years; at the end of the follow up period they were subjected to flexible nasopharyngoscopy to assess the velopharyngeal closure and speech analysis using auditory perceptual assessment. RESULTS: Eighteen cases (85.7%) showed complete velopharyngeal closure, 1 case (4.8%) showed borderline competence, and 2 cases (9.5%) showed borderline incompetence. Normal resonance has been attained in 18 patients (85.7%), and mild hypernasality in 3 patients (14.3%), no patients demonstrated nasal emission of air. Speech therapy was beneficial for cases with residual hypernasality; no cases needed secondary corrective surgery. CONCLUSION: Furlow palatoplasty at a younger age has favorable speech outcome with no detectable morbidity.

Bassoonists' medical problems-current state of knowledge.

Specific musical instruments can be a source of physical problems to their players. Based on reviews of the literature and personal experience, this paper summarizes current knowledge of problems affecting musicians who play instruments in the bassoon family (including the bassoon, contrabassoon, and several other instruments). Prevalence rates are higher in reports of surveys (ranging up to 86%), compared to clinical reports of patients seen and treated. Significant risk factors include young age, small body size, female gender, and use of large instruments. Problems unique to bassoonists are rare; most physical difficulties also are seen in general musculoskeletal clinical practices and in musicians playing all types of instruments. The left upper extremity is more commonly affected by overuse-related conditions in bassoonists. Non-playing-related problems are equally important for consideration (such as degenerative disorders and acute trauma), since they also affect practice and performance. Little experimental data exist to validate current and widely-held principles of treatment, rehabilitation, and prevention.

Functional anatomy of the soft palate applied to wind playing.

Wind players must be able to sustain high intraoral pressures in order to play their instruments. Prolonged exposure to these high pressures may lead to the performance-related disorder velopharyngeal insufficiency (VPI). This disorder occurs when the soft palate fails to completely close the air passage between the oral and nasal cavities in the upper respiratory cavity during blowing tasks, this closure being necessary for optimum performance on a wind instrument. VPI is potentially career threatening. Improving music teachers' and students' knowledge of the mechanism of velopharyngeal closure may assist in avoiding potentially catastrophic performance-related disorders arising from dysfunction of the soft palate. In the functional anatomy of the soft palate as applied to wind playing, seven muscles of the soft palate involved in the velopharyngeal closure mechanism are reviewed. These are the tensor veli palatini, levator veli palatini, palatopharyngeus, palatoglossus, musculus uvulae, superior pharyngeal constrictor, and salpingopharyngeus. These muscles contribute to either a palatal or a pharyngeal component of velopharyngeal closure. This information should guide further research into targeted methods of assessment, management, and treatment of VPI in wind musicians.

Partial adenoidectomy by suction diathermy in children with cleft palate, to avoid velopharyngeal insufficiency.

OBJECTIVES: Adenoidectomy is indicated for the relief of paediatric nasal obstruction, sleep-disordered breathing and otitis media with effusion (OME). Velopharyngeal insufficiency (VPI) is a rare complication. The main risk factor is the presence of pre-existing velopharyngeal closure-impaired mechanisms, including submucosal or overt cleft palate. Despite possible benefits, adenoidectomy is frequently withheld in such children to avoid VPI. This study aims to demonstrate the efficacy and safety of partial adenoidectomy using suction diathermy in children who previously underwent overt cleft palate repair during infancy, to allow selective resection of tissue and symptom resolution without producing VPI. METHODS: Since 1994, 18 patients with previously corrected overt cleft palate have undergone partial adenoidectomy at this centre, for the treatment of nasal obstruction or sleep-disordered breathing, with or without OME. Three had existing VPI following their cleft correction surgery. Selective resection of the adenoid was performed transorally under indirect vision, using a malleable suction coagulator. This allowed exposure of the posterior choanae, leaving the remaining adenoid bulk intact. RESULTS: Patients were followed up at 4 weeks, and subsequently at regular intervals (total follow up 30-180 months, median 92 months), including perceptual speech assessment in all cases. All demonstrated symptomatic improvement with respect to the original indications for surgery. None developed worsening hypernasal speech or other features of VPI, and there were no cases of symptomatic adenoidal re-growth. CONCLUSIONS: Partial adenoidectomy, employing a variety of methods, has been used successfully in children with submucosal cleft palate. This study demonstrates the safe and effective use of suction diathermy to enable partial adenoidectomy in children who have previously undergone surgical correction of overt cleft palate, allowing symptom resolution without producing VPI.

Distraction osteogenesis in the management of severe maxillary hypoplasia in cleft lip and palate patients.

The aim of this study was to systematically review literature reporting on the use of external distraction osteogenesis (DO) and internal DO in the treatment of severe maxillary hypoplasia in cleft and palate patients. Literature research has been performed using the PubMed database of the National Library of Medicine and National Institutes of Health from 1966 to August 2007. We used cleft lip and palate and distraction osteogenesis as key words. Of the 104 articles found, we only considered the Anglo-Saxon literature, which reported on the correction of the maxillary hypoplasia with DO techniques. A total of 32 studies reported on anteroposterior external DO (27 studies on rigid external device and 5 on face mask), 17 studies reported on anteroposterior internal DO, and 3 studies reported on transverse internal DO have been retained for this review. Despite the heterogeneity and methodological limitations of most of the studies, results showed that external DO with rigid external device and internal DO resulted to be a more reliable and accurate technique than the face mask in the management of severe maxillary hypoplasia in patients with cleft lip and palate. The current review demonstrated that external and internal DO in the treatment of severe maxillary hypoplasia in cleft and palate patients (1) is a reproducible and valuable alternative to standard orthognathic surgery procedures, (2) allows for a global improvement in facial aesthetic, (3) allows a maxillary correction in patients during the period of mixed dentition, and (4) allows either for an unchanged or better velopharyngeal function.

Estudo morfométrico comparativo entre três técnicas de palatoplastia para alongamento do palato mole / comparring three palatoplasty techniques to elongate the soft palate: a morphometric study

A palatoplastia é o tratamento indicado para correção da fissura palatina e a busca pela técnica que proporcione melhores resultados é o objetivo permanente. Está claro que fonação é a melhor análise da eficácia de uma técnica, mas há outros fatores importantes, como o reposicionamento anatômico das estruturas e a reprodutibilidade. Comparar morfometricamente o reposicionamento conseguido por três técnicas cirúrgicas diferentes de palatoplastia, por meio de medidads intra-operatórias e pós-operatórias imediatas. Foram operados, por um mesmo cirurgião, 30 pacientes portadores de fissura lábio-palatina unilateral, com idades que variam entre 12 e 24 meses, sem cirurgias prévias no palato mole, sem outras co-morbidades, sendo divididos me três grupos: Grupo 1 - Técnica de Furlow; Grupos 2 - Técnica de Veau-Wardill-Kilner com veloplastia; Grupo 3 - Técnica de Veau- Wardill- Kilner com veloplastia e plástica em Z na mucosa nasal. Duas destas técnicas (G1 e G2) são consagradas pelo uso, e a terceira (G3) é uma modificação destas sugeridas pelo autor. Observou-se que as três técnicas alongam o palato, com uma tendência maior no Grupo 3, sendo o conjunto muscular mais retroposicionado, também nos pacientes do Grupo 3, enquanto o índice de complicações foi maior nos pacientes operados pela técnica de Furlow. Os achados clínicos perioperatórios e morfométricos desses estudos sugerem que a técnica de Veau-Wardill-Kilner com veloplastia e plástica em Z na mucosa nasal é uma alternativa viável e promissora para o tratamento da fissura palatina, e a avaliação fonológica destes pacientes, em longo prazo, será a resposta final para a sua aplicabilidade clínica.

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth.

BACKGROUND: Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth. METHODS: A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis. RESULTS: Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm. CONCLUSION: The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Does palatal muscle reconstruction affect the functional outcome of cleft palate surgery?

BACKGROUND: This study was designed to compare two-layer palatoplasty (Wardill-Kilner V-Y pushback technique) without intravelar veloplasty versus three-layer palatoplasty (Kriens technique) with intravelar veloplasty with regard to postoperative functional outcome of eustachian tube and velopharyngeal competence. METHODS: A prospective cohort study was conducted enrolling 70 patients with nonsyndromic cleft palate (except submucous type of cleft) over a period of 2 years. They were divided into two main groups according to the type of cleft palate: group A (Veau class II) included 32 patients and group B (Veau class I) included 38 patients. In each group, Wardill-Kilner palatoplasty (two-layer repair without intravelar veloplasty) versus Kriens palatoplasty (three-layer repair with intravelar veloplasty) was randomly selected for patients. RESULTS: For the three-layer palatoplasty in both groups, there was a greater tendency for resolution of secretory otitis media in the early postoperative period, less time required for extrusion of the grommet tube, and a lower incidence of recurrent secretory otitis media. The incidence of postoperative velopharyngeal incompetence was greater with two-layer palatoplasty group. The incidence of palatal fistula was greater with three-layer palatoplasty. CONCLUSIONS: Palatal muscle reconstruction in cleft palate patients confers better functional results regarding velopharyngeal competence and eustachian tube function. Although the overall incidence of postoperative palatal fistula is within the accepted range, the incidence of fistula is higher in the palatal muscle reconstruction subgroup. Future studies are required that include a larger number of patients.

Endoscopic adenoidectomy in children with submucosal cleft palate.

OBJECTIVE: To determine the safety and effectiveness of endoscopic partial adenoidectomy for the treatment of nasal obstruction in children with submucosal cleft palate. METHODS: The medical files of children with symptoms of nasal obstruction and submucosal cleft palate who underwent partial transnasal endoscopic adenoidectomy from January 1993 to December 2003 were reviewed. Operative complications, relief of nasal obstruction, presence of postoperative velopharyngeal insufficiency were recorded. RESULTS: There were no operative complications. All the children had relief of nasal obstruction. Velopharyngeal insufficiency was not observed during the postoperative follow-up. CONCLUSIONS: Endoscopic partial adenoidectomy is a safe and effective procedure for the treatment of nasal obstruction in children with submucosal cleft palate.

Surgery of the cleft lip and nose--the GOStA approach.

The technique for primary correction of the cleft lip and nose, as practised by The North Thames Cleft Lip and Palate Centre at Great Ormond Street Hospital/St Andrew's Centre (GOStA) has evolved over 28 years of personal experience. It is an amalgamation of techniques developed by many others with some personal modifications. Patients are routinely audited at 5, 10, 15 and 20 years and outcomes evaluated and compared with other centres where possible. Secondary surgery of lip and nose is based on the same principles of anatomical reconstruction used in the primary surgery.

[Effects of maxillary distraction osteogenesis on the velopharyngeal configuration of cleft palate patients].

OBJECTIVE: To study the effects of internal maxillary distraction osteogenesis(DO) on the velopharyngeal configuration of cleft palate patients. METHODS: Ten patients with severe maxillary hypoplasia secondary to cleft lip and palate patients (7 males and 3 females, average age 20.1 years old) had undertaken high step LeFort I osteotomy, and internal maxillary distraction devices were applied to advance the maxilla. Before surgery, when DO was completed and 6 months after DO was completed, oriented lateral cephalograms at rest position of each patient were taken, and 6 measure indexes of velopharyngeal configuration were collected and analyzed. RESULTS: All patients had successfully accomplished maxillary DO and the maxilla had been averagely advanced 11.3 mm. PNS-PhW, C-PhW, UL and ANS-PNS-T had all significantly increased, and UD had significantly decreased when DO was completed and 6 months after DO was completed as compared with pre-surgery. No significant linear correlation was found between maxilla advancement distance and velopharyngeal configuration changes. CONCLUSION: Correction of maxillary hypoplasia secondary to cleft palate surgery by using internal maxillary DO can increase the velopharyngeal cavity depth, and may impair velopharyngeal competence, but the compensatory changes of velopharyngeal soft tissue can alleviate this impairment to certain extent.