Pharyngoplasty for Speech Disorders Following Brain Injury.

INTRODUCTION: Dysarthria is one of the commonest neurological speech disorders resulting from brain injury. However, hypernasality commonly co-exists in this subgroup of patients and is commonly overlooked. The authors aim to investigate the merit of surgery in improving hypernasality and speech intelligibility in patients with a mixed pattern of dysarthria and hypernasality secondary to brain injury. MATERIALS AND METHODS: Data was collected from the regional plastic surgery unit over a 10-year period. All patients who underwent a pharyngoplasty for speech improvement following total brain injury from either a traumatic injury or a cerebrovascular accident were included. Patients were followed up post-operatively to assess; improvement in speech rehabilitation, complications and the need for surgical revision. RESULTS: Six patients had a pharyngoplasty for speech improvement. Either a Hynes or Jackson pharyngoplasty was performed, with one patient requiring a hemi-pharyngoplasty. Post-operatively, 1 patient experienced self-limiting sleep apnea which resolved within 1 month. One patient developed obstructive symptoms and required revision. Overall, 83% of patients had clear improvement in speech intelligibility and articulation. CONCLUSIONS: The authors have shown that surgical intervention, in the form of a pharyngoplasty, is an effective method of improving speech intelligibility and articulation, by improving hypernasality and restoring communication in this cohort of patients. The aim of this paper is to highlight this option to colleagues and to heighten the awareness that many patients with a total brain injury have a mixed pattern of speech disturbance and not solely the dysarthria that is attributed to this condition.

Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study.

PURPOSE: Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP. METHODS: We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital. RESULTS: For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively. CONCLUSIONS: Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.

Course Review: Newcastle Surgical Training Centre Cadaveric Speech and Palate Surgery Course.

The Newcastle Surgical Training Centre Cadaveric Speech and Palate Surgery Course is an interactive and practical 1-day course for plastic surgery, ear, nose and throat surgery, and maxillofacial surgery trainees wishing to develop skills in cleft palate and speech surgery. The course is delivered by an expert faculty with delegates attending from the United Kingdom and abroad and costs £495 (US $650) to attend. This review provides information and an evaluation of the course.

VALIDATION OF THE DIAGNOSTIC AND TREATMENT COMPLEX FOR PATIENTS WITH ORTHOGNATHIC DEFORMITIES AND PHONETIC DISORDERS.

Recently, there has been a tendency for the growth of dentognathic deformities of various origins, accompanied by phonetic abnormalities. Aim - to increase the effectiveness of orthodontic treatment of dentognathic deformities, accompanied by phonetic disorders, by developing and justifying a set of diagnostic and therapeutic measures based on a multidisciplinary approach. The influence of the state of ENT organs on the formation of dentognathic deformities and phonetic disturbances is studied in 155 children. A clinical dental examination and orthodontic treatment is performed in 82 patients aged 6-12 years. Individual corrective speech therapy work has been carried out to overcome the defects of the phonological side of speech. A certain pathological "chain" of cause-effect relationships of dentognathic deformities with phonetic disorders and diseases of the ENT organs became the basis for a multidisciplinary approach to solving the problems identified. The qualitative and quantitative dependence of sound deterioration on the type of orthognathic deformities is established. A complex of diagnostic and therapeutic measures for patients with dental deformities accompanied by phonetic disorders, consisting of motivational, diagnostic and therapeutic blocks, has been developed and introduced into practice. The proposed complex of diagnostic and treatment measures made it possible to increase the efficiency of orthodontic treatment of children with dentognathic deformities with disturbances of sound pronunciation depending on the type of bite by means of a multidisciplinary approach involving an otolaryngologist, speech therapist, children's therapist and surgeon, which was confirmed in 86.6% of patients by the improvement of electromyography, anthropometric measurements of scanned models of jaws, cephalometry; the analysis of cone-beam computed tomography data showed a significant increase in the upper respiratory tract volume by 53.8±4.2%.

Secondary Palatal Elongation: Improvement in Speech Quality.

Cleft palate is one of the challenging problems in the field of craniofacial surgery. In particular, the conventional methods of bilateral and severe cleft palate repairs have failed to achieve normal speech. In most instances, secondary procedures such as pharyngoplasty and pharyngeal flap surgery are performed to improve speech.This study introduces secondary palatal elongation (SPE) as a new approach to cleft palate repair. The patients included usually had a short palate and unrepaired palatal muscles. The authors' procedure involved dissecting the previously repaired palatal mucosa and pushing back and cutting the nasal mucosa of the palate horizontally and further pushing it back. Then, 1 or 2 buccal mucosal flaps were used to repair the nasal mucosal defect of the palate. In case of unrepaired veloplasty from the primary surgery, the levator muscles were dissected and sutured together to perform veloplasty. The range of palatal elongation was 15 to 25 mm.Secondary palatal elongation has been performed on 17 patients since 2007 with a high rate of speech improvement. Based on this 9-year experience with performing SPE, SPE is a radical anatomic technique of palatal elongation as compared with pharyngoplasty and pharyngeal flap surgery. All 17 patients who underwent SPE showed improvement in speech, from very poor to poor speech and from normal to good speech.

[Surgical treatment of eloquent brain area tumors using neurophysiological mapping of the speech and motor areas and conduction tracts]. / Khirurgicheskoe lechenie opukholei funktsional'no znachimykh zon golovnogo mozga s primeneniem metoda neirofiziologicheskogo kartirovaniya rechevykh, motornykh zon i provodyashchikh putei.

AIM: To evaluate the efficacy of intraoperative neurophysiological mapping in removing eloquent brain area tumors (EBATs). MATERIAL AND METHODS: Sixty five EBAT patients underwent surgical treatment using intraoperative neurophysiological mapping at the Pirogov National Medical and Surgical Center in the period from 2014 to 2015. On primary neurological examination, 46 (71%) patients were detected with motor deficits of varying severity. Speech disorders were diagnosed in 17 (26%) patients. Sixteen patients with concomitant or isolated lesions of the speech centers underwent awake surgery using the asleep-awake-asleep protocol. Standard neurophysiological monitoring included transcranial stimulation as well as motor and, if necessary, speech mapping. The motor and speech areas were mapped with allowance for the preoperative planning data (obtained with a navigation station) synchronized with functional MRI. In this case, a broader representation of the motor and speech centers was revealed in 12 (19%) patients. During speech mapping, no speech disorders were detected in 7 patients; in 9 patients, stimulation of the cerebral cortex in the intended surgical area induced motor (3 patients), sensory (4), and amnesic (2) aphasia. In the total group, we identified 11 patients in whom the tumor was located near the internal capsule. Upon mapping of the conduction tracts in the internal capsule area, the stimulus strength during tumor resection was gradually decreased from 10 mA to 5 mA. Tumor resection was stopped when responses retained at a stimulus strength of 5 mA, which, when compared to the navigation data, corresponded to a distance of about 5 mm to the internal capsule. Completeness of tumor resection was evaluated (contrast-enhanced MRI) in all patients on the first postoperative day. RESULTS: According to the control MRI data, the tumor was resected totally in 60% of patients, subtotally in 24% of patients, and partially in 16% of patients. In the early postoperative period, the development or aggravation of a motor neurological deficit was detected in 18 patients: worsening of paresis was observed in 11 patients, and worsening of speech disorders occurred in 7 patients. After 4 months, motor and speech disorders regressed in 10 patients. Therefore, a persistent neurological deficit developed after surgery in 8 (12%) patients (motor deficit in 5 cases; speech deficit in 3 cases). CONCLUSION: Resection of eloquent brain area tumors using intraoperative neurophysiological monitoring enables complete resection of the tumor at a low risk of persistent neurological deficits, which ultimately improves the patient's life prognosis.

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

BACKGROUND: Velopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. METHODS: The cleft-craniofacial database of the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. RESULTS: A total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0-22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1-104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0-23.0) (SD, 6.13) and 4.11 (range, 0.0-23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, -9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0-26) (SD, 6.70) and 3.11 (range, 0.0-27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was -3.26 (range, -23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0-26) (SD, 6.60) and 3.39 (range, 0.0-27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was -2.26 (range, -23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. CONCLUSIONS: Although there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

[Improving the speech with a prosthetic construction]. / Een prothetische constructie ter verbetering van de spraak.

A 12-year-old boy had problems with his speech due to a defect in the soft palate. This defect was caused by the surgical removal of a synovial sarcoma. Testing with a nasometer revealed hypernasality above normal values. Given the size and severity of the defect in the soft palate, the possibility of improving the speech with speech therapy was limited. At a centre for special dentistry an attempt was made with a prosthetic construction to improve the performance of the palate and, in that way, the speech. This construction consisted of a denture with an obturator attached to it. With it, an effective closure of the palate could be achieved. New measurements with acoustic nasometry showed scores within the normal values. The nasality in the speech largely disappeared. The obturator is an effective and relatively easy solution for palatal insufficiency resulting from surgical resection. Intrusive reconstructive surgery can be avoided in this way.

Effectiveness of tongue-tie division for speech disorder in children.

BACKGROUND: The aim of this study was to determine the effectiveness of tongue-tie division (frenuloplasty/ frenulotomy) for speech articulation disorder in children with ankyloglossia (tongue-tie). METHODS: Articulation test was done in five children (3-8 years old) with speech problems who underwent tongue-tie division. The test consisted of 50 pictures of common Japanese words with 2-3 syllables. The patients were interviewed by a speech therapist and asked to pronounce what the picture card showed. Misarticulations of substitution, omission, and distortion were assessed. The preoperative results were compared with postoperative examinations at 1 month, 3-4 months, and 1-2 years. RESULTS: Nineteen substitutions that were observed in four patients preoperatively decreased to 10 in three patients at 1 month, 7 in three patients at 3-4 months, and 1 in one patient at 1-2 years postoperatively. Five omissions that were observed in four patients preoperatively decreased to 3 in three patients at 1 month, 2 in two patients at 3-4 months, and 1 in one patient at 1-2 years postoperatively. Thirteen distortions that were observed in five patients preoperatively decreased to 8 in four patients at 3-4 months but increased to 11 in three patients at 1-2 years postoperatively. CONCLUSIONS: Substitution and omission improved relatively early after tongue-tie division and progressed to distortion, which is a less-impaired form of articulation disorder. Thus, distortion required more time for improvement and remained a defective speaking habit in some patients.

Total Closure of Enlarged Tracheoesophageal Puncture with Septal Button: Long-Term Results.

Tracheoesophageal puncture enlargement in laryngectomized patients is a significant problem due to complications such as aspiration pneumonia. There are several management methods including conservative and nonconservative techniques. A total closure of the enlarged tracheoesophageal puncture is needed in some cases when conservative approaches have failed. At this point, the insertion of a silicone septal button in the puncture site is a useful, inexpensive, and simple technique. The follow-up of 4 patients managed with this technique revealed satisfactory long-term results.

Improving speech outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow palatoplasty.

BACKGROUND: Velopharyngeal insufficiency occurs in a nontrivial number of cases following cleft palate repair. We hypothesize that a conversion Furlow palatoplasty allows for long-term correction of VPI resulting from a failed primary palate repair, obviating the need for pharyngoplasty and its attendant comorbidities. METHODS: A retrospective review of patients undergoing a conversion Furlow palatoplasty between 2003 and 2010 was performed. Patients were grouped according to the type of preceding palatal repair. Velopharyngeal insufficiency was assessed using Pittsburgh Weighted Speech Scale (PWSS). Scores were recorded and compared preoperatively and postoperatively at 3 sequential visits. RESULTS: Sixty-two patients met inclusion criteria and were grouped by preceding repair (straight-line repair (n = 37), straight-line repair with subsequent oronasal fistula (n = 14), or pharyngeal flap (n = 11). Median PWSS scores at individual visits were as follows: preoperative = 11, first postoperative = 3 (mean, 114.0 ± 6.7 days), second postoperative = 1 (mean, 529.0 ± 29.1 days), and most recent postoperative = 3 (mean, 1368.6 ± 76.9 days). There was a significant difference between preoperative and postoperative PWSS scores in the entire cohort (P < 0.001) with overall improvement, and post hoc analysis showed improvement between each postoperative visit (P < 0.05) with the exception of the second to the most recent visit. There were no differences between postoperative PWSS scores in the operative subgroupings (P > 0.05). Eight patients failed to improve and showed no differences in PWSS scores over time (P > 0.05). Patients with a PWSS score of 7 or greater (n = 8) at the first postoperative visit (0-6 months) displayed improvement at the most recent visit (P< 0.05). CONCLUSIONS: Conversion Furlow palatoplasty is an effective means for salvaging speech. Future studies should elucidate which factors predict the success of this technique following failed palate repair.

Velopharyngeal insufficiency, speech, and language impairment in craniofacial microsomia: a scoping review.

This review provides a comprehensive overview of the literature on velopharyngeal insufficiency, associated anomalies, and speech/language impairment in patients with craniofacial microsomia (CFM). A systematic search of the literature was conducted to identify records on VPI and speech impairment in CFM from their inception until September 2022 within the databases Embase, PubMed, MEDLINE, Ovid, CINAHL EBSCO, Web of Science, Cochrane, and Google Scholar. Seventeen articles were included, analysing 1,253 patients. Velopharyngeal insufficiency results in hypernasality can lead to speech impairment. The reported prevalence of both velopharyngeal insufficiency and hypernasality ranged between 12.5% and 55%, while the reported prevalence of speech impairment in patients with CFM varied between 35.4% and 74%. Language problems were reported in 37% to 50% of patients. Speech therapy was documented in 45.5% to 59.6% of patients, while surgical treatment for velopharyngeal insufficiency consisted of pharyngeal flap surgery or pharyngoplasty and was reported in 31.6% to 100%. Cleft lip and/or palate was reported in 10% to 100% of patients with CFM; these patients were found to have worse speech results than those without cleft lip and/or palate. No consensus was found on patient characteristics associated with an increased risk of velopharyngeal insufficiency and speech/language impairment. Although velopharyngeal insufficiency is a less commonly reported characteristic of CFM than other malformations, it can cause speech impairment, which may contribute to delayed language development in patients with CFM. Therefore, timely recognition and treatment of speech impairment is essential.

[Short lingual frenulum]. / Kireä kielijänne.

Short lingual frenulum is a common structural abnormality with unknown mechanisms of origination. The frequency of occurrence among newborn infants can be as high as 4%. Short lingual frenulum may cause problems, if it restricts the movements of the tongue. Therapeutic indications for short lingual frenulum in newborn infants are mainly breastfeeding problems, whereas in children of preschool age and older the indication is defective pronunciation.

Surgical improvement of speech disorder caused by amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive debilitating neurological disease. ALS disturbs the quality of life by affecting speech, swallowing and free mobility of the arms without affecting intellectual function. It is therefore of significance to improve intelligibility and quality of speech sounds, especially for ALS patients with slowly progressive courses. Currently, however, there is no effective or established approach to improve speech disorder caused by ALS. We investigated a surgical procedure to improve speech disorder for some patients with neuromuscular diseases with velopharyngeal closure incompetence. In this study, we performed the surgical procedure for two patients suffering from severe speech disorder caused by slowly progressing ALS. The patients suffered from speech disorder with hypernasality and imprecise and weak articulation during a 6-year course (patient 1) and a 3-year course (patient 2) of slowly progressing ALS. We narrowed bilateral lateral palatopharyngeal wall at velopharyngeal port, and performed this surgery under general anesthesia without muscle relaxant for the two patients. Postoperatively, intelligibility and quality of their speech sounds were greatly improved within one month without any speech therapy. The patients were also able to generate longer speech phrases after the surgery. Importantly, there was no serious complication during or after the surgery. In summary, we performed bilateral narrowing of lateral palatopharyngeal wall as a speech surgery for two patients suffering from severe speech disorder associated with ALS. With this technique, improved intelligibility and quality of speech can be maintained for longer duration for the patients with slowly progressing ALS.

[Pediatric tracheotomy]. / Tracheotomie bei Kindern.

Tracheotomies are increasingly performed in the pediatric population in the context of long-term treatment. There are specific pediatric aspects that require attention: differences in the pediatric compared to adult anatomy, the necessity for later reconstruction and the negative impact on oral feeding and speech development. Caring for pediatric tracheostomy patients is more challenging compared to adult patients. This needs to be addressed by a dedicated team during both in- and outpatient treatment.

Nasometric and aerodynamic outcome analysis of pharyngeal flap surgery for the management of velopharyngeal insufficiency.

OBJECTIVE: This study aimed to evaluate the effectiveness of pharyngeal flap surgery (PFS) for the management of velopharyngeal insufficiency in cleft lip/palate patients and to assess the impact of age at surgery, surgeon's skills, and postoperative speech therapy on the outcomes. METHODS: Prospective preoperative and postoperative assessments were performed on 240 patients aged 6 to 57 years using nasometry and pressure-flow studies.This study was carried out in a quaternary hospital.This study was superiorly based on PFS.Speech nasalance scores were assessed by nasometry and velopharyngeal orifice area assessed by pressure-flow technique, 2 days before and 1 year after PFS, on average. Differences were considered significant when P < 0.05. RESULTS: Significant reduction in nasalance scores was observed in 68% of the cases, and improvement of velopharyngeal area was observed in 66%. Rates of 55% and 48%, respectively, were observed when complete resolution was considered. Higher success rates were observed in children (81%) compared with other age groups analyzed and in patients who had concluded postoperative speech therapy (86%). Results did not differ among surgeons. CONCLUSIONS: Pharyngeal flap surgery was shown to be effective in reducing nasalance scores and velopharyngeal area during speech for a significant number of patients. Complete resolution was observed in smaller number of cases. Age at surgery and postoperative speech therapy were relevant factors for treatment success.

Speech outcomes and velopharyngeal function after surgical treatment of velopharyngeal insufficiency in individuals with signs of velocardiofacial syndrome.

OBJECTIVE: The objective of the study was to analyze if individuals with velocardiofacial syndrome (VCFS) present the same characteristics of speech and velopharyngeal function (VPF) compared with patients with nonsyndromic submucous cleft palate, as well as to compare the effectiveness of palate surgery on the speech function and VPF between groups. METHODS: This was a prospective study performed at the Speech Therapy Sector and Physiology Laboratory, Hospital for Rehabilitation of Craniofacial Anomalies/University of São Paulo.The procedure performed was primary palatoplasty associated or not to superiorly based pharyngeal flap surgery.There were 50 patients with velopharyngeal insufficiency: 25 with signals of VCFS (VCFS group) and 25 without syndrome with submucous cleft palate (SMCP group).The hypernasality was scored by 3 examiners; nasalance was evaluated by nasometry, and VPF was assessed by the size of the velopharyngeal gap on the nasoendoscopy. The evaluations were conducted before and, in average, 18 months after surgery. RESULTS: Before surgery, the VCFS and SMCP groups presented similar speech function and VPF characteristics in all parameters, with no statistically significant differences. After surgery, there was reduction in the hypernasality, nasalance, and VPF in, respectively, 20%, 31%, and 36% of patients in the VCFS group and in 24%, 30%, and 30% in the SMCP group. Elimination/normalization of variables was obtained in 28%, 19%, and 8% of patients in the VCFS group and 20%, 40%, and 25% in the SMCP group, respectively, for hypernasality, nasalance, and VPF. There was no statistically significant difference between groups. CONCLUSIONS: Patients with VCFS presented similar speech function and VPF characteristics as patients with nonsyndromic SMCP. The surgery for velopharyngeal insufficiency correction was equally effective for the improvement and resolution of speech symptoms and VPF in patients with VCFS compared with the SMCP group.

Robin Sequence: 5-Year Speech Outcomes-A Case-Control Study.

BACKGROUND: Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown. METHODS: Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate-only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible. RESULTS: Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate-only patients.Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only. CONCLUSION: Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair.

BACKGROUND: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS: The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

[Submucous cleft palate--an often late diagnosed malformation]. / Die submuköse Gaumenspalte--eine oft verkannte Fehlbildung.

BACKGROUND: Submucous cleft palate (SMCP) is often diagnosed very late and can cause velopharyngeal insufficiency with open nasal speech and Eustachian tube dysfunction. METHODS: A retrospective analysis of 106 patients (100 children, 6 adults) who had been surgically treated for SMCP was made. Age of diagnosis, physician who initially diagnosed the SMCP, typical symptoms for cleft palate, clinical examination of the palate, therapy options and accompanying diseases were evaluated. RESULTS: SMCP was diagnosed in 79 cases by a specialist for Phoniatrics/ENT surgery of the University and in 21 cases by a physician, who does not work at hospital at the age of 4.9 years. Main symptoms were Eustachian tube dysfunctions (61.3%) and hypernasal speech (48.1%). Typical findings of the palate were: reduced contraction (69.8%), lack of posterior nasal spine (55.7%) and bifid uvula (51.9%). In 18 patients a dysmorphic syndrome was observed and in 83% a conductive hearing loss which resolved after palatoplasty (often in combination with adenotomy and insertion of ventilation tubes). Following surgery 18 patients required speech therapy and of these 6 needed velopharyngoplasty due to continuing open nasal speech. CONCLUSIONS: SMCP is often diagnosed very late, though symptoms of velopharyngeal insufficiency such as open nasal speech, Eustachian tube dysfunction and reduced contraction of the palate with bifid uvula are present. It is also often found in children with craniofacial dysmorphic syndromes. We therefore recommend that all patients with such findings are examined by an appropriate specialist such as Phoniatrics, ENT-Surgeon and Oral-Maxillofacial Surgeon so that early diagnosis and palatoplasty can be performed.