Surgical treatment of velopharyngeal dysfunction: Incidence and associated factors in the Swedish cleft palate population.

INTRODUCTION: Speech in children with cleft palate can be affected by velopharyngeal dysfunction, which persists after primary palate repair. The incidence of surgery to correct velopharyngeal dysfunction in this patient group has previously been reported as 2.6-37%. We aimed to investigate the incidence of velopharyngeal dysfunction surgery in Swedish children with cleft palate and to examine potential associations of independent variables with this incidence. METHODS: In this cohort study, we analysed data from the Swedish cleft lip and palate quality registry for 1093 children with cleft palate with or without cleft lip. Kaplan-Meier analysis was used to estimate the risk of having velopharyngeal dysfunction surgery. Multivariable Cox proportional hazards models were used to estimate the associated effect of cleft subtype, additional diagnoses, gender, and age at and number of stages for primary palate repair on the primary outcome. RESULTS: The risk of having velopharyngeal dysfunction surgery was 25.6%. Complete primary palate repair after the age of 18 months or in more than one stage was associated with a higher risk, but it could not be determined which of these was the more significant factor. Cleft soft palate was associated with a significantly lower risk than other cleft subtypes. CONCLUSIONS: Primary palate repair at a higher age or in more than one stage may increase the risk of having velopharyngeal dysfunction surgery. Further analysis of potential unknown confounding factors and the association between the incidence of velopharyngeal dysfunction and surgery to correct this condition is needed.

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.

Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique.

Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.

Evaluation of late cleft palate repair by a modified technique without relaxing incisions.

OBJECTIVE: To evaluate the postoperative outcomes together with analyzing the associated influencing factors following a late cleft palate repair by the Sommerlad-Furlow modified technique (S-F). MATERIALS AND METHODS: In a retrospective cohort, 320 consecutive patients with cleft palate, who received S-F technique between 2011 and 2017, were reviewed. The patients were divided into three age groups, less than one year (143), one to two years (113), and greater than 2 years (64). The postoperative outcomes included wound healing (complete/fistula) and velopharyngeal function (VPF). RESULTS: The overall cleft width was 10 ± 3.07 mm. The overall rates of complete wound healing and proper velopharyngeal function were 96.6% and 81.56%, respectively. No significant difference was found between the age groups regarding wound healing, with an overall fistula rate of 3.4%. The VPF was significantly varied among the age groups (P<0.001). In context, the rates of velopharyngeal insufficiency (VPI) were 9.8%, 14.2%, and 45.4% among patients repaired at ˂1, 1-2, and >2 years old, respectively. The cleft type was the most potential factor associated with fistula. The age at repair was identified as the most implicating factor for VPI. CONCLUSIONS: The S-F technique had achieved low fistula rate and satisfactory speech outcome, especially in early repair group and even in the wide cleft palate. The older age at repair and severe cleft type had a major impact on the postoperative outcomes.

The Sommerlad-Furlow Modified Palatoplasty Technique: Postoperative Complications and Implicating Factors.

OBJECTIVE: To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique. STUDY DESIGN: Retrospective cohort. METHODS: A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected. RESULTS: Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p Ë‚ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI. CONCLUSIONS: The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:822-829, 2023.

Patterns of velopharyngeal closure during speech in individuals with normal habitual resonance: A nasoendoscopic analysis.

OBJECTIVE: Velopharyngeal valve closure is essential for adequate speech intelligibility as well as for other activities. The variations in the contribution of different components of the velopharyngeal port walls produce different closure patterns. The aim of this cross-sectional study is to identify the prevalence of the different velopharyngeal closure patterns in Arabic-speaking individuals with no perceived hypernasality or velopharyngeal dysfunction. METHODS: After verification of selection criteria, 100 subjects with age range between 15 and 60 years underwent nasoendoscopic examination and both the extent of movement of the different velopharyngeal walls as well as closure pattern were observed. RESULTS: Almost all participants had grade 4 (full range) velar mobility, most participants had grade 3 lateral pharyngeal wall movement, and none showed any observable posterior pharyngeal wall movement. Coronal closure pattern was the most frequent (75%) among participants followed by circular pattern (25%). There was no statistically significant difference between both genders in the extent of velar and lateral pharyngeal wall movements, yet the frequency of closure patterns differed statistically significantly between males and females. CONCLUSION: Coronal pattern was the most prevalent type of velopharyngeal closure in subjects with normal habitual resonance, of both sexes, yet it occurred more frequently in males.

Criteria for early and late velopharyngoplasty in 61 children with cleft palate.

BACKGROUND: Velopharyngeal insufficiency persists in 15 to 30% of children with cleft palate, despite early velar surgery. Pharyngoplasty using a superior pedicle flap is the most common secondary surgery to treat velopharyngeal insufficiency. This study aims to identify the criteria leading to indicate velopharyngoplasty in 3 groups of age. MATERIALS AND METHODS: we conducted a retrospective single center study in the reference center for cleft palate in Paris from 2013 to 2016. We included 61 children with non-syndromic cleft operated on with a velopharyngoplasty for velopharyngeal insufficiency. Pre-operative speech and surgical assessments, as well as the operative reports of the children, were analyzed retrospectively using multivariate models. RESULTS: We included 61 patients. The only criteria factor for an early velopharyngoplasty was the Pittsburgh Weighted Speech Scale (PWSS) score (OR 1.20, CI 95% 1.07 to 1.4 ; P=.006). Criteria for a late velopharyngoplasty were a degradation of the velopharyngeal function (OR 16.07, CI 95% 1.7 to 518.7 ; P=.041) and lost of follow-up (OR 5.78, CI 95% 3.9 to 4320 ; P=.017). CONCLUSION: Criteria for early and late velopharyngoplasty were identified, and we demonstrated the insufficiency of Borel-Maisonny classification for scientific clinical study.

Incidence of New-Onset Obstructive Sleep Apnea After Posterior Flap Pharyngoplasty in Children.

INTRODUCTION: Obstructive sleep apnea (OSA) is a well-recognized complication of velopharyngeal insufficiency (VPI) surgery, but studies assessing OSA by means of a respiratory polygraphy (PG) are scarce. The aim of the study was to evaluate the incidence of new-onset OSA after posterior flap pharyngoplasty (PFP). MATERIALS: The postoperative PG of children with VPI who had a normal preoperative PG were analyzed. RESULTS: Eighteen patients (mean age, 9.8 ± 4.8 years; Pierre Robin sequence [n = 5], isolated cleft palate [n = 7], 22q11 deletion [n = 3], and 3 other diagnoses) were included in the study. Mean delay between surgery and the postoperative PG was 11.5 ± 13.5 months. Two patients (11%) developed severe OSA after PFP. One patient with 22q11 deletion developed overt OSA symptoms immediately after surgery with an apnea-hypopnea index (AHI) of 39 events per hour, requiring continuous positive airway pressure (CPAP) therapy. Obstructive sleep apnea improved spontaneously after 10 months, with an AHI of 2 events/h after CPAP weaning. The second patient had a cleft palate associated with a fetal alcohol syndrome and developed OSA symptoms after surgery with an AHI of 18 events/h requiring CPAP therapy. He could be weaned from CPAP 6 months later after a complete section of the pharyngeal flap with an AHI of 6 events/h during spontaneous breathing. CONCLUSIONS: New-onset OSA after PFP in children with VPI who had a normal preoperative PG was uncommon (11%) in the present cohort.

Velopharyngeal Insufficiency in Craniofacial Microsomia: Prevalence, Diagnosis, and Treatment.

ABSTRACT: The purpose of this study was to analyze the prevalence, diagnosis, and management of velopharyngeal insufficiency (VPI) in patients with craniofacial microsomia (CFM).Craniofacial microsomia patients 13 years of age and above treated at 2 centers from 1997 to 2019 were reviewed retrospectively for demographics, prevalence of VPI, and management of VPI. Patients with isolated microtia were excluded. Comparisons were made between patients with and without VPI using chi-square and independent samples t tests.Among 68 patients with CFM (63.2% male, mean 20.7 years of age), VPI was diagnosed in 19 patients (27.9%) at an average age of 7.2 years old. Among the total cohort, 61 patients had isolated CFM, of which 12 (19.6%) were diagnosed with VPI. Of the patients with isolated CFM and VPI, 8 patients (66.7%) were recommended for nasoendoscopy, of which only 2 patients completed. Seven isolated CFM patients (58.3%) underwent speech therapy, whereas none received VPI surgery. In contrast, 7 patients were diagnosed with both CFM and cleft lip and/or palate (CL/P), all of whom had VPI and were recommended for nasoendoscopy, with 5 (71.4%) completing nasoendoscopy, 6 (85.7%) undergoing speech therapy, and 6 (85.7%) undergoing corrective VPI surgery. Overall, we demonstrated that VPI was present in 27.9% of all CFM patients. On subset analysis, VPI was diagnosed in 20% of patients with isolated CFM and 100% of patients with CFM and CL/P. In addition, despite clinical diagnosis of VPI, a sizeable proportion of isolated CFM patients did not undergo therapy or surgical interventions.

Clinical study on obstructive sleep apnea following pharyngeal flap surgery.

OBJECTIVES: This study aims to investigate the incidence and severity of obstructive sleep apnea (OSA) in cleft patients with velopharyngeal insufficiency (VPI) after pharyngeal flap surgery (PFS) and explore the influence of operation age. METHODS: A retrospective study was conducted in 82 cleft patients after PFS. The patients were divided into two groups according to their age at the time of surgery. The incidence and severity of OSA were assessed at least 1.2 years (mean 6.0 years) postoperatively by polysomnography (PSG). RESULTS: The incidence rates of OSA were 20% in the adult group and 31% in the child group. No significant difference was found between the two groups (P=0.289). Patients with OSA in the adult and child groups were classified into different levels of severity (mild, moderate, severe) according to the apnea hypoventilation index (AHI). No statistically significant difference in the severity of OSA was found between the two groups (P=0.079). CONCLUSIONS: Some patients still have OSA average of 6.0 years after PFS, and operation ageis unrelated to the incidence and severity of OSA.

Furlow Palatoplasty: Should We Also Focus on the Size of the Nasopharynx?

OBJECTIVES: (1) To determine the incidence rate of velopharyngeal dysfunction (VPD) according to 7 speech criteria post-Furlow palatoplasty. (2) To find an anatomical measurement of the cleft palate (or combination of measurements) associated with the occurrence of VPD. STUDY DESIGN: Retrospective cohort study. PARTICIPANTS AND METHODS: Fifty-six patients with cleft palate ± cleft lip underwent palatoplasty with the Furlow technique at the age of 10 months. Pre-and post-palatoplasty cleft palate measurements were collected during the procedure. Three blinded speech-language pathologists (SLPs) retrospectively scored the patients from the chart data at age 4. Student t test and receiver operating characteristic curve analysis were used to evaluate the association and predictive capacity between cleft measurements and parameters (M&P) with all VPD criteria. RESULTS: The SLPs found an incidence of VPD according to 7 criteria: hypernasality (11%), audible nasal emission (4%), nasal rustle (14%), compensatory errors (4%), impairment of speech understandability (7%), and impairment of speech acceptability (16%). The SLPs recommended a secondary surgical procedure in 5 patients (9%). A statistically significant association was found between, respectively, 17 and 5 M&P and the occurrence of compensatory errors and audible nasal emission. Our data suggest that the length of the cleft, the cleft area, and the postoperative transversal size of the nasopharynx are the best indicators of the future positivity of VPD criteria. CONCLUSION: The size of the postoperative transverse nasopharyngeal area during the primary cleft palate procedure may become the focus of the next generation of cleft surgeons to reduce the incidence of VPD.

A Comparison of Outcomes After Palatoplasty in Patients With Non-Syndromic Pierre Robin Sequence Versus Patients With Non-Syndromic Isolated Cleft Palate.

The purpose of this retrospective study was to compare outcomes of cleft palate repair in patients with non-syndromic Pierre Robin sequence (NS-PRS) versus those with non-syndromic isolated cleft palate (NS-ICP). Pierre Robin sequence (PRS) was defined as a diagnosis of the triad of microretrognathia, glossoptosis, and cleft palate, and the severity of PRS was assessed based on the presence of respiratory and feeding problems. All patients underwent palatoplasty between January 2000 and December 2011. The authors examined age at palatoplasty, type of cleft palate, fistula rate, velopharyngeal (VP) function, nasal emission, hypernasality, and need for secondary speech surgery, in addition to PRS severity in the NS-PRS patients. A total of 15 NS-PRS patients and 40 NS-ICP patients were reviewed. The incidence of VP dysfunction, nasal emission, hypernasality, and secondary speech surgery was not significantly different between the NS-PRS patients and NS-ICP patients. Age at palatoplasty was significantly different between the 2 groups (P = 0.012) but type of CP was not (P = 1.00). Only 2 NS-PRS patients were classified as category III (severe), and all of the NS-PRS patients who had VP insufficiency were classified as PRS severity category I (not severe). The findings of this study indicate that NS-PRS patients may not have worse outcomes than NS-ICP patients.

Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair.

OBJECTIVE: To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden. DESIGN: Retrospective cohort with follow-up of 4 to 19 years. SETTING: Academic, tertiary children's hospital. PATIENTS: Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9. INTERVENTIONS: Cleft palate surgery, completed in either a single-stage or 2-stage repair. MAIN OUTCOME MEASURE(S): Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews. RESULTS: A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients (P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI (P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures. CONCLUSION: Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair.

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in "early" versus "standard" cleft palate repair in a cohort of patients treated at a single craniofacial center.A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. "Early repair" is defined as palatoplasty before 6-months of age (108 patients). "Standard repair" is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors' data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.

Causative Factors for Complications in Transpalatal Advancement.

INTRODUCTION: Transpalatal advancement (TPA) is a procedure that is used when modern variants of uvulopharyn-gopalatoplasty are unable to provide enough anterior traction. Although successful in reduction of obstructive sleep apnea (OSA) parameters, it also comes with procedure-specific risks. Formation of an oro-nasal fistula (ONF) is a complication that results in significant morbidity and a protracted treatment course. METHODS: After approval from the University of Wollongong Health Research Ethics Committee, a retrospective chart review of all cases undergoing TPA performed by a single surgeon over a 10-year period from 2008 to 2018 was performed. Patients underwent pre- and postoperative level 1 or 2 polysomnography. Factors potentially contributing to palatal complications, as well as pre- and postoperative polysomnographic parameters, subjective sleep questionnaires, and body mass index (BMI) were statistically analyzed where a P value <.05 was considered a significant result. RESULTS: A total of 59 patients were included. Overall palatal complication rate was 25.4% (15/59), with the most common being transient velo-palatal insufficiency (VPI) (8/59, 13.6%). ONF developed in 4/59 (6.8%) of patients. None of the analyzed contributing factors for palatal complications were statistically significant, except the presence of a high-arched palate and development of ONF. All analyzed sleep parameters, as well as BMI, were significantly different when comparing pre- to postoperative results. CONCLUSION: This study suggests that TPA has a role in current sleep surgery paradigms and can significantly improve both objective and subjective outcome measures of OSA. Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution.

Long-term Complications of Palate Surgery: A Multicenter Study of 217 Patients.

OBJECTIVES/HYPOTHESIS: To investigate long-term complications of newer reconstructive palate surgery techniques. STUDY DESIGN: Retrospective case-series analysis. METHODS: Retrospective six-country clinical study of OSA patients who had nose and palate surgery. RESULTS: There were 217 patients, mean age = 43.9 ± 12.5 years, mean body mass index = 25.9 ± 4.7, mean preoperative apnea-hypopnea index [AHI] = 30.5 ± 19.1, follow-up 41.3 months. A total of 217 palatal procedures were performed, including 50 expansion sphincter pharyngoplasties (ESP), 34 functional expansion pharyngoplasties (FEP), 40 barbed reposition pharyngoplasties (BRP), 64 modified uvulopalatopharyngoplasties (mUPPP), 11 uvulopalatal flap procedures (UPF), nine suspension pharyngoplasties (SP), eight relocation pharyngoplasties (RP), and one z-pharyngoplasty (ZPP). Complications included were constant and/or felt twice per week; dry throat (7.8%), throat lump feeling (11.5%), throat phlegm (10.1%), throat scar feeling (3.7%), and difficulty swallowing (0.5%). Of the 17 patients who had a dry throat complaint, two were constant (one SP, one RP), 15 were occasional (10 mUPPP, three SP, two BRP). Of the 25 patients with the throat lump feeling, four were constant (three RP, one ZPP), 21 were occasional (10 mUPPP, five SP, five UPF, one BRP). Of the 22 patients with the throat phlegm feeling, four were constant (two SP, two RP), 18 were occasional (10 mUPPP, four BRP, two FEP, two SP). Of the eight patients with throat scar feeling, eight were occasional (four SP, two mUPPP, one FEP, one RP), none were constant. One patient had difficulty swallowing (RP procedure). There was no velopharyngeal incompetence, taste disturbance, nor voice change. Highest symptom complaints were mUPPP, SP, and RP, whereas the lowest symptom complaint was ESP. CONCLUSIONS: Newer palatal techniques have shown to have less long-term complications compared to the older ablative techniques. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2281-2284, 2020.

The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: A retrospective study in Isfahan Cleft Care Team.

OBJECTIVES: This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined. METHODS: A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos. RESULTS: Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05). CONCLUSION: Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT.

Outcomes of Primary Palatoplasty: An Analysis Using the Pediatric Health Information System Database.

BACKGROUND: Previous attempts at reporting oronasal fistula development and secondary speech surgery following cleft palate surgery have been limited to single-center case series. This limitation can be overcome by querying large databases created by health care governing bodies or health care alliances. The authors examined the effect of cleft type and demographic variables on the clinical outcomes. METHODS: Data from the Pediatric Health Information System database were queried for patients, aged 6 to 18 months, who had undergone primary palatoplasty between 2004 and 2009. Subsequent repair of an oronasal fistula and/or secondary speech surgery between 2004 and 2015 was identified by procedure codes. Logistic regression models were used to assess the associations between cleft type with oronasal fistula and with secondary speech surgery. RESULTS: Seven thousand three hundred twenty-five patients were identified, and 6.4 percent (n = 468) had a subsequent repair of an oronasal fistula and 18.5 percent (n = 1355) had a secondary speech operation. Adjusted for age, sex, and race, patients with cleft lip and palate have increased odds of oronasal fistula (OR, 5.60; 95 percent CI, 4.44 to 7.07) and secondary speech surgery (OR, 2.32; 95 percent CI, 2.05 to 2.63). CONCLUSIONS: Using a large, multi-institution billing database, the authors were able to estimate the prevalence of oronasal fistula and surgically treated velopharyngeal insufficiency following primary palatoplasty in the United States. In addition, the authors demonstrated that patients with isolated cleft palate develop fewer oronasal fistulas and require less secondary speech surgery than patients with cleft lip and palate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Soft Palate Dysfunction in Children With Microtia.

BACKGROUND: Speech issues in microtia patients have been historically attributed to poor hearing. However, the authors have noted that almost all patients with microtia have palatal dysfunction. The aim of this study is to determine the prevalence of soft palate dysfunction (SPD) and velopharyngeal insufficiency (VPI) in microtia patients. METHODS: A prospective cohort study was performed on consecutive microtia patients from March to June 2017. Clinical characteristics were collected. Palate movement was rated by oral examination and degree of nasal escape by the mirror-fogging test. Correlations between clinical characteristics of microtia and SPD were determined. RESULTS: Ninety-seven (40 unilateral, 27 bilateral, and 30 control) children met inclusion criteria. Among all 67 patients with microtia, 96% (64 patients) showed SPD. Twenty-four unilaterals (60%) and 23 bilaterals (85%) had observable VPI by mirror examination. Of these patients, nasality was noticeable to the examiners in 14 unilaterals (58%) and 21 bilaterals (91%). Sixteen of the 27 bilaterals (59%) showed almost no movement of the soft palate. There was a significant correlation between SPD and mirror-fogging. A less developed middle ear as determined by computed tomography scan was associated with palatal dysfunction (P = 0.007). The severity of mandibular shift (P = 0.048) and presence of a syndrome (P = 0.045) were associated with grade of VPI. The severity of the ear deformity (P = 0.007) and presence of a syndrome (P = 0.034) were also correlated with the presence of SPD. CONCLUSIONS: This is the first study that documents the presence of VPI due to soft palate dysfunction in patients with isolated and nonisolated microtia.

Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence.

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. CONCLUSION: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.