Outcomes of combined Furlow palatoplasty and sphincter pharyngoplasty for velopharyngeal insufficiency.

OBJECTIVE: To compare surgical outcomes between pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty in the management of pediatric velopharyngeal insufficiency. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care pediatric hospital. SUBJECTS AND METHODS: After exclusion of children with velocardiofacial syndrome, 96 patients who underwent surgical intervention between 2008 and 2012 were identified. Surgical interventions were categorized as pharyngeal flap, sphincter pharyngoplasty, and combined Furlow palatoplasty and sphincter pharyngoplasty. Main outcome measures included perceptual speech analyses, complications, and surgical revision rates. RESULTS: Of the 96 reviewed patients, 38 (39.6%) underwent pharyngeal flap, 20 (20.8%) sphincter pharyngoplasty, and 38 (39.6%) combined Furlow palatoplasty and sphincter pharyngoplasty. Choice of surgical intervention was based on patient characteristics, observed palatal length, and formal speech assessments. There were no differences in patient demographics or preoperative perceptual speech analysis scores among the 3 surgical groups. The mean speech improvement was significantly greater in both the pharyngeal flap (P = .031) and combined procedure (P = .013) compared with sphincter pharyngoplasty alone, but no differences were observed between the pharyngeal flap and combined procedure (P = .797). There were no differences in complications among the 3 surgical interventions (P = .220). The combined procedure required significantly less surgical revisions than the pharyngeal flap (P = .019). CONCLUSION: Combined Furlow palatoplasty and sphincter pharyngoplasty is an effective procedure for the management of pediatric velopharyngeal insufficiency and may result in superior speech outcomes and lower revision rates than sphincter pharyngoplasty and pharyngeal flap, respectively.

The effect of cleft palate repair technique on hearing outcomes in children.

OBJECTIVE: Otitis media with effusion causing conductive hearing loss is a problem for many children with cleft palate. This study examines the association between palate repair technique and hearing outcomes in children at 3 and 6 years post-repair. PATIENTS AND METHODS: Retrospective chart review of patients with all types of cleft palate that were repaired between 2001 and 2006 at a tertiary children's hospital. Exclusion criteria included sensorineural hearing loss, ossicular chain abnormalities, and ear canal abnormalities. The primary outcome was pure tone average (PTA) from 0.5 kHz to 2 kHz. RESULTS: 69 patients (138 ears) were analyzed. 30.4% of left ears and 31.9% of right ears had an abnormal (>20 dB) PTA at 3 years; at 6 years this significantly improved to 13.0% (p=0.008) and 15.9% (p=0.011). Double-reverse z-plasty was associated with the lowest median PTA of 10.0 dB (p=0.046) at 6 years. There was no difference in median PTA between children with and without comorbid diagnoses (such as Pierre Robin Sequence, arthrogryposis) at either 3 years or 6 years (p=0.075, p=0.331). Multivariate model showed that extent of cleft influenced technique choice (p=0.027), but only technique choice was associated with significant differences in PTA and only at 6 years post-repair. CONCLUSION: The majority of children developed normal hearing by 6 years with palatoplasty and routine tube insertion. Double reverse z-plasty was associated with the best outcome, but is not ideal for hard palate clefts. Randomized controlled trials are needed to elucidate the relationship between technique, middle ear ventilation and time to recovery, irrespective of type of cleft.