Journal of the Louisiana State Medical Society
Patients were evaluated before and after surgery by the speech pathologists on our multi-disciplinary team. Assessments were made on each follow-up visit to evalu- ate correction of VPI and to determine whether the patient would require further surgical correction. Nasal escape, compensatory substitutions, volume/pitch changes, nasal resonance, tongue placement, oral-nasal balance, and ar- ticulation were all assessed. RESULTS A total of 24 patients with the diagnosis of submucous cleft palate were treated by our team during the period of time included in this study (Figure 1). Seventeen of the 24 patients required surgical intervention to correct their submucous cleft due to the presence of velopharyngeal in- competence. Fifteen of those 17 patients underwent Furlow Z-palatoplasty. Five of those 15 patients later required a secondary pharyngeal flap for persistent VPI, yielding a 67% success rate for correction of VPI by Furlow Z-palatoplasty in this group. The other two surgical patients underwent a primary pharyngeal flap, as it was felt that a Furlow Z- palatoplasty would have been unsuccessful due to their individual palatal anatomic idiosyncrasies. The average age at surgery for all 17 surgical patients was 6.2 years, and this group was followed on average for 3.75 years after their initial procedure. Seven of the 24 patients with submucous cleft did not require surgical cor- rection of any kind, as their condition improvedwith speech therapy alone. Eleven of the 24 patients had previously been diagnosed with a genetic syndrome (Figure 2). Eight of these 11 patients had VPI that required surgical correction with the Furlow procedure, which provided adequate oral-nasal balance in four of the eight patients, for a 50% success rate in this sub- group. The other four patients demonstrated persistent VPI and required a secondary pharyngeal flap to successfully improve their speech. The average age at surgery for the 11 syndrome-associated patients was four years. Among the 13 non-syndromic, submucous cleft pal- ate patients, seven had sufficient VPI to require a primary Furlow Z-palatoplasty (Figure 3). Six of these 7 cases (86%) resulted in functional oral-nasal balance, with only one (14%) requiring secondary pharyngeal flap for persistent VPI (Figure 4). The average age at surgery for this group was 7.3 years. Eustachian tube dysfunction and treatment were also analyzed in our submucous cleft population. Thirteen of the 24 (54%) patients required placement of pressure equalizing (PE) tubes by an otolaryngologist. Nine of the 11 syndromic patients (82%) ulitmately required PE tube placement, com- pared with only 4 of the 13 non-syndromic patients (31%). DISCUSSION
by the Children’s Hospital of New Orleans Craniofacial and Cleft Team between 2000 and 2007. This study was approved by the Institutional Review Board. Operative notes and charts were reviewed for data regarding the pa- tients’ age, gender, diagnosis, type of operation, need for myringotomy tubes, subsequent complications, length of follow-up, need for secondary procedures, and presence of genetic syndromes. In addition, speech therapy notes were carefully reviewed to track changes in patients’ speech pat- terns before and after surgery. SURGICAL PROCEDURE The classic Furlow Z-palatoplasty, as described for overt cleft palates, was used for primary surgical manage- ment in this series. 14-15 Double opposing z-plasties were designed on the oral and nasal surfaces of the soft palate. The levator and tensor musculature were elevated with a posteriorly based flap that included the nasal mucosa on the right side and oral mucosal on the left side. The interdigi- tating z-plasties were then closed, restoring the integrity of the palatal muscular sling and effectively lengthening the soft palate. Figure 1: This schematic illustrates the basic concept of a z-plasty, whereby local tissue flaps are juxtaposed in such a manner as to lengthen the original AB tissue segment.
Dysfunction of the velopharyngeal sphincter from
16 J La State Med Soc VOL 166 January/February 2014
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