Journal of the Louisiana State Medical Society
obvious abnormalities of the pharyngeal wall are readily seen and diagnosed early. However, submucous cleft pal- ate is a relatively rare variant of palatal cleft. Due to the subtle anatomic variations associated with this condition, it may not be recognized on routine well child exams, and diagnosis is often delayed until the child is older, at which time VPI, compensatory corrections, and articulation errors may already be present. 11 There have beenmany attempts to account for this inconsistency, and a number of approaches for evaluation of VPI have been outlined in the literature. Bunke et al. utilized multiple techniques, including de- tailed intraoral exams, subjective speech evaluations, flow studies involving simultaneous intranasal and intraoral pressure measurements, and lateral cephalometric X-rays. 26 Videonasendoscopy and videofluoroscopy have also been described as effective diagnostic modalities. 9,11 At our institution, the degree of VPI is established by subjective speech evaluation performed by a speech pathologist and the plastic surgeon. We also use nasopharyngeal endoscopy to further characterize patients with equivocal evaluations. In these patients, it is important that language be sufficiently developed to permit proper assessment of oral-nasal balance so that effective characterization of VPI can be achieved. In conjunctionwith the inconsistencies that exist regard- ing diagnosis of submucous clefts, debate remains regarding the optimal timing of surgical treatment, and a number of approaches have been reported. In his experience, Calnan advocated treatment similar to that of an overt cleft palate (assuming the diagnosis is made in time), with correction at about one year of age. 2 Porterfield advocated repair of all patients at 16 to 18 months of age. 16 There have also been several studies that reported no correlation at all between age at surgery and successful postoperative outcomes, raising further questions about the need for and timing of surgical intervention. 13,17 Ultimately, most authors recom- mend waiting until speech has adequately developed so that appropriate evaluation of VPI may be performed before considering surgical correction. 5,9,11,13,17 A variety of operative procedures have been described for the surgical treatment of submucous clefts. Calnan reported improvements in speech using a procedure that employed VY retroposition and lengthening of the velum.2 Kaplan used the combination of a VY pushback with a su- periorly based pharyngeal flap and also reported improve- ments in speech in that patient series. 4 In his review of 22 submucous clefts, Cleveland suggested the necessity of a pharyngeal flap to achieve successful correction of speech. 19 Porterfield also suggested the combination of a primary pharyngeal flap in conjunction with a palatal procedure in the primary correction of submucous clefts. 19 However, this procedure is not without risk for significant complications, including airway obstruction, bleeding, flap dehiscence, per- sistent oral-nasal imbalance, and obstructive sleep apnea. 20-25 In contrast, there is significant evidence that palatoplasty alone is adequate treatment for VPI. 11 Similar to other reported protocols, at our institution patients with marginal insufficiency are treated with an
Figure 3: This schematic illustrates the steps involved in pharyngeal flap repair of submucous cleft palate. This repair is not an anatomic repair but rather, reduces the size of the opening between the oral and nasal cavities to reduce the symptoms of velopharyngeal insufficiency.
18 J La State Med Soc VOL 166 January/February 2014
Made with FlippingBook - Online catalogs