Comparison of resonance outcomes after pharyngeal flap and furlow double-opposing z-plasty for surgical management of velopharyngeal incompetence.

OBJECTIVE: The purpose of this study was to test the hypothesis that no significant difference exists in the speech outcomes between patients with severe velopharyngeal incompetence (VPI) who receive a pharyngeal flap and patients with less severe VPI who receive a Z-plasty for management of VPI. DESIGN: This retrospective study from 1993 to 2002 included a review of pre- and postoperative perceptual speech and resonance assessments of patients with marginal VPI who received a Furlow double-opposing Z-plasty and patients with VPI who received a pharyngeal flap. SETTING: All patients had surgical management of VPI at the Cleft Palate-Craniofacial Clinic at University of Iowa Hospitals and Clinics. RESULTS: Both groups benefited from surgery with significant reduction in perceived hypernasality (p < .001). Comparison of postoperative assessments indicated no difference between the groups in hypernasality or hyponasality ratings. Neither group had a significant increase in hyponasality. CONCLUSION: Both pharyngeal flap and double-opposing Z-plasty proved equally effective at reducing hypernasality when the selection of the surgical procedures was based on preoperative ratings of perceived hypernasality and evaluation of velopharyngeal physiology. Severity of the VPI is an important factor when considering surgical management of VPI. Thorough preoperative evaluations of patients with VPI are essential in appropriate treatment planning.     

A profile of the features and speech in patients with mandibulofacial dysostosis.

PURPOSE: To present a profile of the features and speech in patients with mandibulofacial dysostosis (MFD). Data were collected on occlusion, palatal condition, hearing, resonance, voice, and articulation. PATIENTS: Thirty patients with MFD ranging in age from 1.6 to 21.0 years. STUDY DESIGN: Retrospective and prospective cross-sectional designs. SETTING: Pediatric tertiary care hospital. RESULTS: Sixty percent of the patients had an open bite. Isolated cleft palate was found in 37% with other types of cleft conditions occurring less frequently. Twenty-three percent underwent tracheostomy. All patients demonstrated hearing loss, 93% were conductive and 7% were mixed. Resonance, voice, and articulation were also affected. Seventy-seven percent had aberrant resonance including hypernasality, hyponasality, mixed hyper- and hyponasality or muffled resonance, which was found in 40% of the patients. Voice quality was abnormal in 63%. All patients had articulation errors. Although overlap between categories occurred, results showed that 60% had errors related to malocclusion, 30% demonstrated errors usually associated with velopharyngeal inadequacy and 50% had general articulatory or phonological errors that could be attributed to other causes. CONCLUSIONS: The features and speech of patients with MFD are complex. The speech disorders may have multiple overlapping etiologies that require careful differential diagnosis. This is imperative to establish appropriate treatment regimens and evaluate clinical outcomes.     

Prediction of deterioration of velopharyngeal function associated with maxillary advancement using electromyography of levator veli palatini muscle.

OBJECTIVE: The purpose of the present study was to examine the possibility that postoperative velopharyngeal function following maxillary advancement could be predicted using preoperative electromyography of the levator veli palatini. DESIGN: Levator muscle electromyography was recorded preoperatively during speech and blowing. Levator activity was expressed as a percentage relative to the maximum value observed throughout the experiment. Postoperative velopharyngeal function was evaluated by means of perceptual judgment and nasoendoscopy. PARTICIPANTS: The subjects were four patients with repaired cleft palates who underwent maxillary advancement, two by osteotomy and two by distraction osteogenesis. None of the subjects presented with preoperative hypernasality, and nasoendoscopy demonstrated complete velopharyngeal closure in all subjects prior to maxillary advancement. RESULTS: Preoperative levator activity for speech of two subjects was similar to that for normal speakers (< 60% of total range), and postoperative nasality and nasoendoscopic findings revealed no detectible changes. For the other two subjects, levator activity for speech exceeded 60% of the total range, similar to that of speakers with velopharyngeal incompetence. These subjects showed increased hypernasality and deteriorated velopharyngeal closure following maxillary advancement. CONCLUSION: The deterioration of velopharyngeal function associated with maxillary advancement was demonstrated for subjects whose levator activity was at higher levels during speech in comparison with maximal activity observed during blowing, regardless of the amount of maxillary advancement. Preoperative levator muscle electromyography could be a predictor in identifying patients at higher risk of postsurgical deterioration of velopharyngeal function.     

Velopharyngeal changes after maxillary advancement in cleft patients with distraction osteogenesis using a rigid external distraction device: a 1-year cephalometric follow-up

The effect of maxillary advancement on speech may have benefits on articulation improvement but compromises velopharyngeal (VP) closure by increasing the nasopharyngeal distance. The purpose of this study was to evaluate the static VP anatomic changes on lateral cephalograms in patients who underwent maxillary advancement through distraction osteogenesis (DO) with a rigid external distraction device and to correlate these changes with clinical speech data. Twenty-two patients (5 female and 17 male) underwent maxillary advancement through DO utilizing a rigid external distraction device (age, 5.2 to 25.7 years) with various diagnoses, including 13 unilateral cleft lip and palate (CLP) patients, 5 bilateral CLP patients, 1 isolated cleft palate patient, 2 facial cleft patients, and 1 patient with craniosynostosis. Lateral cephalograms of preoperative, immediate postdistraction, and 1-year postdistraction were obtained for analysis. Speech evaluation was performed preoperatively, immediate postdistraction, and then at 6-month intervals, and included assessment of air pressure flow, hypernasality, and articulation. With an average amount of 8.9 mm maxillary forward advancement, 14% of patients (3 of 21) presented deterioration in hypernasality. However, 57% of patients (12 of 21) demonstrated improvement in articulation. The cephalometric analysis demonstrated an increase in nasopharyngeal depth by 8.5 mm (1:1 ratio with bony movement) and velar angle by 14.1 deg. The length of the soft palate remained unchanged. The need ratio (intersection of palatal plane and posterior pharyngeal wall-posterior nasal spine/posterior nasal spine--tip of uvula) worsens after distraction. The deterioration of hypernasality was related to the amount of forward distraction, especially in patients without a preexisting pharyngeal flap (PF). Speech evaluation is an important aspect concerning treatment planning for maxillary distraction. The increase in nasopharyngeal depth may compromise VP closure. The increase in velar angle was considered to be part of the compensation in the VP mechanism. An adverse effect of a preexisting PF on maxillary distraction was not observed; however, it prevented postoperative hypernasality.     

Clinical outcomes of the furlow z-plasty for primary cleft palate repair

Objective: To review the clinical outcomes following the Furlow Z-plasty for primary cleft palate repair. The primary objective was to determine if the presence of an associated sequence or syndrome (i.e., Pierre Robin sequence), age at palate repair, cleft type, or surgeon experience influenced speech outcomes after a Furlow Z-plasty. Design: The outcomes of 140 patients who underwent palate repair were analyzed retrospectively. Speech evaluations were performed to score the severity of hypernasality, nasal escape, articulation errors, and velopharyngeal insufficiency. Results: The mean age at latest evaluation was 4 years 9 months (age range 2 years old to 12 years old and 4 months). Of the 140 patients, 83% had no evidence of hypernasality, 91% had no presence of nasal escape, and 69% had no articulation errors. Overall, 84% of patients had no evidence of velopharyngeal insufficiency. Secondary posterior pharyngeal flap to correct velopharyngeal insufficiency was required in only 2.1% of patients. The formation of an oronasal fistula occurred in only 3.6% of patients. Nonsyndromic patients with Pierre Robin sequence and syndromic patients did just as well as purely nonsyndromic patients in terms of velopharyngeal insufficiency, hypernasality, and nasal escape. Syndromic patients were more likely to make mild-to-moderate articulation errors. In addition, age at palate repair, cleft type, and surgeon experience had no statistically significant effect on speech results. Conclusions: The Furlow Z-plasty yielded excellent speech results in our patient population with minimal and acceptable rates of fistula formation, velopharyngeal insufficiency, and the need for additional corrective surgery.     

Effect of maxillary distraction osteogenesis on velopharyngeal function: a pilot study

OBJECTIVE: The purpose of this study was to examine preoperative and postoperative changes of velopharyngeal function in cleft patients who underwent maxillary distraction osteogenesis using the Rigid External Distraction System. STUDY DESIGN: Six cleft patients followed for a minimum of 12 months after maxillary distraction were examined. Plain and contrast lateral-cephalograms were obtained preoperatively and postoperatively, and speech evaluation was performed by the same authorized speech therapist at the same time points. RESULTS: The mean distraction amount at the anterior nasal spine was 11.7 mm (range, 7.4 mm - 15.0 mm). Both the nasopharyngeal depth and velar length increased after maxillary distraction, but the need ratio (nasopharyngeal depth/velar length) also increased after distraction. Although scores for velopharyngeal closure dropped a few points after maxillary distraction, the rating for hypernasality remained unchanged in all patients but the patient whose distraction amount was 15.0 mm. CONCLUSION: These results suggest that maxillary distraction of less than 15 mm may not markedly affect velopharyngeal function in cleft patients.     

Pharyngeal flap surgery in adults

The elimination of hypernasal speech in patients with cleft palate following pharyngeal flap surgery in childhood is well established. However, pharyngeal flaps in adults have been considered to yield more modest results. This study reports on 20 adult patients with cleft palate-related hypernasality who underwent pharyngeal flap surgery. Normal nasal resonance was achieved in 15 cases, hyponasality occurred in 3 cases, and hypernasality persisted in 2 cases. However, speech intelligibility was not always dramatically improved. Indications and outcome were found to be highly dependent on preoperative articulation.     

Speech outcome and velopharyngeal function in cleft palate: comparison of Le Fort I maxillary osteotomy and distraction osteogenesis--early results.

OBJECTIVE: To compare speech outcome and velopharyngeal (VP) status of subjects with repaired cleft palate who underwent either conventional Le Fort I osteotomy or maxillary distraction osteogenesis to correct maxillary hypoplasia. DESIGN: Prospective randomized study with blind assessment of speech outcome and VP status. SUBJECTS: Twenty-two subjects were randomized into conventional Le Fort I osteotomy and Le Fort I distraction groups. All were native Chinese (Cantonese) speakers. METHOD: Perceptual judgment of resonance and nasal emission, study of VP structures by nasoendoscopy, and instrumental measurement by nasometry. Assessments were performed preoperatively and at 3 months postoperatively. MAIN OUTCOME MEASURES: Assessment of VP closure, perceptual rating of hypernasality and nasal emission, nasalance, and amount of maxillary advancement. RESULTS: There was no statistical difference in any of the outcome measures between the 10 subjects with conventional Le Fort I osteotomy and the 12 subjects with maxillary distraction: hypernasality (chi-square = 3.850, p = 0.221), nasal emission (chi-square = 0.687, p = 0.774), VP gap size (chi-square = 1.527, p = 0.635, and nasalance (t = -0.145, p = 0.886). There was no correlation between amount of maxillary advancement and any of the outcome measures (p = .05 for all). Changes in VP gap size and resonance are described. CONCLUSION: Results need to be interpreted with caution because of the small sample size and early follow-up. However, this study utilized an assessment protocol involving a variety of outcome measures and careful consideration of reliability factors, which can be a model for further and follow-up studies.     

The effects of Le Fort I osteotomy with maxillary movement on articulation, resonance, and velopharyngeal function

Articulation, resonance, and velopharyngeal function were evaluated before and after Le Fort I maxillary advancement in 16 patients (seven with cleft lip and palate, one with cleft lip only, and eight without clefts). On the postoperative evaluation, seven of 11 patients with preoperative articulation errors showed an improvement in articulation after surgery. Two patients without clefts showed slight changes in nasal resonance, and two patients (one with cleft lip and palate and one with cleft lip only) developed mild nasal emission. Nine patients showed diminished velopharyngeal contact during speech on videofluoroscopic studies. Compensatory changes in velopharyngeal function were also observed, which included velar stretching and lengthening and increased lateral pharyngeal wall movement.     

Morphological evaluation of changes in velopharyngeal function following maxillary distraction in patients with repaired cleft palate during mixed dentition.

OBJECTIVE: To describe the morphological changes of nasopharyngeal components after maxillary distraction and clarify whether the morphological characteristics are related to velopharyngeal function (VPF). DESIGN: Perceptual judgments of hypernasality and nasendoscopy were performed before and after treatment. Lateral cephalograms were obtained to describe the morphological changes. SETTING: Department of Oral and Maxillofacial Surgery, Miyazaki Medical College, Miyazaki, Japan. PARTICIPANTS: Nine patients with repaired cleft palate in the mixed dentition stage underwent maxillary distraction using a face mask and an intraoral fixed appliance system. OUTCOME MEASURES: The severity of hypernasality, velopharyngeal insufficiency, and measurements such as pharyngeal depth, velar length, and the rotation of the palatal plane were evaluated. RESULTS: Increase in pharyngeal depth was not always proportional to the amount of advancement. It depended on the posture of the posterior pharyngeal wall and the rotation of palatal plane. CONCLUSION: Cephalometric measurements of the nasopharynx before and after surgery confirmed subsequent changes in VPF. These were suggested to be useful in predicting future VPF. When performing maxillary distraction in patients with cleft palate in the mixed dentition stage, and when velopharyngeal closure is found to occur by velar contact against the hypertrophied adenoid, patients should be counseled about risks of subsequent deterioration in their speech before surgery.     

The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: a critical review.

OBJECTIVES: To review the impact of maxillary advancement by orthognathic surgery and distraction osteogenesis on speech and velopharyngeal status based on the literature of the past 30+ years, to review the methods employed in previous studies to explain discrepancies in results, and to make recommendations for future studies. METHOD: Thirty-nine published articles on the effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status were identified and were systematically analyzed. A total of 747 cases of cleft and noncleft patients were selected, including craniofacial deformities and syndromes mainly involving maxillary hypoplasia. RESULTS: Findings varied. Many studies found that surgery had no impact on speech and velopharyngeal status. Some reported worsening only in patients with preexisting velopharyngeal impairment or those with borderline velopharyngeal function before surgery. There was no clear difference in outcome between distraction and conventional osteotomy, although there have been few systematic comparisons. There was great variation among reviewed studies in the number of subjects, speech sample, number and type of listeners, speech outcome measures, and timing of postoperative assessment. Few studies employed reliability measures. CONCLUSION: None of the 39 reviewed studies compared conventional osteotomy and distraction by including both groups in a single study. Randomized controlled trials with adequate number of subjects and follow-up duration are needed.     

Maxillary distraction versus orthognathic surgery in cleft lip and palate patients: effects on speech and velopharyngeal function

This clinical randomized controlled trial was performed to compare the effects of distraction osteogenesis (DO) and conventional orthognathic surgery (CO) on velopharyngeal function and speech outcomes in cleft lip and palate (CLP) patients. Twenty-one CLP patients who required maxillary advancement ranging from 4 to 10 mm were recruited and randomly assigned to either CO or DO. Evaluation of resonance and nasal emission, nasoendoscopic velopharyngeal assessment and nasometry were performed preoperatively and at a minimum of two postoperative times: 3–8 months (mean 4 months) and 12–29 months (mean 17 months). Results showed no significant differences in speech and velopharyngeal function changes between the two groups. No correlation was found between the amount of advancement and the outcome measures. It was concluded that DO has no advantage over CO for the purpose of preventing velopharyngeal incompetence and speech disturbance in moderate cleft maxillary advancement.     

Buccinator sandwich pushback: a new technique for treatment of secondary velopharyngeal incompetence.

OBJECTIVE: A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. PATIENTS: In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. DESIGN: The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. RESULTS: Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. CONCLUSION: The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.     

Speech outcome after closure of oronasal fistulas with bone grafts.

PURPOSE: The purpose of this prospective study was to evaluate the outcome of speech after complete closure of oronasal fistulas with bone grafts and to determine the possible relationship between outcome of speech and the size and location of the oronasal fistulas. PATIENTS AND METHODS: Ten unilateral cleft lip and palate patients with postoperative oronasal fistulas, ranging in age from 7 to 14 years, underwent secondary alveolar cleft repair and closure of the oronasal fistulas with an iliac bone graft. All patients underwent videofluoroscopic evaluation of the velopharyngeal valve, audiologic assessment, and speech evaluation (resonance, nasal emission, articulation, intelligibility, and nasalance) preoperatively. The examinations were repeated 3 months postoperatively. RESULTS: Six patients had preoperative velopharyngeal competency (60%). Of the 4 patients with slight to mild velopharyngeal incompetency preoperatively, 2 developed velopharyngeal competency postoperatively. All patients had satisfactory audiologic function preoperatively. Every patient also was intelligible before and after surgery. Eight patients (80%) showed nasal emission before surgery and 7 of these patients improved postoperatively (P <.01). Nine patients had articulation errors before surgery, with no significant improvement postoperatively. Nasalance was significantly improved in selected sequences. All patients had variable levels of nasality preoperatively; 8 showed a significant decrease of nasality postoperatively (P <.002). The results were not related to location or size of the oronasal fistulas. CONCLUSION: A significant improvement in speech is noticeable after closure of oronasal fistulas. Early oronasal fistula closure might prevent permanent speech distortions acquired by the cleft palate patients at an early age.     

The intrajudge reliability of the perceptual rating of cleft palate speech before and after pharyngeal flap surgery: the effect of judges and speech samples.

OBJECTIVE: In this pilot study, the reliabilities of the perceptual ratings of four types of speech samples by six judges, with and without expertise in evaluating cleft palate speech, were studied. DESIGN: Pre- and postoperative tape recordings of 15 patients with cleft lip and palate who had undergone a superiorly based pharyngeal flap operation were selected. Five speech-language pathologists and one oral and maxillofacial surgeon perceptually rated the following variables on separate 100-mm visual analog scales: hypernasality, audible nasal emission, intelligibility, misarticulations associated with velopharyngeal insufficiency, voice quality, and the presence or absence of hyponasality. These six variables were rated in four types of speech samples: reading of three sentences, repeating after the speech pathologist of three sentences, 10 sentences containing the aforementioned material, and the same 10 sentences in paired comparison. All speech samples were rerated after 3 months by the same judges. RESULTS: Judges differed largely in the range they used in their rating. Intrajudge reliability of .56 to .78 was found for ratings of hypernasality. No significant differences in intrajudge reliability were found for the ratings with the different types of speech samples. The intrajudge reliability of a judge with expertise was not necessarily higher than of a judge without this expertise. CONCLUSIONS: The improvement in speech is most reliably assessed with speech samples in paired comparison. A speech-language pathologist with expertise in evaluating cleft palate speech does not guarantee a high intrajudge reliability of the rating.     

腭裂咽成形术后患者语音治疗疗效评价

目的:对腭咽成形术后存在语音障碍的患者进行语音治疗,通过治疗前后语音清晰度比较,评价该方法的疗效。方法:咽成形术后患者82例,年龄4~31岁。采用汉语语音清晰度测试表对患者进行治疗前后语音清晰度检测,根据代偿性发音特点进行系统化语音训练:①腭咽闭合功能锻炼;②音素→音节→词组→短句→短文、会话。训练时按发音部位由前→后,按发音方法由易→难、送气音→不送气音、塞音→擦音→塞擦音。训练周期1.5~12个月,平均3.83个月。结果:以腭咽闭合不全型为特点的代偿性语音患者共71例;其中声门塞音患者语音清晰度由治疗前的46.27%提高到治疗后的97.16%;咽摩擦音患者由治疗前的57.19%提高到治疗后的97.72%。以腭咽闭合良好型为特点的代偿性语音共11例,腭化、侧化音患者语音清晰度由治疗前的71.10%提高到治疗后的98.55%;3组经t检验,P均<0.001,具有极显著性差异。结论:对咽成形术后腭咽闭合不全型的代偿性发音,首先加强腭咽闭合功能,再建立正确的发音部位和方法;对咽成形术后腭咽闭合良好型的代偿性发音,可直接建立正确的发音部位和方法。     

上颌前徙术后腭咽闭合功能的临床观察

目的　临床观察评价上颌前徙术后腭咽闭合功能变化。方法　对 7例上颌发育不全患者及 3例唇腭裂继发上颌发育不全患者行LeFortI型截骨术前移上颌骨 ,术前术后行鼻咽纤维镜及发“i”音时的头颅侧位片检查 ,结合术前术后语音的评价 ,对上颌前徙术后腭咽闭合及发音的改变进行观察分析。结果　经统计学分析 ,软腭动度、腭咽闭合程度、语音清晰度等指标术前术后比较差异均无显著性。结论　患者术前腭咽闭合功能良好时 ,上颌前徙术后腭咽闭合功能无明显变化     

大龄腭裂患者治疗模式的初步研究

目的改进大龄腭裂患者的治疗模式,提高大龄腭裂患者术后的腭咽闭合率和语音清晰度。方法对37例年龄大于6岁（含6岁）的腭裂患者进行同期腭裂与腭咽肌瓣咽成形整复术,并对其术后10~15个月的效果进行了随访和语音评估。结果22例患者术后腭咽闭合完全,15例术后虽仍有腭咽闭合不全,但在鼻咽纤维镜下腭咽闭合度达85%以上;所有患者X线侧位咽腔造影显示软腭与咽后壁贴合;语音检测显示,高鼻音和鼻漏气程度显著下降,辅音清晰度提高。结论本研究中建立的大龄腭裂患者治疗模式可以显著提高腭裂患者术后的腭咽闭合率和语音清晰度,为改善其生存质量创造了条件。     

Speech evaluation of velopharyngeal dysfunction

This article reviews concepts basic to the evaluation of the speech of persons with velopharyngeal dysfunction. It defines velopharyngeal dysfunction as well as reviews normal and abnormal velopharyngeal function for speech. It defines the common speech characteristics of persons with velopharyngeal dysfunction, including hypernasality, hyponasality, nasal emission, compensatory articulations, and weak pressure consonants. Speech sounds commonly impacted by velopharyngeal dysfunction are discussed. This article identifies the components of a complete speech evaluation as well as identifies anatomic and physiologic measurements of palatal function used to corroborate perceptual speech judgments indicating palatal problems. It identifies special considerations in the evaluation of persons with suspected velopharyngeal dysfunction. It briefly discusses management of velopharyngeal dysfunction. Review questions follow the article.