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Speech Outcomes After Clinically Indicated Posterior
Pharyngeal Flap Takedown
Evan B. Katzel, MD, Sameer Shakir, MD, Sanjay Naran, MD, Zoe MacIsaac, MD, Liliana Camison, MD,
Matthew Greives, MD, Jesse A. Goldstein, MD, Lorelei J. Grunwaldt, MD,
Matthew D. Ford, MS, CCC-SLP, and Joseph E. Losee, MD
Background:
Velopharyngeal insufficiency affects as many as one in three pa-
tients after cleft palate repair. Correction using a posterior pharyngeal flap
(PPF) has been shown to improve clinical speech symptomatology; however, PPFs
can be complicated by hyponasality and obstructive sleep apnea. The goal of this study
was to assess if speech outcomes revert after clinically indicated PPF takedown.
Methods:
The cleft-craniofacial database of the Children's Hospital of Pittsburgh
at the University of Pittsburgh Medical Center was retrospectively queried to identify
patients with a diagnosis of velopharyngeal insufficiency treated with PPF who
ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS),
preoperative scores were compared to those after PPF takedown. Outcomes
after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown
with conversion to Furlow palatoplasty) were stratified and cross-compared.
Results:
A total of 64 patients underwent takedown of their PPF. Of these,
18 patients underwent PPF takedown alone, and 46 patients underwent PPF
takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43
(range, 3.0
–
22.0)(SD: 3.93) years of age at the time of PPF takedown, and
58% were men. Demographics between groups were not statistically different.
The mean duration of follow-up after surgery was 38.09 (range, 1
–
104) (SD,
27.81) months. For patients undergoing PPF takedown alone, the mean preoper-
ative and postoperative PWSS was 3.83 (range, 0.0
–
23.0) (SD, 6.13) and 4.11
(range, 0.0
–
23.0) (SD, 5.31), respectively (
P
= 0.89). The mean change in PWSS
was 0.28 (range,
−
9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF
with conversion to Furlow palatoplasty, the mean preoperative and postoperative
PWSS was 6.37 (range, 0
–
26) (SD, 6.70) and 3.11 (range, 0.0
–
27.0) (SD, 4.14),
respectively (
P
< 0.01). The mean change in PWSS was
−
3.26 (range,
−
23.0 to
4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range,
0.0
–
26) (SD, 6.60) and 3.39 (range, 0.0
–
27) (SD, 4.48), respectively (
P
< 0.05).
The mean change in PWSS was
−
2.26 (range,
−
23.0 to 7) (SD, 5.7). There was no
statistically significant regression in PWSS for either surgical intervention. Two
patients in the PPF takedown alone cohort demonstrated deterioration in PWSS
that warranted delayed conversion to Furlow palatoplasty. Approximately 90%
of patients, who undergo clinically indicated PPF takedown alone, without
conversion to Furlow Palatoplasty, will show no clinically significant reduction
in speech.
Conclusions:
Although there is concern that PPF takedown may degrade speech,
this study finds that surgical takedown of PPF, when clinically indicated, does
not result in a clinically significant regression of speech.
Key Words:
cleft lip, cleft palate, velopharnygeal insufficiency, sleep apnea,
craniofacial, Furlow plasty, pharyngoplasty, double opposing z-plasty, VPI
(
Ann Plast Surg
2016;77: 420
–
424)
T
he velopharyngeal valve separates the oral and nasal pharynx
during swallowing and speaking. It is created by the lateral pharyn-
geal walls, the posterior pharyngeal wall, and the velum, and selectively
allows and resists airflow during normal speech production. Velo-
pharyngeal insufficiency (VPI) is the inability to completely occlude
the velopharyngeal port during speech and can be an unfortunate
complication seen in approximately 30% of palatal surgery.
1
Data sug-
gest that straightline palatoplasty without intravelar veloplasty or with
incomplete intravelar veloplasty place patients at a greater risk for
VPI.
2
Sphincterplasty, fat grafting, or filler injection to the posterior
pharynx and/or obturators can be used to treat VPI; however, the gold
standard treatment of VPI after cleft palate repair is pharyngoplasty,
and the posterior pharyngeal flap (PPF) is one of the most frequently
performed procedures.
The PPF was initially described for the treatment of VPI in 1865
by Passavant.
3
Creation of a PPF is often used to treat VPI and is well
established to improve clinical speech symptomatology.
4
–
7
Long-term
success rates with PPF range from 74% to 98%.
1,8
–
11
However, PPFs
are accompanied by the potential morbidity of hyponasality and postop-
erative obstructive sleep apnea (OSA), with OSA reported in as many
as 40% of the cases.
12,13
Although, a large body of literature exists re-
garding the identification, prevention, and management of OSA in this
population, studies have yet to answer whether speech symptomatology
suffers as a consequence of PPF takedown.
8,14
–
19
There is also a lack
of literature exploring conversion of previous straightline palatoplasties
to Furlow palatoplasty for these patients. The treatment of these patients
is controversial, given the challenge of treating the OSA
caused by
the PPF
while maintaining the improvement in speech
owed to the
PPF
. Given the lack of existing literature, the study aims to assess
speech outcomes after clinically indicated PPF takedown alone or when
performed with conversion to Furlow palatoplasty. This study hypothe-
sizes that PPF takedown or PPF takedown with conversion to Furlow
palatoplasty can be performed for the treatment of OSAwithout delete-
rious effects on speech outcomes.
METHODS
The study was approved by the Institutional Review Board at the
University of Pittsburgh Medical Center. The Cleft-Craniofacial Data-
base of the Children's Hospital of Pittsburgh of University of Pittsburgh
Medical Center was queried from 1992 to 2012 to identify patients
with a diagnosis of VPI treated with PPF and eventual PPF takedown.
All patients who fit these criteria were included in this study. No pa-
tients who had a diagnosis of VPI treated with PPF and eventual PPF
takedown were excluded. Demographic, operative, and speech data
were stratified based on treatment modality (ie, PPF takedown alone
versus PPF takedown with conversion to Furlow palatoplasty) and
compared. Demographic data included sex and age at time of PPF take-
down. Operative data included surgical complications and postopera-
tive length of follow-up.
The PittsburghWeighted Speech Score (PWSS) was used to quan-
tify preoperative and postoperative speech changes. The PWSS is a vali-
dated measure of clinical speech outcomes that rates 5 components of
Received April 16, 2015, and accepted for publication, after revision July 27, 2015.
From the Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh,
University of Pittsburgh Medical Center, Pittsburgh, PA.
Conflicts of interest and sources of funding: none declared.
Reprints: Evan B. Katzel, MD, Division of Pediatric Plastic Surgery, Children's
Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.
E-mail:
katzeleb@upmc.edu.Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/16/7704
–
0420
DOI: 10.1097/SAP.0000000000000632
H
EAD AND
N
ECK
S
URGERY
www.annalsplasticsurgery.comAnnals of Plastic Surgery
•
Volume 77, Number 4, October 2016
Reprinted by permission of Ann Plast Surg. 2016; 77(4):420-424.
41