2017 Sec 1 Green Book

Annals of Plastic Surgery • Volume 77, Number 4, October 2016

Speech Outcomes After PPF Takedown

TABLE 1. Pittsburgh Weighted Speech Score

Nasal Emission (0 – 3, Highest Value)

Right

Left

Not present

0 1 2 3 3

0 1 2 3 3

Inconsistent, visible Consistent, visible

Audible Turbulent

Statistical Analysis Data were analyzed with unpaired, 2-tailed t tests with a signifi- cance level of P less than 0.05 using Prism GraphPad 5.0 (GraphPad Software, Inc., La Jolla, Calif.) statistical software. RESULTS Sixty-four patients with a history of VPI who underwent PPF takedown were identified during a 20-year period from 1992 to 2012. Forty-two patients (65.6%) underwent PPF takedown for OSA, 5 (7.8%) for OSA and deterioration of speech, 8 (12.5%) for borderline adequate speech and possible midface advancement with or without OSA, and 9 (14.1%) for recurrent VPI and possible conversion Furlow palatoplasty (Fig. 1). All PPFs were in place for greater than 5 years before takedown. Thirty-seven patients (57.8%) were men. Eighteen patients (28.1%) underwent PPF takedown alone, and 46 patients (71.9%) underwent PPF takedown with conversion to Furlow palatoplasty. Mean length of postoperative follow-up period was 38.1 ± 27.8 months (range 1 – 104). Mean age at time of intervention was 12.4 ± 3.9 years (3 – 22). Mean age for patients undergoing PFF takedown with con- version to Furlow palatoplasty was 12.3 ± 3.9 years (3-20) compared to 12.8 ± 4.2 years (7 – 22) for those undergoing PPF takedown alone ( P = 0.63). For all patients, mean preoperative PWSS was 5.7 ± 6.6 (range, 0 – 26) compared to 3.4 ± 4.5 (range, 0 – 27) after PPF takedown. No statistically significant regression in PWSS occurred after PPF take- down ( P < 0.05). For patients undergoing PPF takedown alone, mean preoperative (3.8 ± 6.1 [range, 0 – 23]) and postoperative PWSS (4.1 ± 5.3 [range, 0 – 23]) were not significantly different ( P = 0.89) FIGURE 1. Clinical indications for PPF takedown are obstructive sleep apnea (black), obstructive sleep apnea with deterioration of speech (dark grey), borderline adequate speech and the plan for midface advancement with or without OSA (light grey), and recurrent VPI with plans for conversion to Furlow palatoplasty (white).

Facial Grimace (0/2, Presenc e)

2

Nasality (0 – 4, Highest Value ) Normal

0 1

Mild hypernasality

Moderate hypernasality Severe hypernasality Hypo-/hypernasality

23

4 2 2 0

Cul de sac

Hyponasality

Phonation (0 – 3, Highest Value ) Normal Mild hoarseness/breathiness Moderate hoarseness/breathiness Severe hoarseness/breathiness

0 1 2 3 2 3 0 0 0 0 1 2 3 2 3

Reduced loudness Tension in system

Articulation (0 – 23, Summative ) Normal

Developmental errors Errors not related to VPI Errors related to dentition

Reduced intraoral pressure from sibilants Reduced intraoral pressure for fricatives Reduced intraoral pressure for plosives

Omission of fricatives or plosives

Omission of fricatives or plosives plus hard glottal attack for vowels

Lingual-palatal sibilants

2 3

Pharyngeal fricatives or plosives, “ backing ” , snorting, inhalation or exhalation substitutions

Glottal stops

3 4

Nasal substitutions for pressure sounds

speech: nasality, nasal emission, facial grimace, phonatory characteris- tics, and compensatory misarticulations (Table 1). 20 The complete PWSS assessments as evaluated by the speech pathologists at every visit, were reviewed. A lower PWSS denotes better speech than a higher PWSS. Patients underwent OSA screening and counseling regarding signs/ symptoms at initial evaluation. Clinical suspicion (ie, breath-holding spells, snoring) warranted further evaluation including diagnostic sleep stud- ies. After surgical intervention, parents were questioned and counseled at every postoperative visit regarding the persistence or development of OSA. Further diagnostic studies were ordered as warranted. Clinical indications for PPF takedown included: (1) OSA, (2) OSA and deterioration of speech (ie, worsening PWSS), (3) borderline ade- quate speech and possible midface advancement with or without OSA, and/or (4) recurrent VPI and possible conversion Furlow palatoplasty.

FIGURE 2. Pittsburgh weighted speech scores pre-takedown (black) and post-takedown (white) for all patients, PPF takedown with conversion to Furlow palatoplasty, and PPF takedown alone. All figures denote means with error bars reflecting standard error of the mean. ** represents a P value less than 0.01 and * represents a P value less than 0.05.

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