PURPOSE: The optimal treatment of velopharyngeal incompetence (VPI) in patients with submucous cleft palate(SMCP) remains controversial. We reviewed speech outcomes in all cases where a Furlow palatoplasty (FP) alone was used for management of VPI in patients with SMCP.
METHOD: Patients were identified with overt SMCP based on physical examination. Velopharyngeal competence was ranked on a scale from 0 (no nasal air escape) to 13 by perceptual speech assessment. Patients with VPI underwent nasal endoscopy and videofluoroscopy. Lateral wall motion was graded from 1 (negligible motion) to 5. Speech outcome was determined by perceptual speech assessment 6 months or more following FP.
RESULTS: 11 patients (6 females and 5 males) with SMCP and VPI managed by a single surgeon between 1994 and 2007 were identified. Age at FP was 3 to 8 years; no patient had previous palatal surgery. Nasality rating for all patients was 6.2 ± 2.6 (Mean ± SD) at presentation and 0.8 ± 1.0 following FP, indicative of a highly significant reduction (p < .0001) with a mean reduction of 88 ± 5 percent. No patient required additional surgery or had airway compromise postoperatively. Reduction in nasality was greater than a cohort of patients with post-palatoplasty VPI managed with a FP by the same surgeon (mean reduction in nasality of 59 ± 6 percent). Preoperative velopharygneal gap size was classified as small (< 4 mm), medium (4-7 mm), and large (7-9 mm); and lateral wall motion ranged from 2 to 5. When these factors were analyzed independently, there was no correlation between speech outcome post-FP and either velopharyngeal gap size or lateral wall motion.
CONCLUSION: The FP is a powerful tool in the management of patients with SMCP who develop VPI. The following recommendation can be made in these patients: 1) No surgical management is warranted until at least age 3 years when a quantitative assessment of VPI can be made. 2) In patients with moderate to good lateral wall motion and a velopharyngeal gap size of 9 mm or less, the FP alone is effective. 3) Speech outcomes after FP in patients with SMCP are better than in patients with post-palatoplasty VPI.