Hanawa, Tomoko

Isshiki, Nobuhiko

Kawano, Michio

Kimura, Tadashi

Matsumoto, K Akiko

Nose, Kensuke

Sawada, Masaki

Kyoto University Research Information Repository

Title Velopharyngeal Function after Palatoplasty without Elevationof Mucoperiosteal Flap on the Cleft SideAuthor(s)Matsumoto, K Akiko; Isshiki, Nobuhiko; Sawada, Masaki;Kimura, Tadashi; Nose, Kensuke; Kawano, Michio; Hanawa,TomokoCitation音声科学研究 = Studia phonologica (1991), 25: 14-19Issue Date1991URL http://hdl.handle.net/2433/52471RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversitySTUDIA PHONOLOGICA XXV (1991)Velopharyngeal Function after Palatoplasty withoutElevation of Mucoperiosteal Flap on the Cleft SideAkiko K-MATSUMOTO, Nobuhiko ISSHIKI, Masaki SAWADATadashi KIMURA, Kennsuke NOSE, Michio KAWANO,and Tomoko HANAWAINTRODUCTIONAmong various types of palatoplasty ever reported for cleft palate, the push-back procedure would be the one most frequently utilized. The results in our clinichave been generally satisfactory in terms of velopharyngeal function. Some pro-blem to be solved in this push-back procedure would be among others the under-development of the maxilla, most likely resulting from the bony raw area left follow-ing the push-back of the palatal mucoperiosteal flap.In an attempt to minimize the adverse effect, Isshiki and Koyama*1) modifiedthe procedure in which mucoperiosteal flap only on the non-cleft side was elevatedunilaterally, in contrast to the ordinary push-back procedure w~ere bilateral mu-coperiosteal flaps were usually elevated. This operation is not indicated however forthose cases which require fairly great push-back such as wide cleft, short velum and/or long velopharyngeal distance.After long term follow-up, velopharyngeal function following the unilateralpush-back palatoplasty is reported here, in comparison with that after the ordinarybilateral push-back method.SUBJECTSFrom 1978 to 1990, we performed the unilateral push-back on sixty-seven pati-ents with cleft palate at our institute. Out of 67, we could assess their speech longenough postoperatively in 52, excluding the cases of the mental retardation andsevere hearing disturbance. They consisted of 13 children with complete unilateralcleft palate, 10 with incomplete hard and soft palate, 29 with cleft ve1um(TABLE1). Those operations were performed by several surgeons, at the age of patient be-tween 12 and 30 months, with average being 17.8 months and the S.D. 5.6 months(TABLE 2).Akiko K-MATSUMOTO (fl*~.:r): Research Fellow, Department of Plastic Surgery, Fuculty ofMedicine, Kyoto UniversityNobuhiko ISSHIKI (-~{~~): Professor, as aboveMasaki SAWADA (i¥ffiiE:f1:D: Lecturer, as aboveTadashi KIMURA (**1 iE): Director, Department of Plastic Surgery, Toyooka Public HospitalKennsuke NOSE (!Hm~1r-): Director, Department of Plastic Surgery, Tenri Yorozu Sodansho Hos-pitalMichio KAWANO ()1I!f:iffi~): Instructor, Department of Otorhinolaryngology, Fuculty of Medicine,Kyoto UniversityTomoko HANAWA (~ IDFf): Researdh Fellow, as aboveVelopharyngeal Function after Palatoplasty without Elevation ofMucoperiosteal Flap on the Cleft SideTable 1. Subjects by Cleft Type who underwent Unilateral Elevation15Complete Incomplete Cleft.velumUnilateral Cleft PalateCleft Palate(25.0%) (19.2%) (55.8%)Male Female Total (%)Complete UnilateralCleft Palate 12 1 13 (25.0)Incomplete Cleft Palate 5 5 15 (19.2)Cleft Velum 11 18 29 (55.8)28 24 52 (100.0)Table 2. Diagram Showing the Age of Patients when they Underwent Unilateral Push-back-r-- - r--- - -- f---- f----f---- ..---- '--..---624Cases(N)812 13 14 15 16 17 18 19 20 21 22 23 24 - Age in monthsIt should be noted that this type of operation was performed not uniformly buton some selected cases only, because the unilateral elevation did not seem enough forthe cases of wide cleft, short velum or long velopharyngeal distance. This biasedselection of patients for unilateral elavation operation in terms of cleft size or type ex-cluded simple comparison of the results between the two groups of different operation.Instead, comparison of postoperative velopharyngeal function between the twogroups was made only on those who had comparable preoperative structure, that is,cleft of the velum. Cleft size and type in both the groups were found almost thesame when averaged. Twenty nine cases of unilateral push-back in cleft velumwere examined, in comparison with twenty three cases which were randomly sampl-ed from those who underwent bilateral push-back during the same period at ourinstitute. The unilateral procedure was performed from 12 months to 36 monthsafter birth with the mean = 17.4 months and S.D. =4.0 months, while the bilateralplosive or fricative utterance wasIt can be scored with frost on the16 Akiko K-MATSUMOTO, Nobuhiko ISSHIKI, Masaki SAWADA, Tadashi KIMURAKennsuke NOSE, Michio KAWANO and Tomoko HANAWAone was from 13 months to 26 months after birth, with the mean 17.4 months andS.D. 4.2 months.Assessment. of the velopharyngeal function was made at approximately 4 yearsof age.METHOD1. Velopharyngeal function.All fifty two cases were examined for the function in the following manner.(1) Perceptive assessment of speech was made by two speech pathologists andfive plastic surgeons in terms of: a. hypernasality in plosive or fricatives syllables,b. nasal emission, and c. articulatory distortion (due to velopharyngeal incompe-tence).(2) Oral inspection was directed to the assessment of: a. length and mobilityof the velum, b. mobility of the lateral pharyngeal wall, and c. velopharyngeal dis-tance.(3) Rhinometric mirrorEscape of the air through the nose duringdetected with the use of a rhinometric mIrror.mirror used as a criterion.(4) PneumotachographyThe nasopharyngeal airway resistance (posterior method) during /p/ utterancewas derived from the formula; oral pressure/nasal air flow (dyne·sec/cmti). The val-ues were rated into 3 categories: good; more than 200 dyne'sec/cms, fair; between50 and 200 dyne'sec/cms, poor; less than 50 dyne·sec/cms.Overall velopharyngeal function can be classified into three groups; adequate(velopharyngeal competence) , borderline (marginal velopharyngeal competence),and inadequate (velopharyngeal incompetence). The criteria for the rating arefor adequate: neither hypernasality nor nasal emission, good velopharyngeal clo-sure on oral inspection, no frost on mirror for plosive production, and good naso-pharyngeal resistance., for borderline: slight hypernasality and nasal emission, in-consistent frost on mirror at the velopharyngeal closure, and fair nasopharyngealresistance., and for inadequate: apparent hypernasality and nasal emission, consis-tant frost on mirror, and poor nasopharyngeal resistance.Since the assessment was made in average at 4 years of age, it is quite likely that alarge percentage of the patients in borderline group will go to the normal one, withadvancement of age and speech therapy.2. Symmetry in the velar movement.Fourteen cases of cleft palate with the unilateral push-back operation was studi-ed through fibroptic nasopharyngoscopy whether the velar movement is symmetri-calor not.RESULT1. Seventy three per cent(38J52) of all the cases gained adequate velopharyngealVelopharyngeal Function after Palatoplasty without Elevation ofMucoperiosteal Flap on the Cleft SideTable 3. Velopharyngeal Function after Unilateral Push-back (1978-1990)cleft velum incomplete complete total(%) cleft (%) cleft (%) (%)adequate 23 (79) 8 (62) 7 (70) 38 (73)borderline 4 (14) 3 (23) 3 (30) 10 (19)inadequate 2 ( 7) 2 (15) 4 ( 8)total 29 (100) 13 (100) 10 (100) 52 (100)Table 4. Comparison of the Velopharyngeal Function between the Unilateral Push-backGroup and Bilateral Group, both performed in Velar Cleftunilateral push-back bilateral push-back(%) (%)adequate 23 (79) 18 (78)borderline 4 (14) 3 (13)inadequae 2 ( 7) 2 ( 9)29 (100) 23 (100)17functions without additional operations or speech therapy. The borderline V-Pcompetence or those with slight nasal emission accounted for 190/0(10/52). Inade-quate V-P competence requiring secondary operation or some prosthetic devices wasfound in four (4/52) or 8%. These incompetent cases were treated with either re-push-back, folded pharyngeal flap, closure of the palatal perforation or velum-liftingaid, one case each for each therapy. All these four cases attained adequate velopha-ryngeal function after either one of these secondary treatments. The velopharyn-g~al function after unilateral elevation in each type of cleft was as follows. Forcomplete cleft, it was adequate 70%, borderline 30%, and inadequate 00/0' for in-complete cleft 62%' 23% and 15% respectively in the same order, and for velumcleft, 79%, 14, and 7% (TABLE 3).The result of ordinary push back operation on 23 cases of cleft velum was ade-quate 78 %, borderline 13 %, and inadequate 9 % (TABLE 4).There was no statistically significant difference of postoperative velopharyngealfunction between unilateral and bilateral elevation methods when utilized for cleftvelum.No uvular deviation during vocalization was noted on oral inspection, exceptone, that was hemifacial microsomia which often demonstrates assymmetrical velarmovement without any operation.2. Fibroscopic examination, which was possible in 14 cases, also revealed sym-metrical movement of the velum in all the patients with all types of the cleft in thenasopharynx(FIGURE 1).18 Akiko K-MATSuMmo, Nobuhiko ISSHIKI, Masaki SAWADA, Tadashi KIMURAKennsukc NOSE, Michio KAWANO and Tomoko HANAWAFig. 1. All or the 14 cases had symmetrical movement orSOfl palate on fibroptic observalion.DISCUSSIONVarious types of palatoplasty have been devised) with ever improving the re-sult) and now over 80% of the patients could acquire almost normal speech after pri-mary operation. While the speech problem in cleft palate has been fairly well solv-ed, maxillary underdevelopment afler primary palatoplatsy has become an increas-ingly important problem to be challenged) as initially indicated by Gillies and Fry(1921)*2). From this standpoint of view, many ideas on surgical procedure for thispurpose have been introduced as exemplified by two stage palatoplasty with delay-ed hard palate closure (Schweckendiek(1951)*3), Slaughtcr(1954)*4), Osada(1985)*5) and others), palatoplasty hy use of only palatal mucosal flap (Perco (1974)*6),and Kamiishi(1974)*7) and elc). But, there's no any ideal method yet that resol-ves not only speech but also maxillary problems. lsshiki's unilateral push-backpalatoplasty also aims at serving for the above purpose by minimizing surgical impa-irment on the hard palate on cleft side without elevation of mucoperiosteal flap.Long-term postoperative assessments of the velopharyngeal function revealedthat there was no difference between this method and ordinary push-back method19Velopharyngeal Function after Palatoplasty without Elevation ofMucoperiosteal Flap on the Cleft Sidewhen performed on patients with cleft velum.These results show that the unilateral elevation procedure is capable enough toattain the velopharyngeal function for most of the cases as the ordinary push-backmethod.The maxillary development following this palatoplasty will be reported else-where.REFERENCESI) Isshiki, N. and Koyama H.: Palatoplasty without Elevation of Mucoperiosteal Flap on theCleft Side Ann. Plast. Surg., 4: 456-461, 1980.2) Gillies, H.D. and Fry, W.K.: A new principle in the surgical treatment of "Congenital cleftpalate" and its mechanical counterpart. Br. Med. ]., 1: 335-338, 1921.3) Schweckendiek, H.: Zur Frage der Friih-und Spatoperationen der augeborenen Lippen-Kie-fer-Gaumen-Spalten (mit Demonstrationen). Z. Laryng. Rhin. Otol., 30: 51-56, 1951.4) Slaughter, W.B. and Pruzansky, S.: The rationale for velar closure as a primary procedure inthe repair of cleft palate defects. Plast. Reconstr. Surg., 13: 341-357, 1954.5) Osada, M., Tanino, R., Nishimura, M. et al.: Our two stage operation for cleft lip and palate(Osada Method). ]pn. ].P.R.S. 28: 290-299, 1985.6) Perko, M.A.: Primary closure of the cleft palate using a palatal mucosal flap: an attempt to pre-vent growth impairment. J. max, -fac. Surg. 2: 40-43, 1974.7) Kamiishi, H., Ito, M. and Shioya, N.: Refinement of the push back operation for cleft palaterepair. Cleft Palate]. 14: 365, 1977.

Velopharyngeal Function after Palatoplasty without Elevation of Mucoperiosteal Flap on the Cleft Side

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Velopharyngeal Function after Palatoplasty without Elevation of Mucoperiosteal Flap on the Cleft Side

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