The effect of the age at primary palatal repair on the speech of 3-year old children with isolated cleft palate was assessed. The group comprised 108 consecutive children whose palates were repaired at the mean ages of 12.9 (n = 45), 18.5 (n = 18) and 22.1 months (n = 45). Signs of cleft palate speech and the degree of speech impairment were recorded. The signs sought were: hypernasality, audible nasal air emission, and misarticulations associated with velopharyngeal insufficiency. The speech impairments were subdivided into three categories by combining the signs of cleft palate speech. The results showed that children who were operated on at the age of about 12-18 months were significantly better speakers than those operated on later. Of these 46 were rated as normal or practically normal speakers (73%), compared with 10 of the children who had their repairs delayed until about 22 months (22%). As a result of the speech evaluations, it was predicted that 5 (11%), 0 and 21 (47%) children in the early, middle, and late closure groups, respectively, required secondary surgery to eliminate signs of cleft palate speech associated with velopharyngeal inadequacy. The numbers who had secondary surgery were 4, 0 and 18 in the three groups.
Forty-one of 95 Finnish patients (43%) with diastrophic dysplasia had open cleft palate (CP). Submucous CP or its microforms were observed in an additional 30 patients (32%). Even though most of the patients have micrognathia, the high frequency of submucous clefts speaks against the role of the interposed tongue in the pathogenesis of CP in the Pierre Robin sequence. There was no hypernasality of speech in 27 of the 30 patients with submucous CP or its microforms, and the spontaneous speech of the other three was good. This is in contrast with observations in isolated submucous CP in general. No operative treatment was indicated in any case. Results after treatment of open CP and speech problems were in good agreement with results from the patients with isolated CP from the same period of time. As newborns 11 of the patients (12%) had severe respiratory difficulties caused by glossoptosis, and a Douglas operation was performed in three patients. Spinal compression due to abnormalities in cervical vertebrae and to dorsiflexion necessitated by intubation and velopharyngeal surgery may be a dangerous operative complication of patients with diastrophic dysplasia.
The island flap technique was applied to the secondary repair of 57 cleft patients with persisting open nasality and no velopharyngeal closure. A follow-up investigation showed that closure was achieved in about 50%, and the degree of nasality in spontaneous speech diminished in about 70% of the patients. The general quality of speech was postoperatively good in about 50%, but on the other hand fully normal only occasionally. The island flap secondary repair should probably be reserved for selected patients having a tight, short but mobile velum and relatively slight nasality. Failures of this method can still be improved by a traditional upwards based pharyngeal flap.
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