Cleft Palate Outcomes and Prognostic Impact of Palatal Fistula on Subsequent Velopharyngeal Function—A Retrospective Cohort Study

Abstract

Objective: To assess outcomes from cleft palate repair and define the level of impact of palatal fistula on subsequent velopharyngeal function. Design: A retrospective cohort study. Setting: A regional specialist cleft lip and palate center within United Kingdom. Patients, Participants: Nonsyndromic infants born between 2002 and 2009 undergoing cleft palate primary surgery by a single surgeon with audited outcomes at 5 years of age. Four hundred ten infants underwent cleft palate surgery within this period and 271 infants met the inclusion criteria. Interventions: Cleft palate repair including levator palati muscle repositioning with or without lateral palatal release. Main Outcome Measures: Postoperative fistula development and velopharyngeal function at 5 years of age. Results: Lateral palatal incisions were required in 57% (156/271) of all cases. The fistula rate was 10.3% (28/271). Adequate palatal function with no significant velopharyngeal insufficiency (VPI) was achieved in 79% of patients (213/271) after primary surgery only. Palatal fistula was significantly associated with subsequent VPI (risk ratio = 3.03, 95% confidence interval: 1.95-4.69; P < .001). The rate of VPI increased from 18% to 54% when healing was complicated by fistula. Bilateral cleft lip and palate (BCLP) repair complicated by fistula had the highest incidence of VPI (71%). Conclusions: Cleft palate repair with levator muscle repositioning is an effective procedure with good outcomes. The prognostic impact of palatal fistula on subsequent velopharyngeal function is defined with a highly significant 3-fold increase in VPI. Early repair of palatal fistula should be considered, particularly for large fistula and in BCLP cases.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

“…In contrast, Becker & Hansson (2013) concluded that their low fistula rate (5%) after using the Sommerlad technique was due to their liberal use of lateral releasing incisions (42% of their cohort), considerably higher than in this study. Our study found the highest prevalence of fistula in PRS, in line with others (Lu et al, 2010, Moar et al, 2016, Smyth & Wu, 2019). Furthermore, Lu et al (2010) reported that their fistula rate decreased significantly with greater number of years of surgeon experience, as has also been reported here.…”

“…Others have published on the Sommerlad soft palate repair technique (Andrades et al, 2008; Becker & Hansson, 2013; Doucet et al, 2013; Luyten et al, 2013; 2014; Yang et al, 2013; Cairns et al, 2014; Moar et al, 2016; Rossell-Perry et al, 2015; Dissaux et al, 2016; Nyberg et al, 2018; Bruneel et al, 2018; Klinto et al, 2018; Mapar et al, 2019; Smyth & Wu, 2019). In 3 studies, the Sommerlad intravelar veloplasty was part of a protocol of delayed hard palate closure (Doucet et al, 2013; Dissaux et al, 2016; Klinto et al, 2018 [in 2 of 3 centers]); in another 2 studies, gold standard speech methodology was not used (Andrades et al, 2008; Yang et al, 2013); in 3 studies detailed speech results were not given (Becker & Hansson, 2013; Rossell-Perry et al, 2015; Moar et al, 2016).…”

Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair

“…Our study supports the finding that palatal fistulae increase the likelihood of VPI postoperatively (Smyth & Wu, 2019). This is unsurprising, as fistulae inherently cause defects in the velopharyngeal seal, leading to hypernasality and regurgitation.…”

“…By identifying factors associated with the development of VPI, cleft teams may be able to counsel patients and tailor surgical treatment plans in advance of the primary repair to mitigate increased risks for the development of VPI. Numerous studies have examined patient factors associated with the development of VPI, suggesting a multifactorial nature involving genetic, anatomic, and surgical factors (Cohen et al, 1991; Randall et al, 2000; Sweeney et al, 2015; Yuan et al, 2016; Smyth & Wu, 2019; Stein et al, 2019). However, further studies are needed to determine the exact roles of these factors in the development of VPI (Sainsbury et al, 2019).…”

Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations

“…29,30 This rate more than doubles for cleft palate patients that develop a palatal fistula. 30 Indeed, the majority of patients in our sample had a diagnosis of cleft lip and/ or palate. Cleft patients may be at increased risk of obstructive sleep apnea because of abnormal dimensions of the maxilla and mandible, a small nasopharyngeal space, and scarring from prior procedures.…”