Speech Outcomes After LeFort I Advancement Among Cleft Lip and Palate Patients

Abstract

Background Velopharyngeal insufficiency (VPI) results from incomplete closure of the velopharyngeal (VP) sphincter with oral pressure consonants during speech. Maxillary hypoplasia is common among cleft children and often requires LeFort I advancement. This results in anterior movement of the soft palate with the bony maxillary segment. Consequently, the size of the VP sphincter is increased and may result postoperative VPI or worsening of prior VPI. To better counsel our patients and their families of the risk of VPI after LeFort I advancement, we chose to evaluate our own cohort. Methods We conducted an institutional review board–approved prospective review of all cleft children presenting to Texas Children's Hospital who underwent LeFort I advancement after previous palatoplasty between 2013 and 2016 in a three-surgeon, consecutive patient series. Data collected included age, sex, ethnicity, cleft type, prior secondary speech surgery, presence of preoperative fistula, planned distance of advancement, orthognathic surgery performed, and any concurrent procedures performed. Primary outcomes measured included preoperative and postoperative VP function and hypernasality as measured by a certified speech pathologist. Results Velopharyngeal function was unchanged in 67% of our cohort after LeFort I advancement. Of those patients, 83% had evidence of VPI preoperatively, and 17% had normal speech preoperatively. Twenty-two percent of the patients displayed worsening VP function after surgery, and 6% displayed evidence of improvement. Velopharyngeal function was unable to be assessed in 6% of patients. Nasality ratings worsened in 39% of patients, were unchanged in 39%, and improved in 22%. Of the patients with incompetent VP function after surgery, 50% already received or are currently scheduled for secondary speech surgery, 25% declined secondary surgery, and 25% are pending scheduling. Conclusions Although VP function remains unchanged in a majority of patients after LeFort I advancement, VPI should be carefully screened for after surgery. If detected, secondary operations to correct speech should be strongly considered.

Changes in Nasalance and Velopharyngeal Function Following Conventional Le Fort I and Distraction Osteogenesis Using Perceptual and Instrumental Assessment

“…We hypothesized that there would be a significant difference in velopharyngeal function following DO and LFI, but we found no significant difference (Figure 3). This finding is consistent with previous studies in patients receiving LFI 12-14 and patients receiving DO. 12,21,22 However, this finding contradicts other studies which report a deterioration in velopharyngeal function following LFI 15-20 and DO.…”

“…But the patients in the present study who underwent DO were advanced 8 to 15 mm while the patients the study of Chua et al 28 were The mean increase in nasalance scores is important to consider for patients undergoing LFI and DO, as those in the We hypothesized that there would be a significant difference in velopharyngeal function following DO and LFI, but we found no significant difference (Figure 3). This finding is consistent with previous studies in patients receiving LFI [12][13][14] and patients receiving DO. 12,21,22 However, this finding contradicts other studies which report a deterioration in velopharyngeal function following LFI [15][16][17][18][19][20] and DO.…”

“…Velopharyngeal function was rated as competent, marginally incompetent, or incompetent. 13 Velopharyngeal incompetence described the inability for the palate to separate from the nasal cavity for production of oral or pressure consonants due to abnormal structure. 51 Patients with VPI consistently presented with all or some of the following: reduced oral pressure for high-pressure consonant production, compensatory articulation errors consistent with velopharyngeal dysfunction (ie, glottal stop substitution), hypernasal resonance, audible/inaudible nasal air emission.…”

“…For the oral sentence, patients with previous speech surgery demonstrated a mean increase of 3.1% (SD = 7.2) while patients without previous speech surgery had a mean increase of 21.7% (SD = 20.2). Six of the patients in the LFI group had previous sphincter pharyngoplasty surgeries (patients 1,8,11,12,13,15), 2 had previous pharyngeal flap (patients 5, 18, and 1 had previous palate re-repair (patient 17).…”

“…Some studies of patients undergoing LFI report that there is no adverse effect on speech and velopharyngeal function. [12][13][14] However, other studies report conflicting data that suggest speech deterioration following LFI. [15][16][17][18][19][20] Similarly, a handful of studies of patients undergoing DO have reported no change in speech and velopharyngeal function 12,21,22 while other studies report increased hypernasality and deterioration in velopharyngeal function.…”