Surgical Treatment of Submucous Cleft Palate: A Comparative Trial of Two Modalities for Palatal Closure

Abstract

Submucous cleft palate is a congenital malformation with specific clinical and anatomical features. It can be present with or without velopharyngeal insufficiency. Surgical treatment of this malformation is indicated only when velopharyngeal insufficiency has been demonstrated. This article compares two modalities of surgical treatment for submucous cleft palate. The first includes a minimal incision palatopharyngoplasty, as described in a previous report. The second combines the first technique with additional individualized velopharyngeal surgery (individualized pharyngeal flap or sphincter pharyngoplasty) performed simultaneously. The individualized part of the procedure was selected and performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy, as reported previously. Two hundred and three patients with submucous cleft palate were studied from 1990 to 1999. Videonasopharyngoscopy and multiview videofluoroscopy demonstrated velopharyngeal insufficiency in 72 patients, who were randomly divided into two groups. Those in group 1 (n = 37) underwent a minimal incision palatopharyngoplasty. Patients in group 2 (n = 35) also underwent that procedure but simultaneously received individualized pharyngeal flap or sphincter pharyngoplasty, according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients from both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after palatal closure was not significantly different in both groups of patients (14 percent versus 11 percent; p > 0.5). The mean size of the gap at the velopharyngeal sphincter during speech was not significantly different in both groups of patients before surgery (23 percent versus 22 percent; p > 0.5). After the surgical procedures, there was a nonsignificant difference between both groups of patients in mean residual size of the gap in cases of velopharyngeal insufficiency (7 percent versus 8 percent; p > 0.5). It seems that minimal incision palatopharyngoplasty is a safe and reliable procedure for palatal closure in patients with submucous cleft palate. The use of additional individualized velopharyngeal surgery performed simultaneously did not seem to decrease the frequency of residual velopharyngeal insufficiency. Moreover, the residual size of the gap at the velopharyngeal sphincter was not significantly reduced when an additional surgical procedure was performed simultaneously with palatal closure.

A revised classification of the cleft lip and palate

“…Patients often present after speech has already developed, with abnormal speech as the major complaint. Unfortunately, due to the delayed presentation, surgical repair of the submucous cleft palate does not correct speech (6). Early diagnosis and identification of the types of submucous cleft palate that will lead to a speech abnormality before speech development is the key to successful management of these patients.…”

Diagnosis and Management of Velopharyngeal Insufficiency Associated with Chromosomal Syndromes

“…The diagnosis of a submucous cleft palate may be difficult, especially for inexperienced clinicians. Since the description of submucous cleft palate with the classic triad by Calnan [8][9][10], several reports have demonstrated that there are a number of cases of submucous cleft palate without bifid uvula and/or muscular diastasis of the velum [3,9,10]. It is also of vital importance to perform a careful palpation of the palate in order to detect a notch on the posterior border of the hard palate, which may be the only sign of a submucous cleft palate.…”

“…Moreover, the diagnosis may have to be endoscopic in some cases. It is not until a detailed video nasopharyngoscopy detects hypoplasia or agenesia of the musculus uvulae that a definite diagnosis can be made [10]. The use of the terms submucous cleft palate and "occult" submucous cleft palate have somehow created some confusion.…”

Correlação entre fechamento velofaríngeo e dimensões nasofaríngeas após cirurgia de retalho faríngeo avaliados por meio da técnica fluxo-pressão

“…Há muitos anos tem-se investigado os efeitos da cirurgia sobre a fala e a respiração utilizando julgamento perceptivo associado ou não a métodos objetivos (10)(11)(12)(13)(14)(15)(16)(17)28,29) . As repercussões do retalho faríngeo têm sido objeto de estudo, também, no Laboratório de Fisiologia do HRAC-USP (4,6,21,22) .…”

“…Os dois orifícios posicionados lateralmente ao retalho devem ter diâmetro e permeabilidade suficientes para permitir a respiração nasal em repouso (9) . Muitos estudos relataram a efetividade do retalho farín-geo na redução dos sintomas da fala (4,6,(10)(11)(12)(13)(14)(15)(16)(17)(18) . Por outro lado, o retalho faríngeo está associado a um potencial e significante de comprometimento das vias aéreas superiores, incluindo-se entre esses comprometimentos desde a hiponasalidade, obstrução nasal crônica, até ronco e apnéia obstrutiva do sono, que podem trazer consequências graves aos pacientes (4,10,(19)(20)(21) .…”