Progressive Tightening Of The Levator Veli Palatini Muscle During Intravelar Veloplasty Improves Speech Results In Primary Palatoplasty
Dennis C. Nguyen, MD1, Kamlesh Patel, MD2, Gary Skolnick, BS2, Lynn Grames, MS, CCC-SLP2, Mary Stahl, MS, CCC-SLP2, Albert Woo, MD2.
1Washington University, St. Louis, St. Louis, MO, USA, 2Washington University, St. Louis, Division of Plastic and Reconstructive Surgery, St. Louis, MO, USA.
Impaired speech from velopharyngeal dysfunction (VPD) is one of the major morbidities associated with cleft palate (2). It has been suggested that management of the levator veli palatini muscle with an intravelar veloplasty (IVV) may improve speech outcomes (3). Two popular techniques for repair of the levator musculature include reapproximation of Veau’s cleft muscle (Kriens, 1) and radical IVV with separate dissection and reapproximation of the levator. The senior author (ASW) introduces a more aggressive procedure where the levator is significantly overlapped upon itself and the muscle is maximally tightened. This study compares speech results from 4 separate levator protocols: 1) No IVV, 2) Kriens IVV, 3) Radical IVV, 4) Overlapping IVV.
A retrospective chart review was conducted on 267 patients with documented speech follow-up at a minimum of 3 years of age. Veau classification was used to categorize cleft severity. A single surgeon performed all the radical IVV (n=53), Kriens IVV (n=97) and non-IVV (n=103) procedures while the senior author performed the overlapping IVV procedure (n=14). Speech pathologists evaluated postoperative VPD based on speech resonance, nasal emission, turbulence and grimacing. Patients were then assigned a score on a 4-point scale (0 = normal resonance, no nasal emission, turbulence or grimacing; 1= occasional nasal emission, turbulence, grimacing, no concerns; 2 = mild hypernasality, intermittent nasal turbulence, grimacing, velopharyngeal imaging recommended; 3 = sphincter, pharyngeal flap recommended). Patients scoring either “0” or “1” are considered to have a desirable outcome, whereas “2” or “3” are undesirable outcomes. Fisher’s exact test was used to compare outcomes.
The cleft severity proportions were equivalent across the four procedures (p = 0.335). Postoperatively, patients who underwent (overlapping IVV) demonstrated significantly better velopharyngeal function compared to non-IVV (p=0.015) and Kriens IVV (p=0.002), and a tendency toward better velopharyngeal function than radical IVV (p=0.066). When we further stratify patients into desirable versus undesirable outcomes, patients who underwent overlapping IVV performed better than non-IVV (p=0.003), Kriens (p<0.001) and radical IVV (p=0.028). None of the overlapping IVV patients required further velopharyngeal imaging or secondary surgery.
This study demonstrates that speech outcomes are improved and need for secondary VPD management are reduced when the levator veli palatini is formally dissected out and reconstructed. Results were best when the muscle was maximally overlapped during primary palatoplasty.
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