REVIEW

CURRENT
OPINION Optimizing speech outcomes for cleft palate
Michael M. Lindeborg a, Pramila Shakya b, Shankar Man Rai b, and
David A. Shaye a

Purpose of review
Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft
palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This
significantly impacts child development. There is a lack of evidence exploring, which surgical techniques
optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to
optimize speech outcomes for cleft palate.
Recent findings
The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest
Downloaded from http://journals.lww.com/co-otolaryngology by BhDMf5ePHKbH4TTImqenVAHFSsMzGEyg9QEQrl51YgWv9I2p6x8vndr9+QM3pKcLnMVXhY5fFSU= on 07/11/2020

evidence for optimizing speech. One-stage palatal repair is favored at 10–14 months of age, while delays are
associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between
the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management
should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics.
Summary
According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best
speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are
all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on
incorporating standardized measures and more robust study designs.
Keywords
cleft lip, cleft palate, quality of life, speech, velopharyngeal insufficiency

INTRODUCTION speech outcomes is essential for improving the stan-

Cleft lip with or without palate is the most common
congenital orofacial defect in the world, and glob-
ally occurs once every 500–700 births [1]. A cleft
palate develops when the palatal shelves fail to fuse
during the 6th–12th week of pregnancy [2]. Among
patients who undergo cleft palate repair, up to 5–
40% will have speech deficits because of anatomical
defects that persist after surgery [3,4]. The most
common anatomical defect impacting speech in
cleft palate is velopharyngeal insufficiency (VPI),
when the soft palate does not articulate against
the posterior pharyngeal wall [5]. This results in
persistent air escape from the nasal cavity and nasal
resonance during speech production [6,7]. VPI is
usually present before surgery, and sometimes post-
operatively as a common complication [6].
For patients with cleft palate, speech is an integral
component of care that directly impacts communi-
cation competency, psychological well being, quality
of life, and child development [7,8]. In recent years,
there has been a greater focus on optimizing speech
outcomes during primary palatoplasty or secondary
speech surgery. Understanding how to optimize
dard of care for cleft palate. This article provides an
update on recent literature focused on optimizing
speech outcomes in children with cleft palate.
STANDARD OF CARE FOR OPTIMIZING
SPEECH AFTER CLEFT PALATE REPAIR
Standard-of-care surgical treatment for cleft palate is
a primary palatoplasty between 10 and 14 months of
age. Repairing the cleft palate before phonemic
development supports normal speech production
and minimizes compensatory articulation errors
[9,10]. The most common techniques include the
two-flap palatoplasty with or without intravelar
a
Department of Otolaryngology, Massachusetts Eye & Ear, Harvard
Medical School, Boston, Massachusetts, USA and bDepartment of
Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
Correspondence to Michael M. Lindeborg, Department of Otolaryngol-
ogy, Massachusetts Eye & Ear, Harvard Medical School, Boston, 02114,
MA, USA. E-mail: michael_lindeborg@hms.harvard.edu
Curr Opin Otolaryngol Head Neck Surg 2020, 28:206–211
DOI:10.1097/MOO.0000000000000635

www.co-otolaryngology.com Volume 28  Number 4  August 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Standard-of-care surgical treatment for cleft palate
traditionally includes a wide range of surgical
techniques; however, procedures targeting the levator
muscles are needed to correct underlying
velopharyngeal insufficiency and speech deficits.
 The two-flap palatoplasty with intravelar veloplasty and
Furlow double-opposing Z-plasty at 10–14 months of
age have the strongest evidence for optimizing speech.
 For persistent velopharyngeal insufficiency, there are no
major differences between the pharyngeal flap,
sphincter pharyngoplasty, and posterior pharyngeal
wall augmentation.
 Recent innovations in speech surgical technique include
an autologous fat injection for pharyngeal
augmentation, modified superior-based pharyngeal
flap, and modified Furlow palatoplasty.
 Future research should incorporate standard indicators
for reporting baseline patient characteristics (e.g. cleft
size, closure pattern) and speech outcomes (e.g.
validated speech evaluation tools, nasoendoscopy).
veloplasty (IVVP) and the Furlow double-opposing
Z-plasty. Others include the von Langenbeck
(bipedicled) palatoplasty, and the V-Y pushback
(Veau–Wardill–Kilner) [11].
Past research has investigated differences in
postpalatoplasty speech outcomes, but limited evi-
dence has made it difficult to define, which tech-
nique is best. The two-flap palatoplasty with IVVP
resulted in superior speech compared with the V-Y
pushback as it reconstructs the velar muscle group
and avoids shortening of the palate [12,13]. Yama-
nishi et al. [14] found no significant differences in
speech outcomes between the V-Y pushback and
Furlow palatoplasty techniques. There is conflicting
evidence on whether the two-stage palatoplasty
compromises speech outcomes as it delays complete
palatal closure [12,13,15]. The V-Y pushback tech-
nique was found to significantly reduce hypernasal-
ity, though was not significantly better than other
VPI repair techniques [16].
Overall, there is a dearth of high-quality, compar-
ative speech studies between surgical techniques. Evi-
dence has recently emerged that sheds light onto
which surgical techniques optimize speech outcomes.
PRIMARY PALATOPLASTY: RECENT
INNOVATIONS AND EVIDENCE
A number of recent studies have supported the use
of the IVVP and Furlow palatoplasties for optimal
1068-9508 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Optimizing speech outcomes for cleft palate Lindeborg et al.
&&
speech outcomes. In 2019, Téblick et al. [17 ] per-
formed a systematic review of 23 retrospective and
cohort studies, finding that the IVVP and Furlow
techniques were associated with improved speech
outcomes compared with the two-flap palatoplasty,
V-to-Y pushback technique, and von Langenbeck
palatoplasty. For example, Doucet et al. [18] showed
in a cohort of 40 children that palatoplasty with
IVVP had decreased rates of misarticulation (15 vs.
55%) and improved intelligibility (75 vs. 30%) com-
pared with two-stage repair without IVVP after
3 years. The Furlow palatoplasty was also shown
to produce better speech outcomes when compared
with the von Langenbeck or two-flap palatoplasty
techniques [19–22]. Corroborating these results,
Chorney et al. [23] performed modified Furlow pal-
atoplasty in 289 patients and found that only 5%
required secondary surgery for persistent VPI. When
investigating the two-flap palatoplasty, a small ret-
rospective cohort (n ¼ 29) by Alammar et al. [24]
demonstrated that 21% of patients had VPI and
20% developed fistulas. Bruneel et al. [25] published
a 2018 study showing persistent speech deficits after
palatoplasty with IVVP; however, this case series had
a small sample size and did not directly compare
with other palatoplasty techniques. Of note, none of
these studies stratify by cleft size, which may nega-
tively bias speech results in cohorts with a higher
proportion of wider clefts (>9 mm).
A technique to optimize speech for wider clefts
is the modified Furlow palatoplasty with a unilateral
buccal myomucosal flap [26,27]. The addition of the
buccal myomucosal flap precludes the need to use
relaxing incisions, which via scarring and growth
restriction can impact palatal length and velar mus-
cle positioning [28]. This technique was supported
by a large cohort study (n ¼ 505) by Mann et al. [28],
finding that the addition of the buccal myomucosal
flap for wider clefts produced similar nasal reso-
nance scores compared with the standard Furlow
palatoplasty in narrower clefts. A bilateral buccal
myomucosal flap has also aided in wide palate repair
and VPI correction, though no recent studies have
explored their utility further [29].
With respect to staging palate repair, a 2017
systematic review of 26 studies concluded that there
was not enough high-quality evidence (primarily
retrospective and nonrandomized studies) to con-
clude whether the one-stage or two-stage palato-
plasty was associated with better speech outcomes
for unilateral cleft lip and palate [30]. Recent evidence
favors the one-stage palatoplasy, as cleft repair pre-
cedes phonemic development [31]. Kappen et al. [32]
established that the two-stage palatoplasty has poor
long-term speech outcomes, with high rates of hyper-
nasality (>30%) and pharyngoplasty (40%). Nyberg
www.co-otolaryngology.com 207
Facial plastic surgery
et al. [33] and Hanai et al. [34] found that one-stage
palatal repair leads to significant improvements in
compensatory articulation errors, but moderate rates
of persistent VPI.
Though a number of studies have investigated
when to perform palatoplasty, there has been sig-
&
nificant variability in age cutoffs. Shaffer et al. [35 ]
found that a late palatoplasty (>13 months), was
significantly associated with speech delays when
compared with early (<11 months) or standard
(11–13 months) timing. VPI and speech sound pro-
duction were not associated with palatoplasty tim-
& &
ing [35 ]. Pet et al. [36 ] compared internationally
adopted vs. nonadopted children with cleft palate,
and found that a 10.4 month average delay in
palatoplasty was significantly associated with mod-
erate/severe VPI and secondary speech surgery. Bru-
neel et al. [37] established that delayed palatoplasty
with IVVP will not correct established resonance
and articulation errors that have developed over
time.
Amongst patients who have submucous cleft
palates, cleft surgery was traditionally performed
only after developing hypernasality. Swanson
et al. found in a retrospective cohort of over 60
patients with submucous clefts that a palatoplasty
before 4 years old is associated with less incompe-
tent speech and persistent misarticulation [38].
Overall, the majority of recently published
articles continue to be comparative cohort studies.
Randomized controlled trials would bolster the
palatoplasty evidence base to optimize speech out-
comes.
CLEFT SPEECH SURGERY: RECENT
INNOVATIONS AND EVIDENCE
If a patient develops VPI and fails to improve with
speech therapy, the two most common procedures
used to reduce nasal emissions are the pharyngeal
flap and the sphincter pharyngoplasty. Procedure
choice is partially guided by underlying lateral wall
motion, but there is still mixed evidence about
which produces the best speech outcomes [39–
45]. A 2018 systematic review by de Blacam et al.
&&
[46 ] compared the pharyngeal flap, sphincter
pharyngoplasty, palatoplasty, and posterior pharyn-
geal wall augmentation in 4011 patients with VPI.
There were no significant differences in speech out-
comes or need for further surgery, though 70.7% of
patients had normal resonance and 65.3% had nor-
&&
mal nasal emissions [46 ]. Ekin et al. [47] found that
postoperative nasalance scores were significantly
lower in a cohort of 66 children after modified
superior-based pharyngeal flap, regardless of the
closure pattern (sagittal, circular, or coronal). In a
208 www.co-otolaryngology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
population of syndromic cleft patients (22q11.2
deletion), combined palatoplasty with sphincter
pharyngoplasty was found to produce similar
speech outcomes as a pharyngeal flap [48].
Repeat procedures for cleft palate repair has also
been shown to improve residual VPI. Repeat pala-
toplasty with reorientation of levator muscles was
shown to significantly improve nasal emission,
hypernasality, and articulation in patients with
VPI and evidence of abnormal levator muscle orien-
&&
tation [49 ]. In patients with persistent VPI after
primary palatoplasty, Wong et al. found that a mod-
ified Furlow palatoplasty with pharyngeal flap was
found to significantly improve perceptual speech
&
assessment and velar closing [50 ]. In small cohort
studies by Park et al. and Gosain et al., the double-
opposing Z-plasty was shown to significantly
improve speech outcomes (i.e. perceptual speech
assessment scale, resonance, nasal emission, intrao-
ral pressure, and social/personal problems) after
previous double-opposing Z-plasty (n ¼ 14) and Fur-
low palatoplasty (n ¼ 15), respectively [51,52].
Pharyngeal augmentation using an autologous
fat injection (AFI) has gained interest as a minimally
invasive method for VPI treatment. A 2017 review
by Nigh et al. [53] explored 15 studies with 251
patients who underwent AFI for VPI, the majority
of whom required a velopharyngeal gap closure of at
least 50%. AFI significantly improved speech and
nasalance, though cohort sizes were small, and there
was a lack of comparative studies [53]. An additional
study with a small cohort (N ¼ 21) also supported
AFI, but there was no long-term speech follow-up
[54].
&
Winters et al. [55 ] recently described a novel
approach for the superior-based pharyngeal flap,
which bisects the soft palate along the axial plane
and insets the pharyngeal flap into the soft palate.
The authors advocate that this technique avoids soft
palate midline splitting inherent to most pharyng-
oplasty inset techniques. In a cohort of 78 patients,
there were significant improvements in speech out-
comes using validated assessment tools; however,
&
future comparative studies are needed [55 ].
&
Denadai et al. [56 ] explored factors associated
with speech outcomes in a cohort of 167 patients
with repaired cleft palate who underwent posterior
pharyngeal fat graft for VPI, and found that a large
velopharyngeal gap and a higher number of previ-
ous palatal surgical procedures were associated with
poor speech outcomes. Interestingly, type of pri-
mary palatoplasty and preoperative speech deficits
&
were not associated with speech outcomes [56 ].
VPI surgical management can be partially
guided by the closure pattern and the size of the
velopharyngeal gap; however, there are no past
Volume 28  Number 4  August 2020

studies that stratify by gap size and closure pattern.
Nam [6] presented a conceptual framework for
approaching VPI surgery based on velopharyngeal
gap and closure pattern. The Furlow palatoplasty or
overlapping IVVP with oral Z-plasty may be better
suited for smaller gap sizes in which there is pre-
dominantly pharyngeal wall movement (sagittal). If
there is predominantly soft palate movement (cor-
onal), the sphincter pharyngoplasty or combined
overlapping IVVP with oral Z-plasty are recom-
mended. If there is combined movement of the soft
palate and pharyngeal walls (circular), then the
overlapping IVVP is suited for smaller gaps, and
the pharyngeal flap is best for larger gaps [6]. Over-
all, more research is needed that investigates speech
outcomes stratified by VPI characteristics.
OTHER SURGICAL INTERVENTIONS
Patients with cleft palate also undergo a number of
surgeries to optimize hearing, nasal function, and
maxillary development. The impact of these surger-
ies on speech is largely unexplored and remains a
potential avenue for future investigation. Eusta-
chian tube dysfunction is commonly found in
patients with cleft palate, and recent evidence sug-
gests that children with cleft palate have prolonged
dysfunction compared with those with cleft lip
&
alone [57 ]. Of note, the duration of Eustachian tube
dysfunction was not found to be associated with
cleft size or the presence of a cleft-syndrome/
&
sequence [57 ]. In regards to its impact on speech,
Shaffer et al. [58] discovered an association between
hearing loss or multiple tympanostomy tubes and
impaired speech development in a large cohort of
737 children, suggesting the importance of close
audiometry care in patients with cleft palate. Of
note, early tympanostomy tube placement before
palatoplasty did not impact speech outcomes.
Children with cleft palate often have maxillary
hypoplasia, and maxillary advancement procedures
may worsen speech by moving the soft palate ante-
riorly and worsening velopharyngeal sphincter clo-
sure. Amongst a cohort of 42 patients at Texas
Children’s Hospital, Schultz et al. [59] found that
LeFort I advancement resulted in worsening VPI in
22% of patients. Kobayashi et al. [60] compared a
small cohort of patients (n ¼ 26) who either under-
went simultaneous orthodontic premaxillary set-
back (OPS) and palatoplasty, OPS and palatoplasty
at separate times, or OPS with premaxillary osteot-
omy followed by palatoplasty, and found no signifi-
cant differences in speech. Dentino et al. [61] found
success using a superiorly based pharyngeal flap to
improve VPI that developed after maxillary
advancement in children with cleft palate. Overall,
1068-9508 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Optimizing speech outcomes for cleft palate Lindeborg et al.
more research is needed to explore how speech is
influenced by these auxiliary surgeries [62].
NONSURGICAL INTERVENTIONS AND
PATIENT-REPORTED OUTCOMES FOR
SPEECH
After surgical repair, a multidisciplinary team that
includes surgeons, speech and language patho-
logists (SLPs), orthodontists, prosthodontists, and
audiologists become involved to assure proper
speech development [63]. Speech evaluation
involves evaluating for inappropriate airflow using
nasoendoscopy, videofluoroscopy, nasometry, pres-
sure-flow technique, or MRI [45]. SLPs also utilize
validated speech assessment scales to investigate
aspects of speech including misarticulation, unin-
telligibility, distortion, nasal air escapes, hyperna-
sality, and glottal stop [64]. Speech therapy is a
necessary complement to surgery, as past studies
have shown that continued speech therapy after
palatoplasty can significantly reduce abnormalities
immediately present postoperatively [65]. In low-
resource settings, access to speech therapy has been
expanded through task-shifting and decentralized
outreach programs [66–68].
Patient-reported outcomes for speech have
grown significantly over the past few years
[7,69,70]. The VPI Effects on Life Outcomes (VELO)
instrument is one example that has been validated
across multiple languages in both low-resource and
high-resource settings [69,71,72]. Recent efforts
have demonstrated that the VELO can measure
quality of life improvements in speech after cleft
surgery, including those targeting VPI, such as pha-
ryngeal flap surgery [73].
CONCLUSION
Research continues to be limited by inconsistencies
in postoperative speech and VPI assessment. A
recent review by Kummer [74] investigated studies
between 1990 and 2014 that reported speech out-
comes for palatoplasty and velopharyngeal insuffi-
ciency. Most studies were not blinded, had
variability in speech samples used, had primarily
perceptual ratings, and did not often evaluate velo-
pharyngeal function using objective measures.
Overall, this significantly limits the ability to inter-
pret studies that compare surgical speech outcomes
[74]. The International Consortium for Health Out-
come Measurement published outcomes measures
for cleft lip/palate in 2016 and represents one pos-
sibility for standardizing measures and best practices
[75]. Future work should incorporate standardized
measures for speech and VPI, produce higher quality
www.co-otolaryngology.com 209
Facial plastic surgery
evidence, and aim to stratify by velopharyngeal
gap size, closure pattern, and preoperative charac-
teristics.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
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