Original Article

The Cleft Palate-Craniofacial Journal

2018, Vol. 55(3) 430-436
Timing of Furlow Palatoplasty for Patients ª The Author(s) 2017
Reprints and permission:

With Submucous Cleft Palate sagepub.com/journalsPermissions.nav

DOI: 10.1177/1055665617726989
journals.sagepub.com/home/cpc

Russell E. Ettinger, MD1, Theodore A. Kung, MD1,

Natalie Wombacher, MS, CCC-SLP2, Mary Berger, CCC-SLP2,
M. Haskell Newman, MD1, Steven R. Buchman, MD1,2,3,
and Steven J. Kasten, MD1,2,4

Abstract
Background: Submucous cleft palate (SMCP) is the most common form of cleft involving the posterior palate, resulting in variable
degrees of velar dysfunction and speech disturbance. Although early surgical intervention is indicated for patients with true cleft
palate, the indications for palatoplasty and timing of surgical intervention for patients with SMCP remain controversial.
Methods: Twenty-nine patients with SMCP were retrospectively reviewed. Patients treated with Furlow palatoplasty were
dichotomized based on patient age at the time of surgical correction into early speech development and late speech development.
Primary outcome measures included standardized assessments of hypernasal resonance and quantitative pre- and postoperative
nasometry scores. Patients managed nonoperatively were included for comparison of early and late speech outcomes.
Results: Both early and late groups demonstrated improvement in qualitative assessment of hypernasal resonance following Furlow
palatoplasty. Early and late groups also had significant improvement in pre- to postoperative nasometry scores from 7.4 to 2.3 SD
from norm (P ¼ .01) and 6.0 to 3.6 SD from norm (P ¼ .02), respectively. There was no difference in postoperative nasometry
scores between early and late groups, 2.3 and 3.6 SD (P ¼ .12).
Conclusion: Furlow palatoplasty significantly improves the degree of hypernasality in patients with SMCP based on pre- and
postoperative nasometry scores and on qualitative assessment of hypernasality. There were no differences in speech outcomes
based on early compared with late operative intervention. Therefore, early palatal repair is not obligatory for optimal speech
outcomes in children with SMCP and palatoplasty should be deferred until the emergence of overt velopharyngeal insufficiency.

Keywords
palatoplasty, resonance, soft palate, speech perception

Introduction cleft palate population, there is a general consensus for the

Submucous cleft palate (SMCP) is readily diagnosed by iden-
tifying a distinctive triad of physical examination findings
(Calnan, 1954; Roux, 1825; Weatherley-White et al., 1972).
The presence of a bifid uvula, variable notching of the posterior
hard palate, and midline mucosal attenuation known as the
zona pellucida represent the phenotypic manifestations of the
aberrant hard palate and palatal muscle development during
embryogenesis. Despite these clear diagnostic criteria, the
optimal management of submucous cleft palate remains
controversial. Anatomically, anterior displacement of the leva-
tor veli palatini muscles onto the notched hard palate leads to
variable degrees of velopharyngeal dysfunction (VPD) and
resultant hypernasal speech in patients with a submucous cleft
palate (Hoopes et al., 1970; Sommerlad et al., 2004). In the true
indications and timing of surgical repair, which favor early
intervention to achieve optimal speech outcomes (Rohrich
et al., 2000). However, in the submucous cleft palate popula-
tion, the diagnosis is frequently delayed and patients
1
University of Michigan Section of Plastic Surgery, Ann Arbor, MI, USA
2
Craniofacial Anomalies Program, University of Michigan, Ann Arbor, MI, USA
3
Pediatric Plastic Surgery, CS Mott Children’s Hospital, University of Michigan,
Ann Arbor, MI, USA
4
CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
Corresponding Author:
Russell E. Ettinger, MD, 1500 E. Medical Center Dr., 2130 Taubman, Ann
Arbor, MI 48109-5895, USA.
Email: retting@med.umich.edu
Ettinger et al
commonly present after the critical early years of speech devel-
opment. Management of these patients is further complicated
by a lack of correlation between the degree of anatomic
abnormality seen in submucous cleft palates and the severity
of velopharyngeal dysfunction (Mori et al., 2013; Sommerlad
et al., 2004; Weatherley-White et al., 1972).
The type of operative intervention for symptomatic velo-
pharyngeal dysfunction in the setting of submucous cleft palate
varies by surgeon; some groups advocate performing a phar-
yngeal flap whereas others prefer dynamic sphincter pharyn-
goplasty (Abyholm, 1976; Fara and Weatherley-White, 1977;
Porterfield et al., 1976; Pryor et al., 2006). However, emerging
data demonstrate higher rates of obstructive sleep apnea (OSA)
in the postoperative period following both pharyngeal flap and
dynamic sphincter pharyngoplasty (Ettinger et al., 2012;
Jackson et al., 1976; Kravath et al., 1980; Orr et al., 1987;
Sirois et al., 1994; Thurston et al., 1980; Valnicek et al.,
1994; Ysunza et al., 1993), prompting surgeons to consider
Furlow palatoplasty as a primary treatment for submucous cleft
palate. Furlow palatoplasty has been shown to be an effective
treatment for symptomatic velopharyngeal dysfunction in
patients with submucous cleft palate without the increase in
airway obstruction seen with other techniques (Abdel-Aziz
et al., 2012; Chen et al., 1996). The ability to anatomically
reposition the aberrantly inserted levator veli palatini muscles
and simultaneously lengthening the posterior soft palate makes
the Furlow palatoplasty an appealing primary intervention to
address velopharyngeal dysfunction while leaving the option
for other techniques to be used in refractory cases. Neverthe-
less, the optimal timing of palatoplasty repair in the submucous
cleft palate population remains unknown. The recommended
age of palate repair in the submucous cleft palate population
varies widely in the literature, from 7 months to 26 years
(Abdel-Aziz et al., 2012; Chen et al., 1996; Park et al., 2000;
Pensler and Bauer, 1988; Sommerlad et al., 2004; Sullivan
et al., 2011; Ysunza et al., 2001). Although a subset of older
patients may represent those who presented late in adulthood,
the wide age range denotes an overall lack of agreement on the
optimal timing of palate repair. Similar to the management of
true cleft palate patients, some centers advocate early palate
repair for all patients presenting with submucous cleft palate
prior to critical speech development (18-24 months of age)
(Dorf and Curtin, 1982). Conversely, other centers will defer
surgical intervention until the emergence of symptomatic velo-
pharyngeal dysfunction during later speech development
(beyond 24-48 months). Given these vast discrepancies, the
purpose of our study is to report on how the timing of early
versus late palatoplasty affects ultimate speech outcomes in
patients with submucous cleft palate.
Methods
An institutional review board–approved (no. HUM00087332)
retrospective chart review was performed at the University of
Michigan on all patients with overt submucous cleft palate who
received treatment through the Craniofacial Anomalies
431
Program from January 1, 2000, to August 1, 2015. Patients
with either operative or nonoperative treatment were included
for review. Those treated operatively met inclusion criteria if
they underwent primary palate repair with Furlow palatoplasty.
Patients who underwent Furlow palatoplasty as a secondary
surgery or underwent Furlow palatoplasty with a concomitant
procedure (such as sphincter pharyngoplasty, posterior pharyn-
geal flap, or posterior pharyngeal fat grafting) were excluded.
Patients with occult submucous cleft palate and its subtypes
were excluded from this review. Patients in the operative repair
group were dichotomized into early and late operative inter-
vention groups. The early operative group was defined as those
patients who underwent Furlow repair during early speech
acquisition or <4 years of age. The late operative group was
defined as those patients who underwent Furlow palatoplasty
after critical speech development or >4 years of age. Primary
speech outcome measures were taken from nonblinded formal
speech evaluations conducted by 2 full-time speech and lan-
guage pathologists (M.B., N.W.) and included ratings of sub-
jective pre- and postoperative hypernasality scored on
Universal Parameters for Speech (UPS) severity ratings and
descriptors of the degree of hypernasality as well as objective
nasometry scores obtained using the Simplified Nasometric
Assessment Procedure Test-Revised (SNAP Test-R). Post-
operative speech evaluations were conducted 6 months after
surgery and included both subjective assessments of hypernas-
ality, articulation, and nasometry testing. The frequency of pre-
existing compensatory articulation disorders was calculated for
the early operative, late operative and nonoperative cohorts.
Speech therapy was recommended and continued in the post-
operative period for all groups based on the recommendations
of our speech and language pathologists. Charts were reviewed
for demographic information, age at presentation, syndromic
status, pre-existing comorbidities such as otitis media and
obstructive sleep apnea, prior speech therapy, intraoperative
and postoperative complications, duration of hospital stay, and
late emergence of sleep-disordered breathing. Mean pre- and
postoperative nasometry scores within groups were compared
with Student t test. Postoperative nasometry scores between
groups were compared with Student t test. Patients managed
nonoperatively were included as a reference group for compar-
ison of early and late speech outcomes. All statistical analysis
was performed using SPSS, v. 21 (IBM SPSS Statistics for
Windows, version 21.0; IBM, Armonk, NY). Statistical signif-
icance was defined as P < .05.
Results
A total of 29 patients with the diagnosis of submucous cleft
palate met inclusion criteria for this study. The majority of
patients (n ¼ 22) were diagnosed with isolated submucous cleft
palate whereas the remaining patients (n ¼ 7) exhibited known
syndromic diagnoses (Table 1). Pre-existing comorbidities
included otitis media (55%), gastroesophageal reflux (26%),
conductive hearing loss (11%), snoring (33%), and obstructive
sleep apnea (7%). Of the 29 total patients, 19 were treated
432 The Cleft Palate-Craniofacial Journal 55(3)

Table 1. Demographic and Clinical Variables. Table 2. Universal Parameters for Speech (UPS) Severity Ratings and
Descriptors for Degree of Hypernasality.
Variable
Severity Rating Descriptors
Gender, n (%)
Male 18 (62) 0 ¼ normal Nasality does not exceed nasality heard in regional
Female 11 (38) speech, and there is no perceptual evidence of cleft
Age at time of surgery, y, M + SD (range) speech type
Early operative 2.42 + 0.88 (1.2-3.3)
Late operative 6.41 + 1.93 (4.1-10.0) 1 ¼ mild Nasality exceeds regional speech nasality
Nonoperative (age at presentation) 2.89 + 2.57 (0.42-7.0) There is increased nasality heard on high vowels
Diagnosis, n (%) There is inconsistent or intermittent increased
Isolated SMCP 22 (76) nasality across vocalic segments
Van der Woude 1 (3) Nasality is perceived as socially acceptable in most
Vater 1 (3) circles
4p- syndrome 1 (3) Patient or parent is satisfied with individual’s speech
22q11 1 (3) resonance
Smith-Lemly-Opitz 1 (3) The speech specialist probably would not
Autism spectrum 1 (3) recommend physical management after
instrumental assessment
Andersen Tawil 1 (3)
Comorbidities, n (%) 2 ¼ moderate Hypernasality is perceived as pervasive and draws
Otitis media 15 (55) attention to itself and away from the message
Conductive hearing loss 4 (11) There is increased nasality heard on high and low
Reflux 7 (26) vowels
Snoring/sleep-disordered breathing 8 (33) Most vowels retain their identity
Pre-existing OSA (AHI > 5) 2 (7) Speech is socially unacceptable
Previous speech therapy 7 (26) The speech specialist probably would recommend
Hospital stay (hours), M + SD (range) physical management after instrumental
Early operative 27 + 8.0 (24-48) assessment
Late operative 36 + 26.8 (24-96)
Postoperative complications, n (%) 3 ¼ severe Hypernasality is perceived as pervasive and interferes
Partial palatal dehiscence 2 (7) with speech understandability
Persistent fistula 1 (4) There is increased nasality heard on vowels and some
Reintubation 1 (4) voiced consonants
Infection 0 (0) Some vowels may lose their identity
Persistent OSA 1 (4) Nasality is socially very unacceptable
New OSA 1 (4) The speech specialist definitely would recommend
physical management after instrumental
Abbreviations: AHI, apnea/hypopnea index; OSA, obstructive sleep apnea; assessment
SMCP, submucous cleft palate.
Adapted from Henningsson G, Kuehn DP, Sell D, Sweeney T, Trost-
Cardamone JE, Whitehill TL, Speech Parameters G. Universal parameters for
reporting speech outcomes in individuals with cleft palate. Cleft Palate Craniofac
operatively with Furlow palatoplasty and 10 patients were J. 2008;45:1-17.
managed nonoperatively. The 19 operative patients were
dichotomized into early (<4 years old, n ¼ 9) vs late (>4 years
old, n ¼ 10) operative groups. The average age at the time of repair. The cases of new OSA and persistent OSA were both
surgery for the early operative group was 2.4 years and in the early operative group whereas the patient requiring
6.4 years for the late group (Table 1). All operative patients reintubation was a late operative patient with a known diffi-
underwent Furlow palatoplasty for hypernasal speech or early cult airway.
hypernasal resonance identified during formal preoperative Qualitative assessment of speech outcomes included
speech evaluations. Inpatient hospital stay following Furlow numerical hypernasality ratings scored using interval scales for
palatoplasty varied between early (27 + 6.4 hours, range resonance parameters, based broadly on the design of the Uni-
24-48 hours) and late (38 + 26.8 hours, range 24-96 hours) versal Parameters for Speech (UPS) (Henningsson et al., 2008).
operative groups (P ¼ .10). Postoperative complications These UPS scores were calculated for the early operative, late
included partial palatal dehiscence (n ¼ 2), persistent fistula operative, and nonoperative cohorts (Table 2). Both the early
(n ¼ 1), new OSA (n ¼ 1), airway distress requiring reintuba- and late operative groups demonstrated improvement in mean
tion (n ¼ 1), and persistent OSA (n ¼ 1). The 2 patients with UPS hypernasality rating scores following Furlow palatoplasty
partial palatal dehiscence (<4 mm) were both in the late opera- improving from 1.9 to 0.7 and from 2.2 to 0.9, respectively
tive group. One patient went on to fully heal with expectant (Figure 1). By comparison, the nonoperative cohort was noted
management and the other had an asymptomatic 2-mm fistula to have a lower baseline UPS score of 0.7. Within the nono-
at the junction of the hard and soft palate with minimal effect perative group, 5 patients (50%) were diagnosed with SMCP
on nasal resonance such that the family deferred operative before age 4 and 5 patients (50%) were diagnosed after age 4.
Ettinger et al
Figure 1. Top: Change in UPS hypernasality ratings following Furlow palatoplasty for early and late operative groups. Bottom: Change in
UPS hypyernaslity ratings of nonoperative group on initial evaluation and subsequent follow-up. m ¼ mean score. UPS, Universal Parameters
for Speech.
Figure 2. Change in UPS hypernasality ratings by group. D ¼ change
in hypernasality rating. UPS, Universal Parameters for Speech.
Overall, the nonoperative group demonstrated a gradual trend
toward improvement in UPS hypernasality rating scores over
time from 0.7 to 0.2 despite lack of surgical correction (Figure
1). Aggregate UPS scores by cohort demonstrated similar
trends of improvement in both early operative and late opera-
tive groups (Figure 2).
The frequency of pre-existing compensatory articulation
disorders was recorded for the early operative, late operative,
and nonoperative groups. The early operative and late opera-
tive groups each had 1 patient with evidence of pre-existing
compensatory misarticulations. The nonoperative group
demonstrated a higher frequency of pre-existing compensatory
articulation disorders, with 5 of 10 patients demonstrating com-
pensatory misarticulations on initial speech evaluations.
433
Figure 3. Comparison of nasometry scores between early and late
operative intervention groups.
Pre- and postoperative nasometry testing was performed for
all operative patients using the Simplified Nasometric Assess-
ment Procedures Test–Revised (SNAP-R) (Kummer, 2005).
The SNAP-R test is optimized for utilization in young children
or individuals with minimal compliance, does not require lit-
eracy, and can be used in individuals with known articulation
disorders. Both early and late operative groups demonstrated
significant improvement in nasometry scores following Furlow
palatoplasty improving from 7.4 to 2.3 SD from norm (P ¼ .01)
and from 6.0 to 3.6 SD from norm (P ¼ .02), respectively
(Figure 3). There was no significant difference between
434
preoperative nasometry scores between the early and late
operative groups (P ¼ .23). Similarly, there was no significant
difference between postoperative nasometry scores between
the early and late operative groups (P ¼ .12) (Figure 3).
Discussion
The primary argument for early palatal reconstruction in the
submucous cleft palate population is the belief that a delay in
surgery will negatively impact the ultimate speech outcomes.
Early palatoplasty has proven effective in the true cleft palate
population, which has led to the generalization of this approach
to patients with submucous cleft palate. Although similarities
exist, the management of SMCP is often complicated by factors
such as highly variable degrees of velar dysfunction and fre-
quent delay in diagnosis. Today, there remains an overall lack
of consensus on the optimal timing of palatal repair for children
with SMCP. Historically, Calnan [3] and Porterfield et al. [9]
each advocated for early SMCP repair before speech develop-
ment to prevent the emergence of compensatory misarticula-
tions and aberrant speech behaviors. Subsequent studies
echoed the call for early intervention, including Pensler and
Bauer (1988), who reported on a series of 15 patients with
SMCP in whom intravelar veloplasty and palatal lengthening
was performed for symptomatic VPI. They found that those
operated on before age 2 years improved, with 75% achieving
normal speech but those operated on after age 2 improved to a
lesser degree, with only 14% achieving normal speech and 56%
with mild persistent VPI. Although these results favor early
operative intervention, a major limitation of this study is the
accuracy of their speech assessment for those patients less than
2 years of age, which is clearly at the early limits of modern
prelinguistic screening. Additionally, the authors also note that
71% of patients in their late operative group achieved improve-
ment in their postoperative speech parameters, revealing that
palatal reconstruction remains largely efficacious even after
speech development. Ultimately, the authors conclude that
patients diagnosed with SMCP before age 2 years should be
followed closely for the emergence of VPI rather than opting
for prophylactic palatal reconstruction for all patients prior to
speech development as is the standard of care for the true cleft
palate population.
The significant variability of speech dysfunction seen in
submucous cleft palate remains a critical feature of this condi-
tion. While a subset of patients with submucous cleft palate
will develop early VPD there are others who remain asympto-
matic into adulthood. Clearly, these patients do not warrant
surgical correction before the age of speech development as
is done for children with an overt cleft palate. The applicability
of treatment protocols for the management of true cleft palate
remains limited in the treatment of submucous cleft palate, in
which a large percentage of patients will ultimately not require
operative repair. Evidence from McWilliams’ review (1991) of
130 children with overt submucous cleft palate, including
47 with early diagnosis before age 4 years, demonstrated that
57% these patients never required surgical management for
The Cleft Palate-Craniofacial Journal 55(3)
dysfunctional speech. Furthermore, 36% of their remaining
83 patients diagnosed after age 4 also never required any sur-
gical intervention for dysfunctional speech. This is consistent
with the findings of our study, where a population of patients
did not undergo operative intervention for symptomatic VPI
following the diagnosis of SMCP. In our cohort, 56% of non-
operative patients who were diagnosed with SMCP before age
4 and 50% of those patients who were diagnosed after age 4 did
not receive surgical correction for VPI. These findings reiterate
the need for separate treatment algorithms for submucous cleft
palate, which are not contingent on the normative ages for early
speech development.
Patients with submucous cleft palate who are asymptomatic
or present with obvious speech dysfunction remain straightfor-
ward to classify and treat. However, patients with borderline
hypernasality or mild speech disturbances remain problematic.
Some institutions favor operative correction for intermediate
cases of hypernasality whereas others will opt for more con-
servative management. In our series, several patients presented
with mild hypernasality and intermediate UPS scores on initial
qualitative speech assessment. Surgical repair was not felt to be
warranted in these cases. These patients were referred for
speech and biofeedback therapy and routine follow-up. As
demonstrated in Figures 1 and 2 the nonoperative patients
demonstrated gradual improvement in UPS ratings over time.
This finding demonstrates that a subset of submucous cleft
patients with mild hypernasality can achieve a measurable
improvement with conservative management in lieu of palato-
plasty. This is not to say that true velopharyngeal insufficiency
in submucous cleft palate should be treated with speech therapy
and biofeedback but that some hypernasality in submucous
cleft palate patients may be tied to underlying cleft-related
misarticulations such as glottal stops and nasal fricatives,
which are amenable to speech training. We evaluated the fre-
quency of pre-existing compensatory misarticulation disorders
between both early and late operative groups and noted 1
patient in each group with pre-existing compensatory misarti-
culations on preoperative evaluation. The nonoperative group
demonstrated a higher number of patients with compensatory
articulation disorders (n ¼ 5). These patients were recom-
mended to proceed with speech and biofeedback therapy alone
to address the compensatory articulation errors and were not
recommended for surgical intervention given the lack of sig-
nificant hypernasality.
In this series, operative patients underwent pre- and post-
operative nasometry testing to allow for further objective eva-
luation of the improvement in hypernasality following Furlow
palatoplasty. We saw significant improvement in nasometry
scores for both our early and late operative intervention groups
at 7.4 to 2.3 SD (P ¼ .01) and from 6.0 to 3.6 SD (P ¼ .02),
respectively. No significant difference in the postoperative
intergroup hypernasality scores (P ¼ .12) was seen demonstrat-
ing comparable speech outcomes irrespective of age at the time
of surgery. Comparable outcomes between early and late palate
repair has similarly been demonstrated by other authors.
McWilliams (1991) also compared speech outcomes as a
Ettinger et al 435

function of age at the time of surgery (<4 vs >4 years of age).

They found no difference in speech outcomes based on age at
operation, with normal speech obtained in 58% of early opera-
tive patients and 76% of late operative patients. In their series,
8% of early and 8% of late operative groups demonstrated
persistent VPI following palatal repair. Other groups, including
Sullivan et al. (2011), have also indirectly evaluated age at the
time of palatoplasty as it relates to persistent VPI following
operative repair. In their series, they found no association
between age (<2 vs >2 years of age) and need for secondary
speech operations P ¼ .4. They also found Furlow palatoplasty
to be more effective than 2-flap palatoplasty for primary repair
of the submucous cleft palate, with a success rate of 67% vs
30%, with all patients >4 years old achieving normal speech in
the postoperative period.
We did not see significant differences in speech outcomes
with earlier intervention as compared to delayed Furlow pala-
toplasty beyond the age of critical language development. This
finding is a marked departure from the accepted treatment
algorithm for true cleft palate patients that favors early inter-
vention for optimal speech results. Furthermore, we observed
that many patients managed nonoperatively demonstrated
improvement with speech therapy and biofeedback training
alone. Given these results, we do not recommend early palato- Figure 4. Treatment algorithm following diagnosis of submucous cleft
plasty prior to the development of first words for all patients palate.
who present with submucous cleft palate. Rather, following the
diagnosis of SMCP, patients should undergo prelinguistic between patients. While we cannot fully remove all subjectiv-
screening or formal speech evaluation to identify any evidence ity from the perceptual speech assessments, the use of pre- and
of hypernasal speech. If hypernasality is present, patients postoperative nasometry provided an added measure of objec-
should initiate early speech therapy and biofeedback training. tivity that closely parallels the results of our perceptual speech
When a child is old enough to provide adequate speech sam- analysis. Importantly, the current study only evaluates the use
ples, baseline nasometry and nasopharyngoscopy should be of Furlow palatoplasty for the correction of symptomatic sub-
completed in cases of refractory hypernasality following mucous cleft palate. Therefore, our results on the timing of
conservative management. If there is evidence of true velo- palatoplasty are not directly generalizable to other surgical
pharyngeal insufficiency based on nasometry and nasopharyn- techniques such as fat grafting, pharyngeal flaps, or dynamic
goscopy, surgical correction is indicated (Figure 4). Deferring sphincterpharyngoplasty when used for primary palatal repair
palatoplasty in patients with submucous cleft palate until an in submucous cleft palate patients. At our institution, the Fur-
age after critical language development where true VPI can be low palatoplasty is the surgery of choice in submucous cleft
determined avoids unnecessary surgery in those patients who patients because of its simultaneous lengthening of the velum
may have otherwise remained asymptomatic or have bene- and reorientation of the aberrant palatal musculature without
fited from conservative management alone. Furthermore, precluding the use of any of the aforementioned techniques for
palatal surgery carries the risk of maxillary growth distur- cases of refractory velopharyngeal insufficiency. We acknowl-
bance and should not be undertaken lightly, especially in the edge that additional studies evaluating the timing of palatal
submucous cleft palate population, which demonstrates more repair via alternative techniques are warranted to fully establish
heterogeneous speech dysfunction compared to the true cleft generalizable treatment protocols for patients with submucous
palate population. cleft palate.
Like many studies evaluating cleft speech outcomes, our
study remains limited by its partial reliance on subjective mea-
sures from perceptual speech assessments. This shortcoming is
Conclusion
mitigated by the fact that at our center only 2 full-time speech Patients with submucous cleft palate are a unique subgroup
and language pathologists have provided speech evaluation and within the cleft palate population. The absence of overt clefting
therapy during the past 16 years. While the speech samples of of the palate, frequently delayed diagnosis, and lack of correla-
our patients were not blinded to the listeners, standard speech tion between anatomic severity and degree of speech dysfunc-
passages were utilized to generate the speech samples. Further- tion makes treatment of this population challenging. The
more, all speech samples included in this study were scored application of treatment algorithms derived from the true cleft
with the standardized UPS protocol to enhance reproducibility palate population to children with submucous cleft palate
436
overlooks these important clinical distinctions. The results of
our study indicate that although early screening is beneficial,
the need to intervene with operative palatal repair should be
reserved for patients with clear failure of maximal speech ther-
apy and evidence of overt velopharyngeal insufficiency. Delay-
ing palatoplasty until after the period of critical language
development when adequate speech samples can be obtained
will ensure adequate characterization of velopharyngeal insuf-
ficiency and avoid unnecessary surgery in patients who would
otherwise remain asymptomatic or benefit from conservative
management alone.
Author Note
Presented in part at the 72nd Annual Meeting of the American Cleft
Palate—Craniofacial Association, Palm Springs, USA.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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