Palatal Length in Cleft Palate as a Predictor of Speech Outcome Peter Randall, M.D., Don LaRossa, M.D., Betty Jane MeWilliams, Ph.D., Marilyn Cohen, B.A., Cynthia Solot, M.A., and Abbas F. Jawad, Ph.D. Philadelphia amd Pitargh, Pa In an attempt to predict which pa from primary posterior pharyngeal flaps done at the time of palatal repair, palatal length was assessed before palatal repair and the patient was placed in one of four categories, Patients with longer palates preoperatively had statistically better speech outcomes than patients with shorter palates. ‘Statistical significance was found for most speech param. eters. Information on presurgical palatal length can be useful in predicting which patients might profit from pri- mary “pharyngoplasties.” (Plast. Reconstr. Surg, 106: 1254, 2000.) At the First International Congress on Cleft Palate in Houston, Texas, in 1969, ar B. Stark suggested that combining a posterior pharyngeal flap with primary cleft palate repair would produce better speech results.! He showed better speech in 31 of his patients who had the procedures compared with a group who had not. Two criticisms of this procedure were that most patients undergoing traditional cleft palate repair do not need the additiona surgery and that the operation carries an in- creased risk of morbidity and mortality, The question now, as it was then, is: can we predict which patients will benefit from primary poste- rior pharyngeal flaps or pharyngoplasties PATIENTS AND METHODS In an attempt to answer this question, we prospectively examined the speech results of 46 patients between the ages of 6 and 15 years in whom we had categorized palatal length as one of four types based on examination under anesthesia before the initial surgery. If both halves of the uvula easily reached the posterior From the Children's Hospital of Philadelphia and the University of Pisburgh, Received for publica 1999, Prelimin, 12, 1997; presented in this form atthe Annual Mee ngof the Amer pharyngeal wall below the adenoid pad, pa- nts were classified as type I. We had only two. type I patients. There were 21 subjects whose uvulae on the shortest side touched the post rior half of the adenoids. These were classified as type IL The type II group (20 subjects) consisted of those patients with uvulae that, on the shortest side, reached only as far as the anterior half of the adenoids. When one or both sides of the uvula failed to reach as far as the adenoids, the subjects were classified as type IV (three subjects; Fig. 1). As a control, we also examined 28 children between the ages of 6 and 12 months who were being operated on for other reasons and who, were thought to have normal oral-pharyngeal structures. These examinations were done af ter tracheal intubation using a laryngoscope and a cotton-tipped applicator. In all of these noncleft children, the distal tip of the uvula easily touched the posterior pharyngeal wall well below the level of the adenoid pad in the ype I position. Only 2 of our 46 subjects with clefis in this series had palates that long. All evaluations on cleft palate infants were done after endotracheal intubation with a Dingman mouth gag in place before injection with lidocaine and epinephrine. The head was, moderately extended. Forceps were used to position the uvulae without stretching the tis sue. Only those patients in whom the classifi- cation of palatal length was documented in the written operative notes were examined in the current study. Patients with the following criteria were ex- n June 21, 19%; revised December 7 results presented at the 8th International Congres on Cleft Palate and Related Craniofacial Anomalies, Singapore, September Cleft Palate Craniofacial Asociation, Scottsdale, Arizona, April 16, 19.Vol. 106, No. 6 / PALATAL LENGTH AND Type Vv Fic. 1. Schematic drawing of the four types of palatal length before surgery. In type I, the distal ips of both uvulae easily reach the posterior pharyngeal wall. In type II, one or fhe posterior half of the adenoid pad. both uvulae only reach In ype III, one or both sides of the uvulae reach only the anterior half of the adenoids, and in type IV, one or both sides, ddo not even reach as far as the adenoids. The measurement is made under gener and without stretching the tissues. This system has the ad J] anesthesia before injecting the tissues vantage of being specific for that particular patient, regardless of patient size or pharynx depth. cluded from the study: significant hearing losses (i.e., persistent conductive loss of 30 dB or more in one or both ears), learning disabil- ities, developmental delays, or serious other anomalies (including Pierre Robin sequence). 1255 The four groups of cleft patients were not sig- nificantly different regarding cleft type or sex (Fisher exact; Fig. 2) | infants had their clefis repaired before 1 year of age using a modified Furlow double- reversing Z-plasty technique by one of wo sur geons, who in a previous study had been shown to achieve similar results.*? All speech evalua- tions were performed after the subjects reached 5 years of age unless a secondary pos- terior pharyngeal flap was performed before that age (one patient with type III and one patient with type IV palatal length). In these two cases, immediate preoperative speech eval- uation was used; this occurred at 3.5 and 2.5 years, respectively, in the two patients. Speech was tested by one of two speech pa- thologists, both of whom have had conside able cleft experience and who have previously exhibited a high degree of inter-rater and in- trarater reliability. Speech was assessed using the University of Pittsburgh Weighted Values for Speech Symptoms Associated with Velopha- ryngeal Insufficiency.” This instrument assigns a numerical value to various characteristics as- sociated with nasal emission, nasality, phona- tion, articulation, and facial grimacing. For ex- ample, inappropriate, inconsistent nasal emission that is visible on a mirror but inaudi- ble would be given a value of 1, whereas audi- ble nasal emission would be scored as a 3. Scores for each of the five areas are then added together to provide a total score ranging from 0, indicating velopharyngeal competence, through 7 and above, indicating an incompe- tent mechanism. 4 2j— 10 oi Length " m W Fic. 2 The distribution of patients and the Veau classi No significant differences existed between the types of clefis in each cate- gory or in sex distribution among groups (Fisher exact) fication for clefts in each of the four types.1256, ResuLts. Nasal Emission When comparing the four types of soft pal- ate length, scores on the nasal emission seg ment of the test yielded a significant value of 0.021 (Kruskal-Wallis, a nonparametric test ig several independent groups). Type I subjects had a mean score of 0 (no evidence of nasal emission in any subject), and type IT subjects had a mean score of 0.57 (1.00 is indicative of inconsistent fogging on a mirror) nts had a mean score of 1.05 escape), and type IV patients had a mean score of 3.33 (audible nasal escape; Fig. 3) Hypernasality Hypernasality was almost nonexistent in all four types, and Kruskal-Wallis testing yielded p = 0.205. Because of the small sample size in the type I group (2 patients), we combined these two patients with the type II group (21 patients; total, 23 patients; mean score, 0.17) ‘These scores were compared with a group com- posed of both type III (20 patients) and type IV patients (3 patients; total, 23 patients; mean score, 0.52). As was expected with these low nasality scores, no significant difference ex- isted between these two larger groups (p = 0.114, Student's ¢ test, equal variance not a sumed; Fig. 4, above). Articulation Articulation errors associated with cleft pal- ate were seen in only one type III patient and Nasal Emission POT Kraskat Wall 1 " m Ww Fic. 3. Usiny uues for Speech, the University of Pittsburgh Weighted Vs iptoms Associated with Velopharyny Incompet the patients were 5 years of age [unless posterior pharyngeal flap was done befor rediate preoperative e nce, a number of parameters were examined after thatage (two patients), in which ease the uation was used]. Nasal emission. 1 differences among the four revealed the most signifi types. PLASTIC AND RECONSTRUCTIVE SURGERY, November 2000 in two of the three type IV patients (p = 0.000 by Kruskal-Wallis; Fig. 4, center, lef?) Phonation ‘ores on phonation were not significant (p= 0.59 by Kruskal-Wallis; Fig. 4, center, right). otal Score The Pittsburgh Test provides a total score based on a summation of the scores for the subtests.° The p value based on these data was 0.053, which falls just short of significance (Kruskal-Wallis). Combining types I and I and types III and IV and comparing these total scores yielded a significant p = 0.036 (Stu- dent's é test, equal variances not assumed). As the palates became shorter, the mean total scores grew larger (type I, 0; type I, 1.24; type III, 2.35; and type IV, 6.00), which is consistent with increased velopharyngeal inadequacy (Fig. 4, below). Posterior Pharyngeal Flap Few patients presented with speech symp- toms of sufficient consequence to require pha- ryngoplasties, which were superiorly based pos- terior pharyngeal flaps at that time in our dlinic. No flaps were needed in type I subjects, and only 1 of the 21 type II subjects required flaps. Flaps were required in 4 of the 20 type III subjects and in two of the three type IV pa- tients. The Fisher exact test yielded p = 0.058, which falls short of significance. Combining, type Land type II patients (1 of 23; 4.3 percent) and comparing this with a group combini type III and type IV patients (6 of 2: percent) yielded p = 0.048 (Fisher exact; Ns The one type IV child who did fairly well (i.e., at 7 years of age, she had audible nasal escape but no hypernasality or other speech problems) had a marked linear contraction along the margins of the cleft. When this wa excised, the release allowed both halves of the uyula to touch the anterior half of the adenoid pad in the type HI position, suggesting that she was not a true type IV. Significant differences existed among the four types on nasal emission and articulation. Total score and the need for posterior phary geal flaps fell just short of significance, Com- bining types T'and II patients and comparing them with types III and IV patients did reach significance in these parameters. The differ 8:Vol. 106, No, 6 / PALATAL LENGTH AND SPEECH Nasality my wskal Wallis me | ‘ng 1333 7 | 50 ae | os} 90 2s | a | Articulation Phonation ae | Total Score Total Score Fic. 4. (Above, left) Nasality failed to showa significant difference in comparing the four types. (Above, right) The type I group only had 2 patients; when this group was combined with the type i patients (21 patients) and then compared with a group combining type IIT (20 patients) and type IV patients (3 patients), despite the difference in the means, nasality still fell short of statistical significance, presumably because these means (0.17 and 0.52) are very small on a scale ‘Of0 to 4. (Center, fi) Articulation errors due to a cleft palate were extremely rare; they occurred in only one type III patient and 2 of the 3 type IV patients. The p-value is unusual. (Center, right) Phonation errors were not significantly different among the four types. (Below, lft) The Pits burgh Test p ovides a total score wed! on the summation of the scores in the subtests. The total score failed to reach statistical significance. (Below, right) Combining types Tand Il and comparing their total score with that of types IIT and IV yields a significant difference ences favored those subjects with longer pal- ates. No significant differences existed for na- sality or phonation. Discussion This preliminary report strongly suggests that patients who have type IV palates are very likely to have velopharyngeal incompetence, whereas those with type I palates probably will not. Patients with type II and type III palates present with mixed findings. Although only 1 of the 21 type II subjects (4 percent) and 4 of the 20 type III subjects (26 percent) ultimately required pharyngeal flaps, we must redefine our evaluation system to identify those for whom primary pharyngeal flaps may be the treatment of choice. For years, surgeons have been aware that a short palate after initial repair was often asso- ciated with speech problems. In 1877, Passa- vant and Simon stated “the nasal twang in speech was due to shortening of the palate.”*® Many have suggested steps to lengthen the pal- ate as part of the initial repair.2!” These include Roux (1843), H. L. Smith (1895), Blair (1911), J. B. Roberts (1918), Gillies andPercent P.P.F. Flaher Exact, Fic. 5. (Above) Posterior pharyngeal flap surgery (the op- eration preferred for velopharyngeal incompetence at the time of this study) was performed in 7 of the 46 patients. Comparing the incidence in the four types yields borderline significance. (Below) By combining types I and IL and com- paring them with types IIT and IV, statistical significance is obtained for the incidence of posterior pharyngeal flaps (1921), Ernst (1925), Dorrance (1925), Lim- berg (1927), Rosenthal (1928), Wardill (1928), Veau (1931), and Kilner (1937), We have been unable to find any reference to steps one might take before palatal surgery to determine which palates are likely to be short and incompetent postoperatively. How- ever, we are familiar with short palates that seem to function well and long palates that are incompetent, but we do not know if preope tive findings have a bearing on those out- comes.*! Trier and Dalston® took a number of mea- surements of palates before cleft repair and compared their data with speech outcomes. The only measurement consistently associated with poor speech was increasing width of the cleft. In addition, surgeons sometimes find a paucity of muscle in the soft palate during a primary repair. Although this finding has not been studied as relevant to speech outcome, as far as we know, it does seem likely that palatal function would be negatively affected. Combin- ing data on palatal length with other values, such as cleft width and muscle volume, might provide a more discrete indication of probable outcome. One advantage of the system we used is that the classification depends only on the relation- ship of the soft palate to the adenoids and the PLASTIC AND RECONSTRUCTIVE SURGERY, November 2000 posterior pharyngeal wall in a given patient; thus, regardless of the size of the patient or the depth of the pharynx, the system is relevant We attempted to test the value of primary posterior pharyngeal flaps by looking retro- spectively at a separate group of 20 children who had this operation. Although most of these children had their surgery before our four types of palatal length were defined, they would most likely have fallen into the type IIT and type IV groups on the basis of cleft descrip- tions noted in the chart. In this group, we also considered the width of the cleft and the lack of muscle bulk at the time of surgery. These children were obviously at risk for speech prob- lems associated with velopharyngeal incompe- tence. The speech of 19 of the 20 children was within normal limits, and only one had mild nasal turbulence as a single symptom. One patient had to have the flap taken down be cause of sleep apnea, and another required two revisions for hyponasality. Overall, the speech outcomes in this group were better than the average outcomes of type II and type IV pa- tients described in this report. CONCLUSIONS ‘The need for additional research in this area is unequivocal. We must increase our efforts to specify outcome predictors to select the most appropriate method for the initial repair and to minimize the need for secondary proce- dures. These preliminary data suggest that an evaluation of palatal length can be useful when, weighing the pros and cons of undertaking a primary pharyngoplasty. If one or both halves of the uvula fail to reach as far as the adenoid pad, a primary posterior pharyngeal flap (or similar procedure) seems indicated. If the uvu- lar segments reach only as far as the anterior half of the adenoid pad, a primary pharyngo- plasty might be considered. This decision would probably be reinforced by considering the width of the cleft and the volume of the palatal musculature. If the uvular segments reach the posterior half of the adenoid pad or reach as far as the posterior pharyngeal wall, a primary pharyngeal flap would be contraindi- cated because it is unlikely that a secondary pharyngoplasty will ever be required. Peter Randall, M.D. 609 Foulkeways Gwynedd, Pa, 19436Vol. 106, No. 6 / PALATAL LENGTH AND SPEECH ACKNOWLEDGMENT ‘This work was supported by the Children’s Hospital Plastic Surgery Research Fund, REFERENCES 1. Stark, R. B,,and Dehaan, C. R. Addition of pharyngeal flap to primary palatoplasty. Plast. Reconstr. Surg. 26: 378, 1960; Followup, Plast. Reconstr. Surg. 43: 624, 1969, 2 Veau, V. Division Palatine, Paris: Masson, 1931. Pp. 68, 3, Furlow,L.T.,Jr. Cleft palate repair by double opposing plasty. Plast, Reconstr. Surg. 78: 724, 1986, 4. Randall, P., LaRossa, P., Solomon, M., and Cohen, M. Experience with the Furlow double-reversing Z-plasty for cleft palate repair, Plast, Reconstr. Surg. 77: 569, 1986, 5, McWilliams, B.J., Randall, P., LaRosa, D., etal. Speech, charactetistics associated with the Furlow palatoplasty ‘as compared with other surgical techniques (Discus- sion). Plast, Reconstr. Surg. 98: 610, 1996. 6. McWilliams, B. J. Glaser, E. R., Phillips, B.J., etal. 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