Maxillary Advancement and Velopharyngeal Insufficiency (VPI): Assessing risk and determining management options in high risk patients

Paula G. Klaiman MClSc., CAGS, Department of Communication Disorders/Speech-Language Pathology, The Hospital for Sick Children, Toronto, ON, Canada
Christopher R. Forrest MSc, MD, FRCS(C), FACS, Plastic Surgery, Centre for Craniofacial Care and Research, The Hospital for Sick Children, Toronto, ON, Canada
John H. Phillips MA, MD, FRCS (C), Plastic Surgery, Centre for Craniofacial Care and Research, The Hospital for Sick Children, Toronto, ON, Canada
Simone J. Fischbach MHSc, Department of Communication Disorders/Speech-Language Pathology, The Hospital for Sick Children, Toronto, ON, Canada
Audio File Recorded Presentation
Maxillary hypoplasia resulting in Class III malocclusion is significant to warrant maxillary advancement in approximately 20-25% of patients with cleft palate (McComb et al, 2011).  Advancing  and /or repositioning the maxilla surgically results in the soft palate being carried forward and this can negatively impact velopharyngeal functioning, leading to hypernasal speech  and excessive nasal air emission in at risk patients. Speech-Language Pathologists play an integral role in determining the potential effects maxillary advancement may have on velopharyngeal functioning (resonance) and speech sound production (articulation).  

This presentation will outline the pre-operative speech evaluation used at The Hospital for Sick Children, Toronto, Canada to provide valuable information to patients regarding expected speech outcomes following maxillary advancement.  Audio and videotape samples of perceptual ratings of resonance, articulation analysis, the use of acoustic analysis (Nasometry) and relevant components of the oral peripheral examination will be reviewed. The Hospital for Sick Children modified its assessment protocol in 2005 based on a retrospective clinical audit of cleft palate patients undergoing Le Fort I maxillary advancement over a 3 year period.  Pre-operative nasopharyngoscopy is no longer a standard pre-requisite test to ascertain risk for velopharyngeal insufficiency (VPI).  Results supported the use of perceptual evaluations by specially trained Speech-Language Pathologists to predict post-operative VPI risk and nasopharyngoscopy did not significantly increase predictive values (Phillips et al, 2005).

Patients undergoing maxillary advancement need to be counseled regarding potential increase in hypernasality after maxillary advancement if they pre-operatively present with borderline or inadequate velopharyngeal functioning.   A retrospective chart review over a 2 year period at The Hospital for Sick Children revealed that 14 (7 males, 7 females) out of 54 patients (25.9%) with repaired cleft palate required secondary surgery to manage VPI after maxillary advancement.  Of the 14 patients, 8 had bilateral cleft lip/palate, 4 were unilateral cleft lip/palate and 2 patients were syndromic with cleft palate (Apert's Syndrome, Treacher Collins Syndrome). Thirteen patients presented with some degree of hypernasality pre-operatively and were counselled regarding their increased risk of VPI. Four patients presented with unchanged resonance ratings post-advancement, 9 experienced an increase in hypernasality and for 1 patient there was no pre-operative data for comparison. On average, surgical management for VPI was completed one year post-advancement. Eleven patients were managed with a superiorly based pharyngeal flap, 2 had secondary Furlow palatoplasty and the patient with Treacher Collins Syndrome required a pharyngeal flap revision.

    Explaining the underlying mechanics of velopharyngeal movement and speech production physiology to patients can help them better understand potential speech outcomes and alleviate anxiety. The protocol for post-operative speech assessment for patients who experience VPI will be addressed with emphasis on the timing for additional testing and the role of nasopharyngoscopy to determine surgical/prosthetic management options to treat VPI.  Nasopharyngoscopy samples will illustrate the role of ratings of gap size and closure pattern to determine management options.   These include posterior pharyngeal flaps, sphincter pharyngoplasties, velar lengthening procedures (e.g. secondary Furlow palatoplasty ), pharyngeal wall augmentation and palatal obturator prosthesis.  

 References:

McComb RW, Marrinan EM, Nuss RC, LaBrie RA, Mulliken JB, Padwa BL: Predictors of velopharyngeal insufficiency after Le Fort 1 maxillary advancement in patients with cleft palate. J Oral Maxillofac Surg 69:2226-2232, 2011.

Phillips JH, Klaiman PG, Delorey R, MacDonald DB. Predictors of velopharyngeal insufficiency in cleft palate orthognathic surgery. Plast Reconstr Surg 115:681-686, 2005.

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