Maxillary Advancement and the Presence of Preoperative Pharyngeal Flap in Cleft Palate Patients: Speech and Relapse Implications
Patients with cleft palate are also at risk for maxillary hypoplasia requiring orthognathic surgery. The effects of having a pre-existing pharyngeal flap on orthognathic surgical planning and subsequent speech outcome have not been well documented. Isolated cases have been described as part of a larger series of studies evaluating speech outcomes after maxillary osteotomy (Maegawa et al. 1998, Watzke et al. 1990). As a result of a small number of subjects, firm conclusions about changes in velopharyngeal functioning, flap status and relapse are difficult to make.
A retrospective chart review of patients with non-syndromic cleft lip and/or palate with pharyngeal flaps who underwent maxillary advancement between the 10 year period from January 1, 2003 to December 31, 2013 was conducted. Demographic information, diagnosis, speech and surgical outcomes were collected pre-operatively and where appropriate post-operatively. To evaluate relapse rates, patients with and without pre-existing pharyngeal flap were matched for diagnosis, gender and amount of advancement. Standardized cephalograms were hand traced and digitized. Paired t-tests were used to compare relapse rates between the two matched groups at pre and at least 6 months post- maxillary advancement.
Nineteen cleft lip and/or palate patients (8 females, 11 males) were included. Nine patients had unilateral cleft lip and palate and 10 had bilateral cleft lip and palate. The age range at the time of maxillary advancement was 15.5 to 24.5 years (mean 19.5). The age range at the time of pharyngeal flap surgery was 3.5 to 17.2 years (mean 8.1). Two patients required takedown of the pharyngeal flap at the time of advancement. One patient had an obstructing pharyngeal flap and documented OSA which was managed by BiPap. After takedown, resonance remained acceptable. The other patient required the largest advancement in the series (14 mm) which could not be achieved with the flap in place and pre-operatively mildly hypernasal was documented.
Pre-advancement, 11 patients presented with normal resonance, 4 with mixed slight/inconsistent hypernasality and hyponasality, 2 were hyponasal, and 2 patients had mild hypernasality. Patients were only referred for a post-advancement speech assessment if they reported increased hypernasality after surgery. None of the patients who presented with either normal or mixed resonance were referred for follow up. Resonance remained unchanged in one of the patients with pre-operative mild hypernasality. The other patient required flap takedown and became moderately hypernasal after surgery. A repeat pharyngeal flap pharyngoplasty 17 months after advancement was completed with a successful speech outcome.
The amount of maxillary advancement ranged from 3 to 14 mm. There was no difference in relapse rates between the two groups, likely as a result of the use of rigid internal fixation. Patients with an adequately functioning pharyngeal flap prior to advancement can expect their resonance to remain unchanged after surgery and this is consistent with the findings reported for non-syndromic cleft lip/palate patients without pharyngeal flaps. Patients who require significant advancements may require takedown of a pharyngeal flap which likely will result in increased hypernasality. Patients should be counseled accordingly.
References:
Maegawa J, Sells RK, David DJ: Pharyngoplasty in patients with cleft lip and palate after maxillary advancement. J Craniofac Surg. 9:4:330-335, 1998.
Watzke I, Turvey TA, Warren DW, Dalston R: Alterations in velopharyngeal functioning after maxillary advancement in cleft palate patients. J Oral Maxillofac Surg. 48: 685-689, 1990.