Long-term Morphological Changes of the Velum and the Nasopharynx in Patients With Cleft Palate

Objective To investigate long-term morphological changes in the soft palate length and nasopharynx in patients with cleft palate. We hypothesized that there would be differences in the morphological development of the soft palate and nasopharynx between patients with and without cleft palate and that these developmental changes would negatively affect the soft palate length to pharyngeal depth ratio involved in velopharyngeal closure for patients with cleft palate. Design Retrospective, case-control study. Setting Institutional practice. Patients Ninety-two patients (Group F) with unilateral cleft lip, alveolus, and palate and 67 patients (Group CLA) with unilateral cleft lip and alveolus not requiring palatoplasty were included. Main Outcome Measures The soft palate length, nasopharyngeal size, and soft palate length to pharyngeal depth ratio were measured via lateral cephalograms obtained at three different periods. Results Group F showed a shorter soft palate length and smaller nasopharyngeal size than Group CLA at all periods. Both these parameters increased with age, but the increase in amount was significantly less in Group F compared with that in Group CLA. The soft palate length to pharyngeal depth ratio in Group F decreased with age. Conclusions In patients with cleft palate, the soft palate length to pharyngeal depth ratio, which is involved in velopharyngeal closure, can change with age. Less soft palate length growth and unfavorable relationship between the soft palate and nasopharynx may be masked in early childhood but can manifest later on with age.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty

Introduction Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning. Methods This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length. Results Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001). Conclusions BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.

Comparing the Temporal Aspects of Velopharyngeal Closure in Children with and without Cleft Palate

<b><i>Introduction:</i></b> Children with cleft palate exhibit differences in the 4 temporal components of nasalization (nasal onset and offset intervals, nasal consonant duration, and total speech duration), with various patterns having been noted based on different languages. Thus, the current study aimed to examine the temporal aspects of velopharyngeal closure in children with and without cleft palate; this is the first study to do so in the Turkish language. <b><i>Methods:</i></b> This study evaluated and compared the 4 temporal characteristics of velopharyngeal closure in children (aged 6–10 years) with (<i>n</i> = 28) and without (<i>n</i> = 28) cleft palate using nonword consonant and vowel speech samples, including the bilabial nasal-to-stop combination /mp/ and the velar nasal-to-stop combination /ηk/. Acoustic data were recorded using a nasometer, after which acoustic waveforms were examined to determine the 4 temporal components of nasalization. Flexible nasoendoscopy was then used to evaluate velopharyngeal closure patterns. <b><i>Results:</i></b> With regard to the 4 closure patterns, significant differences in the nasal offset interval (<i>F</i>_4–25 = 10.213, <i>p</i> = 0.04; <i>p</i> &#x3c; 0.05) and the nasal consonant duration ratio (<i>F</i>_4–25 = 12.987, <i>p</i> = 0.02; <i>p</i> &#x3c; 0.05) were observed for only /ampa/. The coronal closure pattern showed the longest closure duration (0.74 s). Children with cleft palate showed prolonged temporal parameters in all 4 characteristics, reflecting oral-nasal resonance imbalances. In particular, the low vowel sound /a/ was significantly more prolonged than the high vowel sounds /i/ and /u/. <b><i>Conclusions:</i></b> The examined temporal parameters offer more accurate characterizations of velopharygeal closure, thereby allowing more accurate clinical assessments and more appropriate treatment procedures. Children with cleft palate showed longer nasalization durations compared to those without the same. Thus, the degree of hypernasality in children with cleft palate may affect the temporal aspects of nasalization.

Evaluation of Velopharyngeal Closure Function With 4-Dimensional Computed Tomography and Assessment of Radiation Exposure in Pediatric Patients: A Cross-Sectional Study

Objective: Some patients with cleft palate (CP) need secondary surgery to improve functionality. Although 4-dimensional assessment of velopharyngeal closure function (VPF) in patients with CP using computed tomography (CT) has been existed, the knowledge about quantitative evaluation and radiation exposure dose is limited. We performed a qualitative and quantitative assessment of VPF using CT and estimated the exposure doses. Design: Cross-sectional. Setting: Computed tomography images from 5 preoperative patients with submucous CP (SMCP) and 10 postoperative patients with a history of CP (8 boys and 7 girls, aged 4-7 years) were evaluated. Patients: Five patients had undergone primary surgery for SMCP; 10 received secondary surgery for hypernasality. Main Outcome Measures: The presence of velopharyngeal insufficiency (VPI), patterns of velopharyngeal closure (VPC), and cross-sectional area (CSA) of VPI was evaluated via CT findings. Organ-absorbed radiation doses were estimated in 5 of 15 patients. The differences between cleft type and VPI, VPC patterns, and CSA of VPI were evaluated. Results: All patients had VPI. The VPC patterns (SMCP/CP) were evaluated as coronal (1/4), sagittal (0/1), circular (1/2), and circular with Passavant’s ridge (2/2); 2 patients (1/1) were unevaluable because of poor VPF. The CSA of VPI was statistically larger in the SMCP group ( P = .0027). The organ-absorbed radiation doses were relatively lower than those previously reported. Conclusions: Four-dimensional CT can provide the detailed findings of VPF that are not possible with conventional CT, and the exposure dose was considered medically acceptable.

Architecture of the Musculus Uvulae- A Review

The architecture of the musculus uvulae is subject to controversy, especially with regard to its crucial role in maintaining the morphology of the cleft palate, and its involvement in surgical procedures of palate repair. Its functional role in the closure of the velum and elevation of the same leading to voice changes are also an element of debate. The fate and orientation of its muscle fibres and its reinforcement with other related muscles of the palate raise concerns with regard to its functional role. Its positioning in the soft palate would give us an insight on the exact role played by this muscle in velopharyngeal closure. Its nerve supply also remains shrouded by various theories without conclusive evidence. Hence, this review aims to highlight its morphological role for the same.

Palatal Lift Appliance in a Case of Palatal Incompetence Secondary to Motor Neurone Disease

Velopharyngeal deficiencies are challenging conditions to manage, often requiring input from a number of different specialties including restorative dentistry. Palatal incompetence, that is, the inability of a structurally intact palate to elevate and close the nasopharynx from the oropharynx can result in hypernasality and air escape, compromising speech sounds as well as causing swallowing difficulty. The palatal lift appliance is a prosthesis designed to elevate the palate to aid velopharyngeal closure, and has been used to manage patients with neurological disorders affecting the palate. This report presents such management in a patient with motor neurone disease. CPD/Clinical Relevance: Dentists should be integral in the management of patients with motor neurone disease to help maintain oral health and prevention of dental disease, but also to provide speech prostheses and liaise with speech and language therapists. Patients with motor neurone disease may present to a generalist for routine dental care, and GDPs should be aware of the challenges of managing the dental work for this group of people.

Anesthetic Management for an Adult With Glycogen Storage Disease Type 0

A 20-year-old woman with glycogen storage disease type 0 (GSD-0) underwent velopharyngeal closure for velopharyngeal insufficiency following palatoplasty. To reduce the risk of complications attributed to GSD-0, general anesthesia was administered using a total intravenous anesthesia (TIVA) technique with propofol and remifentanil, along with supplemental glucose-containing intravenous fluids. Her blood glucose remained stable, intraoperative body temperature ranged from 36.5 to 37.2°C, and the velopharyngeal closure was completed without any adverse events.