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2008 Annual Meeting Abstracts

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Outcomes of the Furlow Palatoplasty for Secondary Management of Velopharyngeal Incompetence: Which Cases Fare Best?
Arun K. Gosain, M.D.1, Yashar Eshraghi, M.D.1, Dennis Kao, M.D.2, Seree Iamphongsai, M.D.1.
1University Hospitals Case Medical Center, Cleveland, OH, USA, 2Medical College of Wisconsin, Milwaukee, WI, USA.

PURPOSE:
The optimal treatment regimen for the secondary management of velopharyngeal incompetence (VPI) is controversial. Although the Furlow palatoplasty (FP) was initially described as a technique for primary palate repair, it has played an increasing role in the secondary management of patients with VPI. The present series reviewed speech outcomes in all cases where a FP alone was used for secondary management of VPI to identify selection criteria that identify which cases of VPI are best managed with the FP.
METHODS:
All cases of VPI managed by a single surgeon between 1994 and 2007 with a FP alone were identified. All patients underwent a preoperative evaluation consisting of 1) perceptual speech assessment; 2) nasendoscopy; 3) videofluoroscopy. All patients selected for management with a FP alone had a velopharyngeal gap size on phonation of 9 mm or less. Nasality was ranked on an ascending scale from 0 (no nasal air escape) to 13. Lateral wall motion was graded on an ascending scale from 1 (negligible motion) to 5. Speech outcome was determined by perceptual speech assessment 6 months or more following FP.
RESULTS:
37 patients (16 females and 21 males) underwent FP alone for secondary management of VPI between ages 3 to 7 years. Adequate speech outcomes data were available in 34patients. The etiology of VPI was following cleft palate repair in 21 patients, submucous cleft palate (SMCP) in 10 patients, and miscellaneous causes of palatopharyngeal disproportion in 3 patients. Nasality rating for all patients was 6.4 + 0.4 (Mean + SEM) at presentation and 2.2 + 0.4 following FP, indicative of a highly significant reduction in nasality (p < .0001). This reduction was greatest in patients with SMCP, with a mean nasality reduction of 88 + 5 percent. In contrast, mean reduction in nasality in patients with VPI following cleft palate repair was 59 + 6 percent (Figure 1). Preoperative velopharygneal gap size was classified as small (< 4 mm), medium (4-7 mm), and large (7-9 mm); there was no correlation between gap size and speech outcome following FP. In contrast, preoperative lateral pharyngeal wall motion demonstrated a strong correlation with final speech outcome. Reduction in nasality score of 67% or more was achieved in less than 45% of patients with lateral wall motion of 3 or below, and in 71% of patients with lateral wall motion of 4 or 5.
CONCLUSION:
The FP is a powerful tool in the secondary management of VPI. Based on the present series, the following selection criteria for its use can be proposed: 1) The FP is effective in patients with velopharyngeal gap size of 9 mm or less, with speech outcomes independent of gap size. 2) Patients with good lateral wall motion have markedly improved speech outcomes. 3) Speech outcomes in patients with SMCP are better than those with VPI from other causes, including post-palatoplasty VPI.


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