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2008 Annual Meeting Abstracts

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Outcomes of Primary Palatoplasty and Secondary Pharyngeal Flap in Non-
syndromic Patients with Cleft lip/Palate or Cleft Palate

Stephen R. Sullivan, MD1, Eileen M. Marrinan, MS, MPH2, Gary F. Rogers, MD, JD, MPH, MBA1, John B. Mulliken, MD1.
1Harvard Medical School, Boston, MA, USA, 2Upstate Medical University Hospital, Syracuse, NY, USA.

PURPOSE:
Velopharyngeal competence is the principle objective of cleft palate repair. The occurrence of velopharyngeal insufficiency (VPI) following palatoplasty has diminished over the past two decades; nevertheless, the frequency remains at 10 to 20%. Superiorly-based pharyngeal flap is traditionally used to correct VPI; however, many units prefer sphincter pharyngoplasty. This is an assessment of a one surgeon’s 28-year experience in palatoplasty as documented by the need for pharyngeal flap and complications.
METHODS:
We retrospectively reviewed all children with cleft lip/palate or cleft palate treated by the senior author between 1976 and 2004. Patients with identifiable syndromes and Robin sequence were excluded. A two-flap technique and vomerine flap(s), as necessary, was used for palatal closure. We calculated the fistula rate and evaluated speech results. Patients with VPI were treated with a superiorly-based pharyngeal flap; the width was customized based on lateral pharyngeal wall motion seen on videofluoroscopy.
We evaluated speech results following pharyngeal flap. Speech assessment focused on three structurally correctable variables; a successful flap was defined as normal resonance, normal intraoral pressure, and no audible nasal emission. We also calculated the rate of obstructive sleep apnea.
To evaluate for a possible association between surgical experience and VPI, we compared the pharyngeal flap rate of patients who had palatoplasty from 1976-1997 (Group 1, n=326) to those who had a palatoplasty from 1997-2004 (Group 2, n=331).
RESULTS:
Primary palatoplasty was performed on 657 patients with non-syndromic cleft lip/palate or cleft palate; the fistula rate was 1.7%. Pharyngeal flap was necessary in 12.8% (84/657) of patients.
Speech assessment following pharyngeal flap demonstrated no audible nasal emission or reduced intraoral pressure in 98.2%; normal nasal resonance or barely perceptible hypernasality in 87.2%; mixed resonance in 4.2%; hyponasality in 8.5%; and obvious hypernasality in 0% of patients. Obstructive sleep apnea was documented in 2.4% (2/84) of patients.
Comparing groups 1 and 2, surgical experience was associated with a 3-fold reduction in pharyngeal flap rate (95% CI=1.7-4.6, P<0.001).
CONCLUSION:
There was a low incidence of fistula and VPI after primary palatoplasty for a large series of patients with non-syndromic cleft lip/plate or cleft palate in a single surgeon’s practice. A customized superiorly-based pharyngeal flap was effective in correcting VPI and rarely caused obstructive sleep apnea. The need for pharyngeal flap following palatoplasty decreased significantly with experience.


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