The Occult Submucous Cleft Palate: Diagnosis, Treatment and 5-Year Patient Outcomes
Michael R. Bykowski, M.D., Jack E. Brooker, MB BChir, Matthew Ford, MS CCC-SLP, Jesse A. Goldstein, MD, Joseph E. Losee, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Occult submucous cleft palate (OSMCP) is often misdiagnosed as non-cleft velopharyngeal insufficiency (VPI) and mismanaged with little available long-term speech outcome literature. The goal of this study is to report our experience with diagnosis, treatment, and long-term outcomes of OSMCP.
Records were retrospectively reviewed for patients with OSMCP who were surgically treated for VPI between September 2004 and September 2013. OSMCP was defined by the lack of zona pellucida, hard palate notching, and bifid uvula and is diagnosed a soft palate that elevates in a vaulted V-shaped pattern consistent with levator muscle malposition. Records with <3 years of clinical follow-up were excluded from analysis. The primary outcome was the requirement of secondary speech surgery. Speech was evaluated over time using Pittsburgh Weighted Speech Scores (PWSS).
Long-term follow-up (mean= 5.5 years) was available for 41 patients who underwent Furlow palatoplasty to treat OSMCP and VPI (mean age= 6.7 years). OSMCP was diagnosed by a combination of techniques: 1) intraoral examination demonstrating vaulted V-shaped palatal elevation with gag (87.8%; 36/41 patients); 2) magnetic resonance imaging (19.5%; 8/41 patients); and 3) videofluoroscopy (65.8%; 27/41 patients). 39.0% of patients required secondary speech surgery due to persistent or re-development of VPI, which was performed an average of 2.96 years after initial palatoplasty (range: 1.02 – 5.71 years). Posterior pharyngeal flap (PPF) was performed in 87.5% of secondary cases, of which 14.2% developed obstructive sleep apnea and required PPF takedown. Patients who underwent secondary speech surgery had a significantly lower change in PWSS (postoperative PWSS minus preoperative PWSS) compared to those who did not undergo repeat surgery (4.4 and 10.0; p=0.022).
OSMCP is often confused with non-cleft VPI. Furlow palatoplasty can achieve successful long-term speech outcomes in many patients with OSMCP-associated VPI. However, patients must be monitored over time for recurrence and need for secondary speech surgery. Importantly, Furlow palatoplasty can limit the risk of PPF-related obstructive sleep apnea.
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