Repairing the submucous cleft palate with Furlow palatoplasty: a single-center review
Jack E. Brooker, MD1, Michael Bykowski, MD1, James J. Cray, PhD2, Matthew M. Ford1, Jesse A. Goldstein, MD1, Joseph E. Losee, MD1.
1University of Pittsburgh, Pittsburgh, PA, USA, 2Ohio State University, Columbus, OH, USA.
BACKGROUND: The submucous cleft palate (SMCP) was described by Calnan as possessing the classical triad of zona pellucida, bifid uvula and hard palate notching. Kaplan later described the occult SMCP which lacked this triad but still possessed misaligned musculature which can lead to velar incompetence. Our center's preferred surgical repair for SMCP is the Furlow palatoplasty which repositions misaligned muscle fibers, elongates the palate and improves velopharyngeal closure. We wanted to describe our experience in overt and occult SMCP.
METHODS: Patients undergoing primary Furlow palatoplasty for SMCP with documented follow-up in EMR were collated. Patients included underwent surgery between April 2004 and December 2017. Demographics, pre/postoperative assessment including Pittsburgh Weighted Speech Score (PWSS), complications and secondary speech surgery (SSS) were recorded. Statistical analysis utilized Fishers extract and Mann Whitney U test for non-parametric analysis.
RESULTS: 351 patients were included: male:female ratio was 1.36, 95% were Caucasian, 35.6% were overt and 64.4% were occult, mean age at surgery: 7.2 years, mean follow-up time: 2.1 years. Average age at surgery: 6.5 vs 7.5 for overt and occult, respectively (P=0.001). 92.0% of occult SMCP had visible v-shaped velar vaulting upon gag elicitation. Mean preop PWSS was 15.7 vs 14 for overt and occult SMCP (p=0.035), postop PWSS was 5.6 vs 5.2 (p=0.805). 13.4% of patients required SSS; mean preoperative PWSS were 16.9 vs 14.3 for those requiring SSS vs those not (p=0.005). Mean age at surgery: 6.7 vs 7.3 for those requiring SSS vs those not (p=0.395). 11.9% of occult vs 16.0% of overt (P=0.327) underwent SSS (pharyngoplasty in 85.1% of cases). Three surgical complications were documented; tethering of velar sling to tonsillar pillar (1), scarring and shortening of velar sling (1), hypomobile palate (1). Complication rate did not vary by surgeon (p=0.558). 109 patients had videofluoroscopy results documented; lower lateral wall motion was associated with SSS (p=0.019).
CONCLUSIONS: This is the largest database of Furlow palatoplasty repair of SMCP. Complication rate was low and did not differ by surgeon. PWSS significantly improved in overt and occult SMCP with no differences in postoperative PWSS between these groups. Occult SMCP presented significantly later in life with lower mean PWSS than overt. V-shaped velar vaulting was overwhelmingly present in occult SMCP. Patients undergoing SSS (primarily pharyngoplasty) had higher pre-op PWSS but age at primary palate surgery was not predictive. Lateral wall motion on videofluoroscopy was lower in patients requiring SSS.
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