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Surgical correction of velopharyngeal insufficiency with and without compensatory articulation
International Journal of Pediatric Otorhinolaryngology
ELSEVIER
34 (1996) 53-59
Surgical correction of velopharyngeal insufficiency with and without compensatory articulation M. Pamplona”,
A. Ysunza*“, M. Guerrero”, M. Garcia-Velascob
I. Mayer”,
“Sub-Dirrccicin de Diagndstico, Hospital Gea Gonzrilez, Calzada Tlalpart 4800, h4Psico D.F. 14000 hDeparramento de Cirugia Pkistica y Reconstrucriva, Hospital Gea Gonzcilez. Calzada Tlalpan 4800, MP.xico D.F. 14000 Received 3 December 1994; revision received 17 May 1995; accepted 23 May 1995
Abstract The final speech outcome in cleft palate patients depends on two elements: normalization of nasal resonance and correction of compensatory articulation (CA). The purpose of this paper is to demonstrate whether early surgical correction of velopharyngeal insufficiency (VPI) may decrease total time of speech therapy (ST) necessary to completely eliminate CA. A group of 29 cleft palate patients in which VP1 and CA were demonstrated, were selected for the study group. Fourteen patients were randomly selected and underwent surgical correction of VP1 as soon as placement of articulation during isolated speech was normal. The other 15 patients underwent speech therapy aimed to correct CA, these patients were followed until articulation was normal during connected speech. At this point in time they underwent surgical correction of VP1 as the other 14 patients. Success rate for correcting VP1 after the operation was not significantly different for both groups. Furthermore, total time of ST was not significantly different for both groups. It is concluded that normalization of nasal resonance before articulation is corrected during connected speech does not seem to reduce total time of ST necessary to completely correct CA in cleft palate patients. Cleft palate; Velopharyngeal velopharyngeal insufficiency
Keywords:
* Corresponding
insufficiency; Compensatory
articulation;
author.
0165-5876/96/$09.50 0 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0165-5876(95)01245-7
Surgery for
54
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
1. Introduction The final speech results in cleft palate patients depend on articulation as much as correct nasal resonance balance for normality. Certain articulation disorders are generally regarded as compensatory behaviors secondary to velopharyngeal insufficiency (VPI) [9-121. In casesof cleft palate, nasal resonance is corrected by physical management of the velopharyngeal sphincter, this is accomplished either by surgery or prosthetic appliances. However, compensatory articulation (CA) disorders associated with poor velopharyngeal function appear to be slightly influenced by physical management of the velopharyngeal sphincter. These disorders require speech therapy since they include dysfunction, not only of the velopharyngeal sphincter, but the entire vocal tract. Speech therapy may correct faulty articulation patterns. Nonetheless, some patients may require speechtherapy (ST) over an extensive period of time before speech may be completely normal [2,121.
When cleft palate is surgically repaired, function of the velopharyngeal sphincter becomes adequate in approximately 80-90% of the cases [ll]. The remaining lo-20% of the patients have persistent VP1 and approximately half of these patients show CA [ 151. Surgical management of the velopharyngeal sphincter for communication impairments has only one goal - the elimination of abnormal hypernasal resonance. However, speech can only be rendered normal after physical management of the velopharyngeal sphincter if all other aspects of speech, such as articulation language, voice, fluency and rate are normal [9]. CA is corrected by speech therapy. Once articulation is normal, nasal resonance may be surgically or prosthetically corrected. Nonetheless, many children require an extensive period of ST before they are able to modify abnormal placement and manner of articulation and this may delay the surgery for VPI. In this paper, the relationship between early surgical correction of VP1 and total time of speech therapy is studied. For this purpose unilateral cleft lip and palate (UCLP) patients were studied in order to determine whether early surgical management of VP1 reduces the time necessaryto completely correct CA. 2. Materials and methods All cleft palate patients at the Cleft Palate Clinic of the Hospital Gea Gonz;ilez in Mkxico City, from January 1988 to December 1990 were studied. In order to qualify for the study group for this paper the patients had to meet the following criteria: 1. Total, unilateral cleft of primary and secondary palate [5]. These patients were non-syndromic and their UCLP was not associated with any congenital anomalies, thus ruling out extraneous factors which could influence speech and language development and learning. In other words, the patients had to be normal in all respects other than the UCLP. 2. Cleft palate width had to be grades I or II 131.
M. Pamplona et al. i Int. J. Prdiatr.
Otorhinolaryngol.
34 (1996) 53-59
55
3. Surgical repair of the UCLP had to be performed according to the surgical routine of the Cleft Palate Clinic as reported previously [lo]. This routine includes: surgical repair of the lip and primary palate between 1-3 months and surgical repair of the secondary palate between 12- 18 months with a push-back palatoplasty [13] and simultaneous posterior pillars pharyngoplasty [7]. 4. The patients had to show VP1 after surgical correction of the cleft palate as demonstrated by clinical assessment videonasopharyngoscopy and multi-view videofluoroscopy [4]. 5. The patients with post-operative fistulae were excluded from the study group. 6. The patients had to show consistent CA in association with VPI. 7. Speech therapy had to be indicated between 42 months and 9 years of age. 8. Language development had to be within normal limits as demonstrated by a battery of age-appropriate standardized language tests [6]. 9. Normal hearing had to be demonstrated by behavioral pure tone audiometry. The patients were randomly divided into two groups. The patients included in the first group received speech therapy aimed to correct compensatory articulation until placement of articulation was normal during connected speech even when hypernasality was present. At that point in time these patients underwent additional videonasopharyngoscopy and multi-view videofluoroscopy studies for pre-operative surgical planning. Surgical correction of VP1 was performed according to the findings of the direct visualization of the velopharyngeal sphincter in each patient [ll]. All patients received a tailor made pharyngeal flap [l]. The patients from the second group received speech therapy aimed at correcting CA during the production of isolated phonemes. Once placement of articulation was normal during isolated speech even when hypernasality was present, all the patients underwent additional nasopharyngoscopy and multi-view videofluoroscopy for pre-operative surgical planning. These patients were operated according to the findings of the direct visualization of the velopharyngeal sphincter during the production of isolated phonemes [l 11.All patients received a tailor made pharyngeal flap [l]. The patients included in this group continued receiving speech therapy post-operatively until articulation was normal during connected speech. Total time of speech therapy was considered as the time from the onset of speech therapy after palate closure until the complete normalization of articulation as assessedin conversational speech in both groups of patients regardless of the time at which a tailor made pharyngeal flap was performed. The following variables from both groups were compared: total time of speech therapy, size of the gap, successrate for correcting velopharyngeal insufficiency and age at onset of speech therapy. A Student’s t test was used in all cases. 3. Results
Six-hundred-and-fifty-eight cleft palate caseswere revised. A total of 29 patients met the criteria for being included in the study group. Fifteen patients were randomly selected and were included in the first group whereas 14 patients were included in the second group.
56
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
All 15 patients from the first group successfully completed speech therapy. Once articulation placement was normal during connected speech, they underwent a tailor made pharyngeal flap. The 14 patients included in the second group corrected placement of articulation during the production of isolated phonemes and were then operated on. The interval of speech therapy necessary to correct placement of articulation during isolated speech ranged from 3 to 8 months with a mean interval of 5.2 months. Post-operatively, all 14 patients were followed-up until articulation was completely normal during connected speech. Speech therapy was initiated at a median age of 5 years and 1 month in the first group. Patients from the second group started speech therapy at a median age of 4 years and 11 months. Furthermore, mean age at which speechtherapy was initiated was not significantly different for both groups (Table 1). Size of the gap of velopharyngeal closure during speech as observed pre-operatively by videonasopharyngoscopy and multi-view videofluoroscopy was not significantly different for both groups (Table 2). Successrate for correcting VP1 after the operation was not significantly different for both groups (Table 2). Total time of speech therapy was not significantly different for both groups (Table 3).
Table 1 Age at the onset of speech therapy Group 1 (months)
Group 2 (months)
85 54 38 46 68 63 116 61 41 44 65 65 39 43 113
49 42 70 60 90 96 93 60 35 44 95 38 58 42
X = 62.1 S.D. = 24.8 M.D. = 61 P > 0.05
X = 62.2 S.D. = 22.6 M.D. = 59
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
51
Table 2
Size of the gap pre-operatively and post-operatively after a tailor-made pharyngeal flap Group 2
Group I Pre (‘!A)
Post (“A,)
Pre (‘X)
30
0 0 0 0 0 IO 0 IO 0 0 0 0 0 0
30 30 30 80 30 40 50 50 40 20 30 40 30
40 20 60 30 40 30 30 40 60 30 50 50 30 x = 38%
X = 37.8%
S.D. = 12%
SD. = 14.7%
Post (‘%) 0 0 0 0 5 IO 0 0 0 0 0 0 0
P > 0.05
Successrate for correcting VP1 = 86%
Successrate for correcting VP1 = 85%
P > 0.05
4. Discussion
From the results of this study it appears evident that timing of surgical correction of VP1 does not seem to reduce the length of speech therapy necessary to completely eliminate CA. The pharyngeal flap has only one purpose i.e. to eliminate VPI. However, eliminating VP1 does not necessarily improve intelligibility, especially if speech is marked by severe CA. In patients from the second group, even with the successful elimination of VPI, intelligibility was not initially enhanced since CA was corrected only during the production of isolated phonemes pre-operatively. These patients continued receiving speech therapy until CA was completely corrected during connected speech. In contrast, intelligibility was improved in the first group of patients which corrected CA during connected speech pre-operatively. These cases underwent a pharyngeal flap operation which corrects hypernasality. Nasal resonance does not necessarily cause a decrease in intelligibility even though it is abnormal and unpleasant. Therefore, both groups of patients were followed until intelligibility was practically normal. The difference was that some patients received most of the speechtherapy prior to the surgery, whereas others received most of the speech therapy after the surgery. Ysunza and Pamplona demonstrated that correction of compensatory patterns of articulation increases velopharyngeal sphincter motion [ 141.Therefore, the degree
58
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
of nasal obstruction necessary to successfully eliminate VP1 is reduced following speech therapy. In this study, the size of the defect at the velopharyngeal sphincter was not significantly different for both groups. Furthermore, success rate for correcting VP1 was similar for both groups of patients. A possible explanation for the similar successrate is that all patients from both groups were operated with a tailor made pharyngeal flap which was performed according to findings of videonasopharyngoscopy and multi-view videofluoroscopy. The only difference was that patients from group 2 were operated as soon as they achieved adequate placement of articulation during isolated speech. In contrast patients from group 1 were not operated until articulation was normal during connected speech. Another factor is that the groups of patients studied herein were kept as homogenous as possible [8], cleft type, cleft width, language development, hearing level, surgical repair VPI, CA and absenceof fistulae were similar in all the patients included in the study groups. Nonetheless, the small number of patients that finally met the criteria for being included in the study does not allow us to draw any definite conclusions. As mentioned herein the surgical correction of VP1 did not reduce total time of speech therapy necessary to eliminate CA. A possible explanation is that articulation may be considered not only as a peripheral process, but rather a central cognitive-linguistic process which is developed depending, not only on the structural elements of the vocal tract, including the velopharyngeal sphincter, but the individual characteristics of the system used by each child [2]. Table 3 Total time of speech therapy Group 1 (months)
Group 2 (months)
18 42 42 28 26 38 25 14 32 18 46 39 28 29 46
45 54 32 15 10 38 40 38 48 60 14 21 12 20
x=31.4 S.D. = 10.39 P > 0.05
x = 31.9 SD. = 16.6
M. Pamplona et al. 1 Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
59
Although all the patients included in this small group required surgery for VPI, it should be pointed out that sometimes ST for CA may correct VP1 without surgery. In any case, the results of this study supports the statement that surgical remediation of VP1 should be delayed until compensatory articulation errors have been completely eliminated. References [I] Argamaso, R.V. and Shprintzen, R.J. (1989) The role of lateral pharyngeal wall movement in pharyngeal flap surgery. Plast. Reconstr. Surg. 66, 214-219. [2] Chapman, K.L. (1993) Phonologic processesin children with cleft palate. Cleft Palate-Craniofacial J. 30, 64-71. [3] Converse, M.J. (1977) Cleft lip and palate craniofacial deformities. In: Converse, M.J. (Ed.), Plastic Surgery. W.B. Saunders, Philadelphia, pp. 2508-2070. [4] Golding-Kushner, K., Ysunza, A., et al. (1990) Standardization for the reporting of videonasopharyngoscopy and multi-view videofluoroscopy. A report from an international working group. Cleft Palate J. 27, 3377347. [5] Kernahan, D.A. and Stark, R.B. (1958) A new classification for cleft lip and palate. Plast. Reconstr. Surg. 22, 4355443. [6] Rangel, E. et al. (1988) Bateria de evaluation de la lengua espariola (BELE) para nirios mexicanos de 3 a I I atios. Mexico, SEP-DGEE, l-383. [7] SanVenero Roselli, G. (1934) Divisione palatina sua cura chirurgica, In: SanVenero Roselli, G. Divisione Palatina Roma, Luigi Pozzi, pp. 268-275. [8] Shprintzen, R.J. (1991) Fallibility of clinical research. Cleft Palate-Craniofacial J. 28, 136-140. [9] Shprintzen, R.J. and Golding-Kushner, K.L. (1989) Evaluation of velopharyngeal insufficiency. Otolaryngol. Clin. North Am. 22, 519-536. [IO] Trigos, I. and Ysunza, A. (1988) A comparison of palatoplasty with and without primary pharyngoplasty. Cleft Palate J. 25, 163-166. [I I] Trigos, I., Ysunza, A. and Garcia-Velasco, M. (1993) Selection del procedimiento quirurgico para corregir IVF basados en la actividad motora del esfinter velofaringeo. Cirugia Plastica Ibero Latin0 Americana 19, 149%I57 (english abstract). [I21 Trost-Cardamone, J.E. (1990) Speech anatomy physiology and pathology. In: Kernahan, D. and Rosenthal, S. (Eds.), Cleft Lip and Palate: A System of Management. Williams and Wilkins, Baltimore, pp. l27- 140. [13] Wardill, W.E. (1937) Palate repair technique. Br. J. Plast. Surg. 16, 127-135. [I41 Ysunza, A. and Pamplona, M.C. (1992) Change in velopharyngeal valving after speech therapy in cleft palate patients: a videonasopharyngoscopic and multi-view videofluoroscopy study. Int. J. Pediatr. Otorhinolaryngol. 24 45554. [I 51 Ysunza, A., Trigos, I. and Baldizon, N. (1987) Sustituciones articulatorias gruesas en el diagnostic0 y tratamiento de la insuficiencia velofaringea. Boletin Medico de1 Hospital Infantil de Mexico 44, 81-86.
ELSEVIER
34 (1996) 53-59
Surgical correction of velopharyngeal insufficiency with and without compensatory articulation M. Pamplona”,
A. Ysunza*“, M. Guerrero”, M. Garcia-Velascob
I. Mayer”,
“Sub-Dirrccicin de Diagndstico, Hospital Gea Gonzrilez, Calzada Tlalpart 4800, h4Psico D.F. 14000 hDeparramento de Cirugia Pkistica y Reconstrucriva, Hospital Gea Gonzcilez. Calzada Tlalpan 4800, MP.xico D.F. 14000 Received 3 December 1994; revision received 17 May 1995; accepted 23 May 1995
Abstract The final speech outcome in cleft palate patients depends on two elements: normalization of nasal resonance and correction of compensatory articulation (CA). The purpose of this paper is to demonstrate whether early surgical correction of velopharyngeal insufficiency (VPI) may decrease total time of speech therapy (ST) necessary to completely eliminate CA. A group of 29 cleft palate patients in which VP1 and CA were demonstrated, were selected for the study group. Fourteen patients were randomly selected and underwent surgical correction of VP1 as soon as placement of articulation during isolated speech was normal. The other 15 patients underwent speech therapy aimed to correct CA, these patients were followed until articulation was normal during connected speech. At this point in time they underwent surgical correction of VP1 as the other 14 patients. Success rate for correcting VP1 after the operation was not significantly different for both groups. Furthermore, total time of ST was not significantly different for both groups. It is concluded that normalization of nasal resonance before articulation is corrected during connected speech does not seem to reduce total time of ST necessary to completely correct CA in cleft palate patients. Cleft palate; Velopharyngeal velopharyngeal insufficiency
Keywords:
* Corresponding
insufficiency; Compensatory
articulation;
author.
0165-5876/96/$09.50 0 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0165-5876(95)01245-7
Surgery for
54
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
1. Introduction The final speech results in cleft palate patients depend on articulation as much as correct nasal resonance balance for normality. Certain articulation disorders are generally regarded as compensatory behaviors secondary to velopharyngeal insufficiency (VPI) [9-121. In casesof cleft palate, nasal resonance is corrected by physical management of the velopharyngeal sphincter, this is accomplished either by surgery or prosthetic appliances. However, compensatory articulation (CA) disorders associated with poor velopharyngeal function appear to be slightly influenced by physical management of the velopharyngeal sphincter. These disorders require speech therapy since they include dysfunction, not only of the velopharyngeal sphincter, but the entire vocal tract. Speech therapy may correct faulty articulation patterns. Nonetheless, some patients may require speechtherapy (ST) over an extensive period of time before speech may be completely normal [2,121.
When cleft palate is surgically repaired, function of the velopharyngeal sphincter becomes adequate in approximately 80-90% of the cases [ll]. The remaining lo-20% of the patients have persistent VP1 and approximately half of these patients show CA [ 151. Surgical management of the velopharyngeal sphincter for communication impairments has only one goal - the elimination of abnormal hypernasal resonance. However, speech can only be rendered normal after physical management of the velopharyngeal sphincter if all other aspects of speech, such as articulation language, voice, fluency and rate are normal [9]. CA is corrected by speech therapy. Once articulation is normal, nasal resonance may be surgically or prosthetically corrected. Nonetheless, many children require an extensive period of ST before they are able to modify abnormal placement and manner of articulation and this may delay the surgery for VPI. In this paper, the relationship between early surgical correction of VP1 and total time of speech therapy is studied. For this purpose unilateral cleft lip and palate (UCLP) patients were studied in order to determine whether early surgical management of VP1 reduces the time necessaryto completely correct CA. 2. Materials and methods All cleft palate patients at the Cleft Palate Clinic of the Hospital Gea Gonz;ilez in Mkxico City, from January 1988 to December 1990 were studied. In order to qualify for the study group for this paper the patients had to meet the following criteria: 1. Total, unilateral cleft of primary and secondary palate [5]. These patients were non-syndromic and their UCLP was not associated with any congenital anomalies, thus ruling out extraneous factors which could influence speech and language development and learning. In other words, the patients had to be normal in all respects other than the UCLP. 2. Cleft palate width had to be grades I or II 131.
M. Pamplona et al. i Int. J. Prdiatr.
Otorhinolaryngol.
34 (1996) 53-59
55
3. Surgical repair of the UCLP had to be performed according to the surgical routine of the Cleft Palate Clinic as reported previously [lo]. This routine includes: surgical repair of the lip and primary palate between 1-3 months and surgical repair of the secondary palate between 12- 18 months with a push-back palatoplasty [13] and simultaneous posterior pillars pharyngoplasty [7]. 4. The patients had to show VP1 after surgical correction of the cleft palate as demonstrated by clinical assessment videonasopharyngoscopy and multi-view videofluoroscopy [4]. 5. The patients with post-operative fistulae were excluded from the study group. 6. The patients had to show consistent CA in association with VPI. 7. Speech therapy had to be indicated between 42 months and 9 years of age. 8. Language development had to be within normal limits as demonstrated by a battery of age-appropriate standardized language tests [6]. 9. Normal hearing had to be demonstrated by behavioral pure tone audiometry. The patients were randomly divided into two groups. The patients included in the first group received speech therapy aimed to correct compensatory articulation until placement of articulation was normal during connected speech even when hypernasality was present. At that point in time these patients underwent additional videonasopharyngoscopy and multi-view videofluoroscopy studies for pre-operative surgical planning. Surgical correction of VP1 was performed according to the findings of the direct visualization of the velopharyngeal sphincter in each patient [ll]. All patients received a tailor made pharyngeal flap [l]. The patients from the second group received speech therapy aimed at correcting CA during the production of isolated phonemes. Once placement of articulation was normal during isolated speech even when hypernasality was present, all the patients underwent additional nasopharyngoscopy and multi-view videofluoroscopy for pre-operative surgical planning. These patients were operated according to the findings of the direct visualization of the velopharyngeal sphincter during the production of isolated phonemes [l 11.All patients received a tailor made pharyngeal flap [l]. The patients included in this group continued receiving speech therapy post-operatively until articulation was normal during connected speech. Total time of speech therapy was considered as the time from the onset of speech therapy after palate closure until the complete normalization of articulation as assessedin conversational speech in both groups of patients regardless of the time at which a tailor made pharyngeal flap was performed. The following variables from both groups were compared: total time of speech therapy, size of the gap, successrate for correcting velopharyngeal insufficiency and age at onset of speech therapy. A Student’s t test was used in all cases. 3. Results
Six-hundred-and-fifty-eight cleft palate caseswere revised. A total of 29 patients met the criteria for being included in the study group. Fifteen patients were randomly selected and were included in the first group whereas 14 patients were included in the second group.
56
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
All 15 patients from the first group successfully completed speech therapy. Once articulation placement was normal during connected speech, they underwent a tailor made pharyngeal flap. The 14 patients included in the second group corrected placement of articulation during the production of isolated phonemes and were then operated on. The interval of speech therapy necessary to correct placement of articulation during isolated speech ranged from 3 to 8 months with a mean interval of 5.2 months. Post-operatively, all 14 patients were followed-up until articulation was completely normal during connected speech. Speech therapy was initiated at a median age of 5 years and 1 month in the first group. Patients from the second group started speech therapy at a median age of 4 years and 11 months. Furthermore, mean age at which speechtherapy was initiated was not significantly different for both groups (Table 1). Size of the gap of velopharyngeal closure during speech as observed pre-operatively by videonasopharyngoscopy and multi-view videofluoroscopy was not significantly different for both groups (Table 2). Successrate for correcting VP1 after the operation was not significantly different for both groups (Table 2). Total time of speech therapy was not significantly different for both groups (Table 3).
Table 1 Age at the onset of speech therapy Group 1 (months)
Group 2 (months)
85 54 38 46 68 63 116 61 41 44 65 65 39 43 113
49 42 70 60 90 96 93 60 35 44 95 38 58 42
X = 62.1 S.D. = 24.8 M.D. = 61 P > 0.05
X = 62.2 S.D. = 22.6 M.D. = 59
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
51
Table 2
Size of the gap pre-operatively and post-operatively after a tailor-made pharyngeal flap Group 2
Group I Pre (‘!A)
Post (“A,)
Pre (‘X)
30
0 0 0 0 0 IO 0 IO 0 0 0 0 0 0
30 30 30 80 30 40 50 50 40 20 30 40 30
40 20 60 30 40 30 30 40 60 30 50 50 30 x = 38%
X = 37.8%
S.D. = 12%
SD. = 14.7%
Post (‘%) 0 0 0 0 5 IO 0 0 0 0 0 0 0
P > 0.05
Successrate for correcting VP1 = 86%
Successrate for correcting VP1 = 85%
P > 0.05
4. Discussion
From the results of this study it appears evident that timing of surgical correction of VP1 does not seem to reduce the length of speech therapy necessary to completely eliminate CA. The pharyngeal flap has only one purpose i.e. to eliminate VPI. However, eliminating VP1 does not necessarily improve intelligibility, especially if speech is marked by severe CA. In patients from the second group, even with the successful elimination of VPI, intelligibility was not initially enhanced since CA was corrected only during the production of isolated phonemes pre-operatively. These patients continued receiving speech therapy until CA was completely corrected during connected speech. In contrast, intelligibility was improved in the first group of patients which corrected CA during connected speech pre-operatively. These cases underwent a pharyngeal flap operation which corrects hypernasality. Nasal resonance does not necessarily cause a decrease in intelligibility even though it is abnormal and unpleasant. Therefore, both groups of patients were followed until intelligibility was practically normal. The difference was that some patients received most of the speechtherapy prior to the surgery, whereas others received most of the speech therapy after the surgery. Ysunza and Pamplona demonstrated that correction of compensatory patterns of articulation increases velopharyngeal sphincter motion [ 141.Therefore, the degree
58
M. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
of nasal obstruction necessary to successfully eliminate VP1 is reduced following speech therapy. In this study, the size of the defect at the velopharyngeal sphincter was not significantly different for both groups. Furthermore, success rate for correcting VP1 was similar for both groups of patients. A possible explanation for the similar successrate is that all patients from both groups were operated with a tailor made pharyngeal flap which was performed according to findings of videonasopharyngoscopy and multi-view videofluoroscopy. The only difference was that patients from group 2 were operated as soon as they achieved adequate placement of articulation during isolated speech. In contrast patients from group 1 were not operated until articulation was normal during connected speech. Another factor is that the groups of patients studied herein were kept as homogenous as possible [8], cleft type, cleft width, language development, hearing level, surgical repair VPI, CA and absenceof fistulae were similar in all the patients included in the study groups. Nonetheless, the small number of patients that finally met the criteria for being included in the study does not allow us to draw any definite conclusions. As mentioned herein the surgical correction of VP1 did not reduce total time of speech therapy necessary to eliminate CA. A possible explanation is that articulation may be considered not only as a peripheral process, but rather a central cognitive-linguistic process which is developed depending, not only on the structural elements of the vocal tract, including the velopharyngeal sphincter, but the individual characteristics of the system used by each child [2]. Table 3 Total time of speech therapy Group 1 (months)
Group 2 (months)
18 42 42 28 26 38 25 14 32 18 46 39 28 29 46
45 54 32 15 10 38 40 38 48 60 14 21 12 20
x=31.4 S.D. = 10.39 P > 0.05
x = 31.9 SD. = 16.6
M. Pamplona et al. 1 Int. J. Pediatr. Otorhinolaryngol.
34 (1996) 53-59
59
Although all the patients included in this small group required surgery for VPI, it should be pointed out that sometimes ST for CA may correct VP1 without surgery. In any case, the results of this study supports the statement that surgical remediation of VP1 should be delayed until compensatory articulation errors have been completely eliminated. References [I] Argamaso, R.V. and Shprintzen, R.J. (1989) The role of lateral pharyngeal wall movement in pharyngeal flap surgery. Plast. Reconstr. Surg. 66, 214-219. [2] Chapman, K.L. (1993) Phonologic processesin children with cleft palate. Cleft Palate-Craniofacial J. 30, 64-71. [3] Converse, M.J. (1977) Cleft lip and palate craniofacial deformities. In: Converse, M.J. (Ed.), Plastic Surgery. W.B. Saunders, Philadelphia, pp. 2508-2070. [4] Golding-Kushner, K., Ysunza, A., et al. (1990) Standardization for the reporting of videonasopharyngoscopy and multi-view videofluoroscopy. A report from an international working group. Cleft Palate J. 27, 3377347. [5] Kernahan, D.A. and Stark, R.B. (1958) A new classification for cleft lip and palate. Plast. Reconstr. Surg. 22, 4355443. [6] Rangel, E. et al. (1988) Bateria de evaluation de la lengua espariola (BELE) para nirios mexicanos de 3 a I I atios. Mexico, SEP-DGEE, l-383. [7] SanVenero Roselli, G. (1934) Divisione palatina sua cura chirurgica, In: SanVenero Roselli, G. Divisione Palatina Roma, Luigi Pozzi, pp. 268-275. [8] Shprintzen, R.J. (1991) Fallibility of clinical research. Cleft Palate-Craniofacial J. 28, 136-140. [9] Shprintzen, R.J. and Golding-Kushner, K.L. (1989) Evaluation of velopharyngeal insufficiency. Otolaryngol. Clin. North Am. 22, 519-536. [IO] Trigos, I. and Ysunza, A. (1988) A comparison of palatoplasty with and without primary pharyngoplasty. Cleft Palate J. 25, 163-166. [I I] Trigos, I., Ysunza, A. and Garcia-Velasco, M. (1993) Selection del procedimiento quirurgico para corregir IVF basados en la actividad motora del esfinter velofaringeo. Cirugia Plastica Ibero Latin0 Americana 19, 149%I57 (english abstract). [I21 Trost-Cardamone, J.E. (1990) Speech anatomy physiology and pathology. In: Kernahan, D. and Rosenthal, S. (Eds.), Cleft Lip and Palate: A System of Management. Williams and Wilkins, Baltimore, pp. l27- 140. [13] Wardill, W.E. (1937) Palate repair technique. Br. J. Plast. Surg. 16, 127-135. [I41 Ysunza, A. and Pamplona, M.C. (1992) Change in velopharyngeal valving after speech therapy in cleft palate patients: a videonasopharyngoscopic and multi-view videofluoroscopy study. Int. J. Pediatr. Otorhinolaryngol. 24 45554. [I 51 Ysunza, A., Trigos, I. and Baldizon, N. (1987) Sustituciones articulatorias gruesas en el diagnostic0 y tratamiento de la insuficiencia velofaringea. Boletin Medico de1 Hospital Infantil de Mexico 44, 81-86.