RESUMEN
OBJECTIVE: To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair. PATIENTS: Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992. INTERVENTIONS: Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991. OUTCOME MEASURES: For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project. RESULTS: There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes. CONCLUSIONS: Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.
Asunto(s)
Fisura del Paladar/cirugía , Procedimientos Quirúrgicos Orales/métodos , Paladar Duro/cirugía , Niño , Preescolar , Fisura del Paladar/complicaciones , Femenino , Humanos , Lactante , Masculino , Maxilar/crecimiento & desarrollo , Nariz/patología , Fístula Oral/etiología , Fístula Oral/cirugía , Procedimientos de Cirugía Plástica/métodos , Pruebas de Articulación del Habla , Colgajos Quirúrgicos , Resultado del Tratamiento , Insuficiencia Velofaríngea/etiología , Calidad de la VozRESUMEN
It is recognised that superiorly based pharyngeal flaps tend to contract resulting in narrowing and lowering of the flaps. If lateral pharyngeal-wall motion is unable to close against the "tubed" flap or if the flap migrates below the level of medial displacement of the lateral pharyngeal walls, velopharyngeal insufficiency will result. The extent of this phenomenon of flap contracture or shrinkage has not been previously quantified. A consecutive series of 120 superior flap pharyngoplasty operations were assessed critically and carefully. The mean width of the harvested flap measured 89% of the width of the pharyngeal posterior wall and shrank over 6 months to 45% of the lateral pharyngeal diameter. The relations between speech results, complication rate and remaining flap width are analysed. All flaps shrink but to a varying degree.
Asunto(s)
Trastornos de la Articulación/cirugía , Fisura del Paladar/cirugía , Faringe/cirugía , Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Insuficiencia Velofaríngea/cirugía , Adolescente , Adulto , Trastornos de la Articulación/rehabilitación , Niño , Preescolar , Fisura del Paladar/complicaciones , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Insuficiencia Velofaríngea/etiologíaRESUMEN
The results of 132 consecutive endoscopically selected pharyngoplasties were assessed. Depending on the size and shape of the velopharyngeal defect on attempted closure, patients had been allocated to one of four pharyngoplasties: (1) a superiorly based pharyngeal flap combined with a V-Y pushback of the soft palate (Honig), (2) a modified Hynes approach, (3) a superiorly based pharyngeal flap, or (4) a fish flap. Patients were categorized according to etiology as having cleft palate, submucous cleft palate, disproportion, or neurologic origin. Acceptable nasal resonance was found after 81 percent of the Honig operations, 81 percent of the Hynes operations, and 63 percent of the superiorly based flap operations, vindicating the selection criteria based on palatal and pharyngeal wall movement. The fish flap operation was successful in only 50 percent and is not recommended. The cleft, submucous cleft, disproportion, and neurologic categories were equally well corrected by the Honig and Hynes operations. Side effects were common, with catarrh or snoring in 51 percent, difficulty breathing through the nose in 27 percent, and 9 percent requiring revision of their pharyngoplasty (6 of 53 Honig and 5 of 63 Hynes operations). The higher median age for those patients requiring pharyngoplasty revision (17 versus 10 years) suggests more cautious use in the older patient.
Asunto(s)
Fisura del Paladar/cirugía , Paladar Blando/cirugía , Faringe/cirugía , Colgajos Quirúrgicos/métodos , Insuficiencia Velofaríngea/cirugía , Endoscopía , Humanos , Complicaciones Posoperatorias , Respiración , Ronquido/etiología , Acústica del Lenguaje , Trastornos del Habla/etiología , Colgajos Quirúrgicos/rehabilitación , Trastornos de la Voz/etiologíaRESUMEN
Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.
Asunto(s)
Fisura del Paladar/complicaciones , Otitis Media con Derrame/etiología , Otitis Media con Derrame/terapia , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Desarrollo del Lenguaje , Masculino , Ventilación del Oído Medio , Otitis Media con Derrame/cirugía , Estudios Retrospectivos , LogopediaRESUMEN
The treatment of velopharyngeal incompetence remains unsatisfactory because the causes are many, as are the variations in anatomic and physiologic defects. Therefore, full assessment and investigation are essential in tailoring the surgery to the defect. A modified Hynes pharyngoplasty has been used in 40 patients, aged 4 to 52, over a 4-year period for velopharyngeal incompetence of varying etiologic causes. Speech was assessed before and at least 6 months after pharyngoplasty. At the same time, radiologic and, when possible, nasendoscopic investigations were undertaken. Thirty-eight patients had no or variable nasal escape (variable defined as achieving intermittent closure), whereas 33 had normal or slight hyponasal resonance. There was only one complication, an asymptomatic dehiscence of the "bucket handle" flap from the posterior wall. Thirteen patients had an assortment of side effects, none requiring surgical treatment. We believe that patients who are suitable for the described sphincter pharyngoplasty are those with slight or moderate nasal escape having a mobile palate with an anteroposterior gap of 5 mm or less.
Asunto(s)
Faringe/cirugía , Cirugía Plástica/métodos , Insuficiencia Velofaríngea/cirugía , Adolescente , Adulto , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Cirugía Plástica/efectos adversos , Técnicas de Sutura , Insuficiencia Velofaríngea/clasificación , Insuficiencia Velofaríngea/diagnóstico por imagenRESUMEN
Of one hundred patients with velopharyngeal incompetence subjected to a pharyngoplasty selected on the results of endoscopic and radiological examination 97% were cured of unacceptable nasal escape and 93% of unacceptable nasal resonance on the criteria described. It was considered that this provided a vindication of the system of treatment. Critical examination of the morbidity revealed an unacceptably high proportion of hyponasality. This appeared to be due to ignoring the criteria for selection for pharyngoplasty and opting for the more radical operation resulting in over-treatment in some cases. With the numbers available in the smaller treatment groups it was not possible to state that there was no significant difference in the results between the different pharyngoplasties in the groups for which they were selected. It is expected that there will be a larger proportion of patients receiving less radical treatment without detriment to the success rate, but with a lower morbidity. Assuming that it is accepted that as much accurate information as possible prior to operation is needed for the correct selection of operation, simultaneous endoscopic and radiological examination provide a time- and cost-efficient system the benefit of which becomes overwhelming for revision of the failed pharyngoplasty.