RESUMO
Submucous cleft palate is a congenital malformation with specific clinical and anatomical features. It can be present with or without velopharyngeal insufficiency. Surgical treatment of this malformation is indicated only when velopharyngeal insufficiency has been demonstrated. This article compares two modalities of surgical treatment for submucous cleft palate. The first includes a minimal incision palatopharyngoplasty, as described in a previous report. The second combines the first technique with additional individualized velopharyngeal surgery (individualized pharyngeal flap or sphincter pharyngoplasty) performed simultaneously. The individualized part of the procedure was selected and performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy, as reported previously. Two hundred and three patients with submucous cleft palate were studied from 1990 to 1999. Videonasopharyngoscopy and multiview videofluoroscopy demonstrated velopharyngeal insufficiency in 72 patients, who were randomly divided into two groups. Those in group 1 (n = 37) underwent a minimal incision palatopharyngoplasty. Patients in group 2 (n = 35) also underwent that procedure but simultaneously received individualized pharyngeal flap or sphincter pharyngoplasty, according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients from both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after palatal closure was not significantly different in both groups of patients (14 percent versus 11 percent; p > 0.5). The mean size of the gap at the velopharyngeal sphincter during speech was not significantly different in both groups of patients before surgery (23 percent versus 22 percent; p > 0.5). After the surgical procedures, there was a nonsignificant difference between both groups of patients in mean residual size of the gap in cases of velopharyngeal insufficiency (7 percent versus 8 percent; p > 0.5). It seems that minimal incision palatopharyngoplasty is a safe and reliable procedure for palatal closure in patients with submucous cleft palate. The use of additional individualized velopharyngeal surgery performed simultaneously did not seem to decrease the frequency of residual velopharyngeal insufficiency. Moreover, the residual size of the gap at the velopharyngeal sphincter was not significantly reduced when an additional surgical procedure was performed simultaneously with palatal closure.
Assuntos
Fissura Palatina/cirurgia , Palato/cirurgia , Transtornos da Articulação/etiologia , Transtornos da Articulação/reabilitação , Criança , Pré-Escolar , Fissura Palatina/complicações , Fissura Palatina/patologia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Faringe/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Fonoterapia , Resultado do Tratamento , Insuficiência Velofaríngea/diagnóstico , Insuficiência Velofaríngea/etiologia , Insuficiência Velofaríngea/cirurgiaRESUMO
A prospective study of speech outcome and maxillofacial growth was carried out in cleft palate patients. Seventy-six cleft palate patients were randomly selected for the study group; 41 patients were operated on at 12 months of age, and 35 patients were operated on at 6 months of age. All patients were followed until they were 4 years of age. All patients underwent a complete speech evaluation, videonasopharyngoscopy, videofluoroscopy, and maxillofacial assessment. The rate of velopharyngeal insufficiency did not differ between the two groups (17 to 19 percent; p > 0.05). However, phonologic development was significantly better (p < 0.05) in the patients operated on at 6 months of age. Furthermore, none of the patients operated on at 6 months of age showed compensatory articulation disorder. In contrast, 62 percent of the patients with postoperative velopharyngeal insufficiency operated on at 12 months of age showed compensatory articulation disorder (p < 0.05). Maxillofacial assessment showed that there were non-significant differences (p > 0.05) in maxillofacial growth in both groups of patients. All patients showed similar degrees of maxillary collapse (p > 0.05). The results of this study suggest that cleft palate repair performed at 6 months of age significantly enhances speech outcome and prevents compensatory articulation disorder.
Assuntos
Transtornos da Articulação/etiologia , Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Desenvolvimento Maxilofacial/fisiologia , Complicações Pós-Operatórias/etiologia , Transtornos da Articulação/fisiopatologia , Cefalometria , Pré-Escolar , Fenda Labial/fisiopatologia , Fissura Palatina/fisiopatologia , Endoscopia , Feminino , Seguimentos , Humanos , Lactente , Masculino , Faringe/fisiopatologia , Faringe/cirurgia , Fonação/fisiologia , Complicações Pós-Operatórias/fisiopatologia , Testes de Articulação da Fala , Insuficiência Velofaríngea/fisiopatologia , Insuficiência Velofaríngea/cirurgia , Gravação em VídeoRESUMO
El trabajo compara el incremento en el desarrollo del habla (DH) y la disminución en los trastornos de articulación compensatoria (AC) en dos grupos de pacientes, uno (35 pacientes) con cierre quirúrgico de paladar secundario (PS) con técnica de incisiones mínimas a los 6 meses de edad, y el otro (41 pacientes) con cierre quirúrgico convencional al año de edad. También compara los efectos de cada tipo de operación sobre el crecimiento maxilofacial (CMF). Se observó a los pacientes hasta cumplir los 4 años de edad, momento en que se les practicó estudio foniátrico completo que incluyó valoración de DH, mediante la escala de articulación de la batería de evaluación de la lengua española (BELE) y estudios de imagen del tracto vocal. Además se realizó evaluación del CMF por cefalometría, modelos dentales y medición de perfiles de tejidos blandos. La frecuencia de insuficiencia velofaríngea (IVF), no mostró diferencia significativa entre los dos grupos de pacientes. El promedio de DH en la BELE, fue significativamente mejor en el grupo de pacientes operados a los 6 meses de edad. La CMF no mostró diferencias válidas entre cada grupo. Todos los pacientes mostraron algún grado de colapso maxilar. Los resultados de este trabajo sugieren que el cierre de la fisura de PS, realizado a los 6 meses de edad, incrementa significativamente el DH y previene el desarrollo de trastornos de AC
Assuntos
Humanos , Masculino , Feminino , Lactente , Fatores Etários , Articulação Temporomandibular/fisiopatologia , Fissura Palatina/cirurgia , Oclusão Dentária , Fonação/fisiologia , Linguística , Desenvolvimento Maxilofacial , Insuficiência VelofaríngeaRESUMO
Videonasopharyngoscopy was used as an instrument for visual biofeedback during speech in cleft palate patients. Seventeen cleft palate patients were randomly selected for the study. All patients showed velopharyngeal insufficiency (VPI), compensatory articulation (CA) and negative movement of lateral pharyngeal walls (NMLPW) during speech. Nine patients received speech therapy for correcting CA. Eight patients received speech therapy and underwent videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter. After 12 weeks, NMLPW was modified in the patients receiving speech therapy and visual biofeedback. In contrast, NMLPW was still present in eight out of nine patients receiving only speech therapy. These patients received visual biofeedback and NMLPW was corrected in all cases. After six months, all 17 patients had corrected CA during isolated speech. All patients received a tailor-made pharyngeal flap. VPI was completely corrected in 15 cases. In the two cases in which VPI was still present postoperatively, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used postoperatively for increasing lateral pharyngeal walls (LPW) motion towards the borders of the flap. After 18 months since the onset of speech therapy all the patients had normal nasal resonance and normal articulation during connected speech.
Assuntos
Biorretroalimentação Psicológica , Fissura Palatina/complicações , Endoscopia , Nasofaringe/cirurgia , Distúrbios da Fala/etiologia , Distúrbios da Fala/reabilitação , Fissura Palatina/cirurgia , Humanos , Estudos Retrospectivos , Fonoterapia , Retalhos Cirúrgicos , Insuficiência Velofaríngea/complicações , Insuficiência Velofaríngea/cirurgiaRESUMO
Diversas comunicaciones discuten la relación entre la edad en que se cierra quirúrgicamente el paladar hendido y la calidad de lenguaje que se obtiene. Este trabajo explora el efecto de la edad y el desarrollo de la articulación del lenguaje, especialmente la articulación compensatoria. Treinta y ocho casos de paladar hendido fueron estudiados, todos operados con la misma técnica que inclye una palatoplastía tipo Wardill-Killner (push-back) con faringoplastía de pilares posteriores simultánea. Los pacientes formaron cinco grupos según su edad en el momento de la cirugía: seis meses, 12 meses, 18 meses, 24 meses y 36 meses. La nasalidad era semejante en todos los grupos. El desarrollo de la articulación era subnormal, por igual en todos los grupos. la articulación compensatoria resultó similar en los tres primeros grupos, pero fue significativamente mayor en los operados a los 24 meses y a los 36 meses. Se concluye que la operación es beneficiosa para prevenir la articulación compensatoria cuando se efectuá antes de los 18 meses de edad
Assuntos
Lactente , Pré-Escolar , Humanos , Masculino , Feminino , Fissura Palatina/cirurgia , Insuficiência Velofaríngea/cirurgia , Testes de Linguagem , Faringostomia , Distúrbios da Fala/reabilitação , Fala/fisiologiaRESUMO
El resultado final del tratamiento de pacientes con paladar hendido depende principalmente de dos elementos; la normalización de la resonancia nasal y la corrección de la articulación compensatoria. El propósito de este estudió es demostrar si la corrección quirúrgica de la insuficiencia velofaríngea efectuada tempranamente, es capaz de reducir el tiempo total de terapia de articulación que estos pacientes requieren. Se seleccionaron 25 casos de paladar hendido. Diez pacientes fueron seleccionados aleatoriamente, y fueron sometidos a corrección quirúrgica de la insuficiencia velofáringea tan pronto como el punto y modo de articulación durante la producción de fonemas aislados hubiera sido corregida. El procedimiento quirúrgico empleado en todos los casos fue colgajo faríngeo diseñado específicamente a los hallazgos de la visualización directa del esfínter velofaríngeo de cada paciente mediante videonasofaringoscopía y videofluoroscopía de incidencia múltiple. Los otros 15 pacientes recibieron terapia de articulación encaminada a corregir la articulación compensatoria y fueron seguidos hasta que la articulación fuera normal durante la producción de habla espóntanea-conectada y hasta este momento fueron sometidos a corrección quirúrgica de la insuficiencia velofáringea después de la operación no varió significativamente en ambos grupos (93 por ciento). No existió diferencia significativa en el tiempo total de terapia de articulación de ambos grupos. Se concluye que la normalización de la resonancia nasal antes de que la articulación sea completamente corregida durante la producción de habla espóntanea-conectada no parece reducir el tiempo tal de terapia de articulación necesario para corregir la articulación compensatoria de pacientes con paladar hendido e insuficiencia velofáringea
Assuntos
Pré-Escolar , Criança , Humanos , Masculino , Feminino , Fissura Palatina/cirurgia , Fissura Palatina/terapia , Insuficiência Velofaríngea/cirurgia , Insuficiência Velofaríngea/reabilitação , Reabilitação dos Transtornos da Fala e da LinguagemRESUMO
The files of 585 patients who had had pharyngeal flap surgery for the correction of velopharyngeal insufficiency were reviewed. Eighteen patients, ranging in age from 6 to 16 years, showed clinical symptoms of obstructive sleep apnea syndrome. All of these cases had a polysomnographic evaluation and videonasopharyngoscopy. Fifteen cases met the criteria for the diagnosis of obstructive sleep apnea syndrome and eventually underwent surgical treatment. A modified uvulopalatopharyngoplasty was done in 14 of the 15 cases. One patient had a prominent uvula flipping into the port of a Jackson's type pharyngoplasty, so a partial resection of the uvula was performed. Surgical treatment was successful in 14 of 15 cases, including the case with the partial uvular resection. In one case, severe sleep apnea persisted after surgery and a complete section of the flap was performed to correct the obstruction. Sizeable tonsils were found in 13 out of 15 cases, whereas flap width appeared unrelated to obstruction. Preoperative assessment of tonsillar tissue is of vital importance before pharyngeal flap surgery.
Assuntos
Faringe/cirurgia , Síndromes da Apneia do Sono/etiologia , Retalhos Cirúrgicos/efeitos adversos , Insuficiência Velofaríngea/cirurgia , Adolescente , Criança , Pré-Escolar , Endoscopia , Feminino , Humanos , Masculino , Nasofaringe/patologia , Palato/patologia , Faringe/patologia , Polissonografia , Retalhos Cirúrgicos/patologia , Úvula/patologia , Gravação em VídeoRESUMO
The files of 108 patients with submucous cleft palate were reviewed. Special attention was focused on the findings of videonasoendoscopy, videofluoroscopy, and audiometry. Velopharyngeal insufficiency was found in 53 percent of the cases. Since surgical correction is indicated only in the presence of insufficiency, waiting until speech has developed is recommended before considering treatment. A relationship between coronal pattern of velopharyngeal closure and velopharyngeal insufficiency was found. This relationship appears to be caused by the malformation of the musculus uvulae in the submucous clefts. Conductive hearing loss was significantly associated with velopharyngeal insufficiency. This suggests that a velar muscle malformation, which is frequently responsible for the insufficiency in these patients, may also cause Eustachian tube malfunction, resulting in serous otitis with conductive hearing loss.