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In 1973, Morris reviewed 11 years' worth of published reports on the
success of primary cleft palate surgery. The author drew the conclusion,
after pooling all types of clefts and several types of surgical approaches,
that palate repairs produced good speech results in roughly 75% of the
cases. Now, more than 40 years later, it is much more common to see
reported success rates of 85% to 90% and sometimes even higher. This
improvement should mean that SLPs in schools and other nonmedical
seings are now encountering far fewer children with poor surgical
outcomes.
This was exactly the experience of the senior author of this book after
the advent of the Furlow double-reversing Z-plasty. The success rate of
primary palatal closures in the Craniofacial Center of the University of
California, San Francisco, went up to 91%. However, this number was
based solely on the perceptual judgments of one SLP.
Guidelines for Judging the Results of Palatal
Surgery
Usually SLPs in schools or other nonmedical seings are not the first to
judge the result of palatal surgery because most surgery takes place in
infancy. However, if the child has not been treated within a team
seing, it is possible that no professional assessment (meaning SLP
assessment) has been made of the speech outcome of a palate repaired
years before the child begins preschool or kindergarten. In other words,
entry into the educational system may be the first opportunity to assess
the child's speech. Thus, the school SLP is the first to document the
outcome.
The initial step in speech assessment is to listen to what the parents
have to say about the child's speech. When you do your first screening
of the child, your ears will tell you whether what you hear is normal for
his or her age level. If the answer is negative, then additional
assessment will be required, as described in Chapter 8. That chapter
provides highly detailed guidelines on the assessment and diagnosis of
an inadequately functioning velopharyngeal system and on deciding
whether this problem can be treated through speech therapy or through
further physical management. As stressed in Chapter 8, it is wise for the
SLP to document his or her perceptions of the child's postoperative (or
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postprosthetic) speech result by video recording, combined with one or
more of the instrument-based evaluations discussed in Chapter 9.
Secondary surgical procedures are discussed in Chapter 10.
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Prosthetic Treatment of Clefts
If for some reason a cleft palate cannot be completely closed by surgery,
prosthodontists can fabricate an obturator that consists of a palatal plate
to cover the palatal defect, with or without a “speech bulb” (Fig. 3-9)
designed to provide a seal between the nose and the mouth during
speech. If necessary, the obturator can also carry anterior dental units to
replace missing teeth. Successful use of a speech bulb requires adequate
movement of the posterior and lateral pharyngeal walls to contact the
bulb during speech. Obturators can also be used to obtain
velopharyngeal closure when an unsuccessfully repaired velum cannot
reach the posterior pharyngeal wall. In addition, prosthetic treatment
for clefts includes (1) palatal lifts (Fig. 3-10) designed to raise the velum
into position to facilitate velopharyngeal closure and (2) temporary use
of obturators or lifts as training devices to increase the potential for
closure. These treatment approaches are discussed in Chapter 10.
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FIGURE 3-9 A and B, Two under-and-up prostheses fabricated
for patients with repaired palates but inadequate velopharyngeal
closure. (From Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft palate
speech [4th ed]. St. Louis: Elsevier, 2010.)
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FIGURE 3-10 A and B, Two views of a palatal lift
prosthesis. (Courtesy David Gratton, DDS, University of Iowa Hospitals and Clinics,
2015.)
Although geing used to a speech bulb may require the child to make
several visits to the prosthodontist and to the SLP, occasionally a wellfied prosthetic device can instantly convert a speaker from nasal to
oral (if somewhat hyponasal) speech. The speech bulb will not eliminate
maladaptive compensatory articulations if these are present, but it will
prevent loss of air through the nose. This can be of significant diagnostic
help to the SLP; if the child can produce good pressure consonants with
the device in place, then the child can learn what those consonants feel
like and sound like as he or she produces them. After extensive practice
with the device in place, can the child make the same sounds when the
device is removed? This change in speech behavior has been reported
occasionally in the clinical literature and is assumed to be the result of
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the child's receiving the appropriate auditory and tactile feedback from
the high pressure consonants being produced with oral (instead of
nasal) airflow. We can envision the child realizing (perhaps
unconsciously), “So this is what this is supposed to sound like! Hey, I
can do this!”
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Summary for Speech-Language
Pathologists
Information on surgical and prosthetic approaches to the physical
management of clefts and noncleft VPI is included in this book because
SLPs who provide therapy for these children may be mystified by some
of what they learn about the child's treatment history or worried that
they do not understand enough about a proposed treatment. Details of
a specific procedure can be found both in the Web-based material
accompanying this book and on the Internet. (But remember that the
Internet is not peer reviewed.) In addition, SLPs are strongly urged to
make direct contact with the treating surgeon or the cleft palate or
craniofacial team. Beer flow of information between the SLP and the
team translates to beer care of the child.
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References
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philosophy, technique, and results. Bardach J, Morris HL.
Multidisciplinary management of cleft lip and palate. Saunders:
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Byrd HS, El-Musa KA, Yazdani A. Definitive repair of the
unilateral cleft lip nasal deformity. Plast Reconstr Surg.
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Byrd HS, Ha RY, Khosha RK, Gosman AA. Bilateral cleft lip and
nasal repair. Plast Reconstr Surg. 2008;122:1181–1190.
Friede H, Lilja J, Lohmander A. Long-term, longitudinal follow-up
of individuals with UCLP after the Gothenburg primary early
veloplasty and delayed hard palate closure protocol:
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Furlow LT. Cleft palate repair by double opposing Z-plasty. Plast
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Kael EB, Basile P, Kol PF, et al. Current surgical practices in
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Kriens OB. Anatomical approach to veloplasty. Plast Reconstr Surg.
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Marsh JL, Grames LM, Holtman B. Intravelar veloplasty: a
prospective study. Cleft Palate J. 1989;26:46–50.
Mehendale FV, Sommerlad BC. Unilateral Moore pharyngoplasty
in the treatment of unilateral or asymmetric velopharyngeal
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Mendoza M, Molina F, Azzolini C, Ysunza Rivera A. Minimal
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Morris HL. Velopharyngeal competence and primary cleft palate
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Reisberg DJ. Prosthetic rehabilitation of patients with clefts. Clin
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Salyer KE. Primary correction of the nasal deformity associated
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Mastery of plastic and reconstructive surgery. vol 1.
Salyer KE. Primary correction of the unilateral cleft nose: a 15-year
experience. Plast Reconstr Surg. 1986;77:558–566.
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