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Reprinted by permission of Ann Plast Surg. 2016; 77(4):420-424.

H EAD AND N ECK S URGERY

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown Evan B. Katzel, MD, Sameer Shakir, MD, Sanjay Naran, MD, Zoe MacIsaac, MD, Liliana Camison, MD, Matthew Greives, MD, Jesse A. Goldstein, MD, Lorelei J. Grunwaldt, MD, Matthew D. Ford, MS, CCC-SLP, and Joseph E. Losee, MD

T he velopharyngeal valve separates the oral and nasal pharynx during swallowing and speaking. It is created by the lateral pharyn- geal walls, the posterior pharyngeal wall, and the velum, and selectively allows and resists airflow during normal speech production. Velo- pharyngeal insufficiency (VPI) is the inability to completely occlude the velopharyngeal port during speech and can be an unfortunate complication seen in approximately 30% of palatal surgery. 1 Data sug- gest that straightline palatoplasty without intravelar veloplasty or with incomplete intravelar veloplasty place patients at a greater risk for VPI. 2 Sphincterplasty, fat grafting, or filler injection to the posterior pharynx and/or obturators can be used to treat VPI; however, the gold standard treatment of VPI after cleft palate repair is pharyngoplasty, and the posterior pharyngeal flap (PPF) is one of the most frequently performed procedures. The PPF was initially described for the treatment of VPI in 1865 by Passavant. 3 Creation of a PPF is often used to treat VPI and is well established to improve clinical speech symptomatology. 4 – 7 Long-term success rates with PPF range from 74% to 98%. 1,8 – 11 However, PPFs are accompanied by the potential morbidity of hyponasality and postop- erative obstructive sleep apnea (OSA), with OSA reported in as many as 40% of the cases. 12,13 Although, a large body of literature exists re- garding the identification, prevention, and management of OSA in this population, studies have yet to answer whether speech symptomatology suffers as a consequence of PPF takedown. 8,14 – 19 There is also a lack of literature exploring conversion of previous straightline palatoplasties to Furlow palatoplasty for these patients. The treatment of these patients is controversial, given the challenge of treating the OSA caused by the PPF while maintaining the improvement in speech owed to the PPF . Given the lack of existing literature, the study aims to assess speech outcomes after clinically indicated PPF takedown alone or when performed with conversion to Furlow palatoplasty. This study hypothe- sizes that PPF takedown or PPF takedown with conversion to Furlow palatoplasty can be performed for the treatment of OSAwithout delete- rious effects on speech outcomes. University of Pittsburgh Medical Center. The Cleft-Craniofacial Data- base of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center was queried from 1992 to 2012 to identify patients with a diagnosis of VPI treated with PPF and eventual PPF takedown. All patients who fit these criteria were included in this study. No pa- tients who had a diagnosis of VPI treated with PPF and eventual PPF takedown were excluded. Demographic, operative, and speech data were stratified based on treatment modality (ie, PPF takedown alone versus PPF takedown with conversion to Furlow palatoplasty) and compared. Demographic data included sex and age at time of PPF take- down. Operative data included surgical complications and postopera- tive length of follow-up. The PittsburghWeighted Speech Score (PWSS) was used to quan- tify preoperative and postoperative speech changes. The PWSS is a vali- dated measure of clinical speech outcomes that rates 5 components of METHODS The study was approved by the Institutional Review Board at the

Background: Velopharyngeal insufficiency affects as many as one in three pa- tients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. Methods: The cleft-craniofacial database of the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. Results: A total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0 – 22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1 – 104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoper- ative and postoperative PWSS was 3.83 (range, 0.0 – 23.0) (SD, 6.13) and 4.11 (range, 0.0 – 23.0) (SD, 5.31), respectively ( P = 0.89). The mean change in PWSS was 0.28 (range, − 9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0 – 26) (SD, 6.70) and 3.11 (range, 0.0 – 27.0) (SD, 4.14), respectively ( P < 0.01). The mean change in PWSS was − 3.26 (range, − 23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0 – 26) (SD, 6.60) and 3.39 (range, 0.0 – 27) (SD, 4.48), respectively ( P < 0.05). The mean change in PWSS was − 2.26 (range, − 23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. Conclusions: Although there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech. Key Words: cleft lip, cleft palate, velopharnygeal insufficiency, sleep apnea, craniofacial, Furlow plasty, pharyngoplasty, double opposing z-plasty, VPI ( Ann Plast Surg 2016;77: 420 – 424)

Received April 16, 2015, and accepted for publication, after revision July 27, 2015. From the Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh,

University of Pittsburgh Medical Center, Pittsburgh, PA. Conflicts of interest and sources of funding: none declared.

Reprints: Evan B. Katzel, MD, Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA. E-mail: katzeleb@upmc.edu. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7704 – 0420 DOI: 10.1097/SAP.0000000000000632

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Annals of Plastic Surgery • Volume 77, Number 4, October 2016

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