Lynn Marty Grames

the Effect of Surgeon Experience on Velopharyngeal Functional Outcome following Palatoplasty: Is There a Learning Curve?

&NA; There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of “total procedures” and “procedure per year” were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of “total procedures” was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeons improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high‐volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low‐volume surgeons. The influence of the surgeons cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty. (Plast. Reconstr. Surg. 102: 1375, 1998.)

Videofluoroscopic and Nasendoscopic Correlates of Speech in Velopharyngeal Dysfunction

Objective To compare videonasendoscopy, lateral videofluoroscopy, and perceptual speech examination in the assessment of velopharyngeal dysfunction. Design Retrospective observational. Setting Multidisciplinary cleft palate team at a tertiary academic institution. Patients, Participants Patients who had undergone videonasendoscopy and lateral videofluoroscopy for suspected velopharyngeal dysfunction at our center were evaluated. Inclusion required that videonasendoscopy, lateral videofluoroscopy, and the perceptual speech exam were performed on the same day. A total of 88 patients were analyzed. Main outcome Measure(s) Primary outcome measures included percent closure on videonasendoscopy, percent closure on lateral videofluoroscopy, and quantitative scores for hypernasal resonance, nasal emission, and facial grimace. Additional outcome measures included linear and angular anatomic measurements obtained from lateral videofluoroscopy. Results Moderately strong correlation was found between closure estimates of videonasendoscopy and lateral videofluoroscopy (ρ = .583; p < .001). Lateral videofluoroscopy estimates of closure averaged 11.7% higher than videonasendoscopy. Closure correlated moderately with overall speech severity (ρ = .304; p = .005); whereas, a stronger correlation was seen with hypernasal resonance (ρ = –.479; p < .001). Patients exhibiting grimace had worse closure than those without (79.1% versus 70.7%; ρ = .035). Movement angle of the velum and change in genu angle correlated significantly with closure function (ρ = –.304; p = .034 and ρ = –.395; p < .001, respectively). Conclusions Videonasendoscopy and lateral videofluoroscopy closure estimates correlated moderately. Lateral videofluoroscopy tended to give smaller gap estimates. Hypernasal resonance and facial grimace are useful clinical indicators of large gap size. Velar movement angle and change in genu angle were identified as anatomical correlates of closure function.

Quantification of dynamic velopharyngeal port excursion following sphincter pharyngoplasty.

&NA; The sphincter pharyngoplasty is a surgical procedure designed to correct velopharyngeal dysfunction. Its advocates cite the theoretical advantage of its induction of dynamic activity of the neovelopharyngeal port, but this dynamic activity has yet to be quantitatively demonstrated in the literature. The purpose of this study was to quantify postoperative velopharyngeal dynamism and to document the results of intervention outcome on sphincteric excursion measurements from minimal‐to‐maximal orifice closure. We conducted a 7‐year retrospective review of speech videofluoroscopy evaluations in patients who had undergone sphincter pharyngoplasty in our center. Between 1989 and 1994, there were 58 patients so treated for postpalatoplasty velopharyngeal dysfunction by two surgeons using the same operative technique. Patients for whom sphincter pharyngoplasty was recommended fulfilled both of the following criteria: (1) velopharyngeal dysfunction caused by an anatomic, myoneural, or combined deficiency of the velopharyngeal sphincter that would not be expected to be managed by speech therapy alone, and (2) preoperative videonasendoscopy and speech videofluoroscopic studies that demonstrated large‐gap coronal, circular, or bow‐tie closure patterns or velopharyngeal hypodynamism. Of the original 58 patients, 24 underwent postoperative speech videofluoroscopic evaluations with basal views. Of these, 20 of the evaluations (83 percent) were of adequate quality to be included in a research study. Still images showing maximum and minimum excursion of the sphincter in basal view were obtained. To test for observer reliability, the speech videofluoroscopic studies were randomized and presented for measurement to the same individual on two occasions, each session separated by a 1‐month time interval. Topographic imaging software was used to obtain maximum and minimum measurements to within 0.1 mm. Partitioning the variance of the data showed that measurement variability was a very small portion of the total, and that difference between the minimum and maximum values was the largest source of variability. Of the total variability in the data, 64.0 percent originated in the minimum/maximum difference, 34.3 percent came from patient variability, and only 1.7 percent resulted from original or repeat measurements. The patient variability may be exaggerated because of variability in the scale of measurement. Results of this study indicate a quantifiable and statistically significant difference in maximum‐to‐minimum excursion of sphincteric closure. Sphincter pharyngoplasty appears to be dynamic in the majority of cases. (Plast. Reconstr. Surg. 101: 1205, 1998.)

Speech outcome following palatoplasty in primary school children: do lay peer observers agree with speech pathologists?

&NA; The aim of this study was twofold: (1) to test the ability of normal children to discriminate the speech of children with repaired cleft palate from the speech of unaffected peers and (2) to compare these naive assessments of speech acceptability with the sophisticated assessments of speech pathologists. The study group (subjects) was composed of 21 children of school age (aged 8 to 12 years) who had undergone palatoplasty at a single cleft center and 16 matched controls. The listening team (student raters) was composed of 20 children who were matched to the subjects for age, sex, and other variables. Randomized master audiotape recordings of the children who had undergone palatoplasty were presented in blinded fashion and random order to student raters who were inexperienced in the evaluation of patients with speech dysfunction. The same sound recordings were evaluated by an experienced panel of extramural speech pathologists whose intrarater and interrater reliabilities were known; they were not direct care providers. Additionally, the master tape was presented in blinded fashion and random order to the velopharyngeal staff at the cleft center for intramural assessment. Comparison of these assessment methodologies forms the basis of this report. Naive raters were insensitive to speech differences in the control and cleft palate groups. Differences in the mean scores for the groups never approached statistical significance, and there was adequate power to discern a difference of 0.75 on a 7‐point scale. Expert raters were sensitive to differences in resonance and intelligibility in the control and cleft palate groups but not to other aspects of speech. The expert raters recommended further evaluation of cleft palate patients more often than control patients. Speech pathologists discern differences that the laity does not. Consideration should be given to the utilization of untrained listeners to add real‐life significance to clinical speech assessments. Peer group evaluations of speech acceptability may define the morbidity of cleft palate speech in terms that are most relevant to the patients themselves and may safeguard against the possibility of offering treatment that may be unnecessary.

Perception of Postpalatoplasty Speech Differences in School-Age Children by Parents, Teachers, and Professional Speech Pathologists

&NA; The aims of this study were twofold: (1) to test the ability of parents and teachers to discriminate the speech of children with repaired cleft palate from that of their unaffected peers and (2) to compare these lay assessments of speech acceptability with the critical perceptual assessments of expert clinicians. The subjects for this study were 20 children of school age (age range, 8 to 12 years) who were drawn from a large population (n = 1282) of patients. All subjects had been referred for palatoplasty to the same tertiary cleft center between 1978 and 1991. There were 16 matched controls. The listening team included parents of subjects (n = 32) and teachers of age‐matched school children (n = 12). Randomized master audiotape recordings of the study group were presented in blinded fashion to both groups of the adult raters, who were inexperienced in the evaluation of patients with speech dysfunction. An experienced panel of three extramural speech pathologists evaluated the same recordings. In all parameters rated, both parents and teachers showed a consistent tendency to give the subject children more negative ratings than the control children. Expert raters were sensitive to differences in resonance and intelligibility in the control and cleft palate groups. Results of this study differ from similar previous research, indicating that naive peer raters (similar‐age children) were insensitive to speech differences in the cleft palate and control groups. (Plast. Reconstr. Surg. 100: 1655, 1997.)

The effect of timing of surgery for velopharyngeal dysfunction on speech.

The timing of surgery for velopharyngeal dysfunction has been based on assumptions about the relation between age, speech development, and velopharyngeal dysfunction. Cleft palate teams often counsel parents to have an intervention for velopharyngeal dysfunction performed earlier rather than later, believing that earlier interventions result in more rapid or better normalization of speech. The objective of this retrospective chart review study is to determine whether the age at surgical intervention for velopharyngeal dysfunction has an effect on the subsequent length of speech therapy. Of 174 patients included in the study database, 36 had velopharyngeal dysfunction for which further velopharyngeal management was required. Of the 36 patients who received surgical velopharyngeal dysfunction management, 27 had verifiable speech therapy records. These 27 patients represent the study population. The outcome measure was the total length of subsequent speech therapy until speech normalization. The data suggest that there is no relation between the age at velopharyngeal dysfunction surgical management and the amount of speech therapy needed to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management. In conclusion, 1) the age at surgical velopharyngeal dysfunction management (pharyngeal flap or sphincter pharyngoplasty) does not have an effect on subsequent normalization of speech as measured by the duration of speech therapy necessary to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management, and 2) the age at surgical velopharyngeal dysfunction management does not affect the likelihood of subsequent surgical velopharyngeal dysfunction management procedures.

Long-term stability of postpalatoplasty perceptual speech ratings: a prospective study.

This prospective study was undertaken to assess the long-term stability of velopharyngeal perceptual speech ratings of patients with repaired cleft palate. All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Childrens Hospital. Patients alternately received palatoplasty with or without intravelar veloplasty. Two senior surgeons standardized their operative procedures and performed or supervised directly all operations. Perceptual speech and language evaluations were conducted by the same experienced speech pathologist when the children were 6 years old and 12 years or older. Data were analyzed from the 28 patients available for long-term follow-up. The intravelar veloplasty (N = 14) and nonintravelar veloplasty (N = 14) groups were similar with respect to cleft anatomy and mean age at palatoplasty and at the second perceptual speech evaluation. Evaluation of the 12-year-old and older ratings indicated that the overwhelming majority of patients improved or maintained clinical stability in perceptual ratings of velopharyngeal function. When assessing direction and magnitude of change (i.e., incremental improvement vs. deterioration), the intravelar veloplasty and nonintravelar veloplasty groups had a similar distribution of perceptual speech ratings at both the 6-year and 12-year or older speech evaluations. Results were consistent with previously published data from our center, that the intravelar veloplasty procedure did not affect demonstrably the incidence of postpalatoplasty auditory perceptual symptoms of velopharyngeal dysfunction.

Evaluation of two palate repair techniques for the surgical management of velopharyngeal insufficiency.

Background: The Furlow palatoplasty is commonly used for the correction of velopharyngeal insufficiency in cleft patients. An alternative procedure is introduced involving a single Z-plasty with overlapping intravelar veloplasty (Woo palatoplasty). This study compared the results of both techniques in the correction of velopharyngeal insufficiency. Methods: After institutional review board approval, a retrospective chart review was performed of all patients who had undergone secondary palatoplasty for the correction of velopharyngeal insufficiency. All nonsyndromic patients with imaging data were evaluated. Data elements included preoperative and postoperative velopharyngeal gap size and perceptual speech examination results. Results: Fifty-two subjects were included: 30 subjects had undergone Furlow palatoplasty and 22 underwent Woo palatoplasty. Overall, a larger proportion of Woo (95 percent) than Furlow subjects (63 percent) did not require secondary surgery (p = 0.005). However, mean presurgery closure was significantly different between groups (p = 0.042). For a more refined assessment, only those with 80 percent or greater preoperative closure were evaluated. Successful results were achieved in 67 percent (10 of 15) in Furlow and in 100 percent (19 of 19) in Woo. Again, this finding was significant (p = 0.005). Linear regression analysis suggested a significant effect of cleft type (&bgr; = 2.3, p = 0.013) on closure after repair, with decreased closure in cases with isolated cleft palate. Conclusions: The Woo palatoplasty compared favorably with Furlow palatoplasty for correction of velopharyngeal insufficiency. The technique appears to be a viable alternative for palatal re-repair, especially in circumstances when Furlow palatoplasty cannot be performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Does preexisting posterior pharyngeal wall motion drive the dynamism of sphincter pharyngoplasty

&NA; Lateral speech videofluoroscopic evaluations were videotaped preoperatively and postoperatively for 20 patients who underwent sphincter pharyngoplasty. Randomized videotapes were constructed and subsequently evaluated by speech/language pathologists experienced in assessing patients with velopharyngeal dysfunction. Rating forms assessing various motion parameters of the posterior pharyngeal wall were completed and analyzed statistically. Results showed that the posterior pharyngeal wall configuration postoperatively was less likely to be rated as smooth relative to the preoperative configuration (p = 0.019). No other statistically significant data were obtained, although there was a trend for posterior pharyngeal wall movement rated as discrete preoperatively to be described as generalized postoperatively. We conclude that when comparing preoperative and postoperative parameters, sphincter pharyngoplasty does not significantly affect posterior pharyngeal wall motion. Posterior pharyngeal wall configuration is less likely to be categorized as smooth after sphincter pharyngoplasty relative to the preoperative condition. Although sphincter pharyngoplasty has been shown to improve velopharyngeal function, there is little evidence from this study to suggest that preexisting posterior pharyngeal wall motion causes sphincteric movement. (Plast. Reconstr. Surg. 101: 1457, 1998.)

An Innovative Collaborative Treatment Model: The Community-Based Speech-Language Pathologist and Cleft Palate Team.

Problem Children with cleft-related articulation disorders receive ineffectual or inappropriate speech therapy locally due to lack of training and a disconnect between the team and local speech-language pathologists. Solution A collaborative care program that is billable for the team allows the local speech-language pathologist to earn continuing education units and facilitates effective local speech therapy. This program is the first of its kind, according to the American Speech-Language-Hearing Association Continuing Education Board for Speech Pathology.