Cleft palate repair and velopharyngeal dysfunction

After studying this article, the participant should be able to: (1) Describe the technical details common to all cleft palate repairs that optimize outcomes and minimize complications. (2) Explain the subjective and objective evaluation of speech in children with cleft palate. (3) Practice with an increased awareness of the management of complications associated with cleft palate repair. (4) Design a treatment plan for velopharyngeal dysfunction.

Goals of a successful cleft palate repair include separation of the oral and nasal components without fistula, achieving sufficient velar length, and creating functional transverse orientation of the levator muscle sling. A number of techniques have been described to achieve these goals, but they all have the following technical details in common: elevation of oral mucosal flaps based on the greater palatine arteries, tension free nasal lining mobilization, and functional intervelar muscle dissection. After palate repair, speech evaluation needs to be performed by an objective interdisciplinary team following a standardized protocol. Identification of velopharyngeal insufficiency secondary to an incompetent nasopharyngeal port will necessitate secondary speech surgery. These secondary techniques include pharyngeal flaps, soft palate lengthening, or pharyngeal sphincters, which should be tailored to optimize speech, while minimizing the risk of obstructive sleep apnea.