Longitudinal Evaluation of Articulation and Velopharyngeal

Competence of Patients with Pharyngeal Flaps

D. R. Van Demark, PH.D.

M. A. Harpin, PH.D.

In this study, 129 patients with cleft palate who had pharyngeal

flaps were evaluated longitudinally. Articulation scores improved ap-proximately 15 percent following surgery, and by age 16 the majorityof subjects achieved velopharyngeal competence and 90 percent cor-rect articulation. The findings also demonstrated that the risk of re-

quiring secondary management increased with the severity of the cleft.In addition, a higher percentage of patients who had received a pri-

mary Von Langenbeck procedure required secondary managementthan did patients who had the Wardill primary palatoplasty. Age attime of the pharyngeal flap operation did not emerge as a critical

factor in speech outcome.

It is generally reported that the pharyn-

geal flap operation successfully improves

articulation and establishes velopharyn-

geal competence for approximately 80

percentof patients. At present, however,

very little is known about the factors re-

lated to the success of the procedure. In

an early study, Moll et al (1963) found that

pharyngeal flap width and the patient's age

at time of secondary operation were re-

lated to the success of the pharyngeal flap

operation. More recently, Riski (1979) re-

ported that patients who received pharyn-

geal flaps prior to 6 years of age demon-

strated more rapid improvement in

articulation and resonance balance than did

children who received a pharyngeal flap

after age 6.

In contrast, Van Demark and Hammer-

Dr. Van Demark is a Professor in the Departmentof Otolaryngology-Head and Neck Surgery and De-partment of Speech Pathology and Audiology at theUniversity of Iowa, Iowa City, IA. Dr. Hardin is anAssistant Professor in the Department of Commu-nication Sciences and Disorders at the University ofMontana, Missoula, MT. _

This paper was presented at the Annual Meeting

of the American Cleft Palate Association, Seattle,

Washington, May 24, 1984, and was supported in part

by Public Health Service Grant no. DE-00853, Na-

tional Institute of Dental Research.

quist (1978) found that early secondary

management (performed before 4 years of

age) was not associated with better artic-

ulation proficiency or velopharyngeal

competence. However, when secondary

management was delayed until after 10

years of age, there was also a trend for

poorer articulation. When compared at age

10, subjects who received a pharyngeal flap

prior to 5 years of age were given poorer

velopharyngeal competence ratings than

subjects who received secondary manage-

ment after 5 years of age. Van Demark and

Hammerquist concluded that the optimal

time of secondary management was be-

tween 4 and 10 years of age. Although the

primary objective of their study was to ex-

amine the relationship between the timing

of the pharyngeal flap operation and the

success of the technique, Van Demark and

Hammerquist also noted that type of cleft

and type of palatoplasty appeared to be risk

factors associated with the need for sec-

ondary management. According to the au-

thors, subjects with cleft of the soft palate

only, required a pharyngeal flap operation

less frequently than subjects with more se-

vere types of cleft. However, Riski's (1979)

data indicated little difference in types of

cleft that needed secondary management.

Additional research is needed to iden-

163

164

tify those factors that are related to the

success of the pharyngeal flap technique.

Further study is also needed to identify

those factors that may increase the need

for secondary management. The purposes

of this study were to examine the longi-

tudinal development of articulation, na-

sality, and velopharyngeal competence of

a group of subjects with cleft palate who

had undergone the pharyngeal flap op-

eration and had participated in the Iowa

Cleft Palate Longitudinal Research Proj-

ect.

Specifically, the data, although neces-

sarily retrospective in nature, could pro-

vide some insight into the following ques-

tions:

1) Does the age of initial palatoplasty

appear to relate to the need of sec-

ondary management and speech re-

sults? »Does the type of initial palatoplastyappear to relate to the need of sec-ondary management and speech re-sults?Does the type of cleft appear to re-late to the need of secondary man-agement and speech results?Does the age of pharyngeal flap sec-ondary management relate to speechresults?

2)

3)

4)

PROCEDURE

Subjects

All subjects in this study were part of theIowa Cleft Palate Longitudinal Project.Initially, subjects were enrolled in theproject when treatment was needed; how-ever, after 1963 subjects were enrolled inthelongitudinal project at birth. Approx-

Cleft Palate Journal, July 1985, Vol. 22 No. 3

imately 520 subjects have been enrolled in-the project, which includes computer stor-age of pertinent speech-articulation dataand information about various types ofphysical management.

All subjects who had a secondary palatalprocedure, which in this case was a supe-riorly-based pharyngeal flap operation,were identified from the computer iden-tification program. A total of 129 subjectswere available for study. Subjects' birth-dates ranged from 1946 to 1975, with themean year of birth, 1963.

Information about the type of cleft andtype of palatal operation for these subjectsis shown in Table 1. Eleven of the 129subjects had cleft of the soft palate only,28 had cleft of the hard and soft palate,58 had unilateral cleft of the lip and pal-ate, and 32 had bilateral cleft of the lip andpalate. As shown, the majority of subjectsreceived either the Von Langenbeck orWardill procedure for surgical repair ofthe palate. Timing of palatoplasty rangedfrom 3 months to 9 years of age, with amean age of 3 years. Age of secondarymanagement ranged from 2 years, 5months to 16 years, 2 months, with a meanage of pharyngeal flap management of 7years, 2 months.

DATA COLLECTION

Annual articulation test scores, obtainedwith the 105-item articulation test used inthe research protocol, were retrieved foreach subject using the computer programdescribed previously by Van Demark andTharp (1973). This test includes the IowaPressure Articulation Test, the Templin-Darley Screening Test of Articulation, aswell as other phonemes in various word

TABLE 1. Subjects Categorized According to Cleft Type and Type of Primary Palatoplasty Type of Cleft Male Female N Type of Surgery N

Soft Palate Only (including subjectswith submucous) 1 10 11 l-stage Von Langenbeck 49

Hard and Soft Palate 8 20 28 2-stage Von Langenbeck 14Unilateral Lip and Palate 35 23 58 Wardill (NVB®* intact) 37Bilateral Lip and Palate 25 7 32 Wardill (NVB* severed) 24

Other 5 *NVB = neurovascular bundle

Van Demark and Hardin, LONGITUDINAL EVALUATION

positions. A total of 1506 articulation tests

for the 129 subjects was available for study.

Clinical ratings of velopharyngeal com-

petence assigned by the examining speech

pathologist during each examination were

also retrieved. These clinical ratings (com-

petence, marginal competence, or incom-

petence) were made by the speech pa-

thologist as the best estimate of the

adequacy of the mechanism. Routinely,

these ratings were based on a combination

of observations including conversational

speech, word, and sentence articulation

testing, stimulability, examination of the

oral mechanism, and for some patients,

information obtained from lateral x-ray

films and fluoroscopy. Parental reports and

reports from speech clinicians working with

the child locally were considered in the

composite rating. In addition, severity rat-

ings (7 point scales where 1 = normal and

7 = severe) of nasality and articulation de-

fectiveness in connected speech were re-

trieved.

Approximately 90 percent of the obser-

vations obtained from the longitudinal

project were made by two speech pathol-

ogists who were experienced in evaluating

the speech of children with cleft palate.

Estimates of their current interreliability

in articulation test scoring and severity

ratings of articulation and nasality were

obtained in a recent report (Hardin, 1984).

Agreement between the two examiners in

scoring articulation tests was high (84%).

Interjudge reliability of severity ratings was

also relatively high with ratings exact or

within one scale value on 92 percent (ar-

ticulation) and 84 percent (nasality) of the

samples. An estimate of their interjudge

reliability in assigning clinical judgments

of velopharyngeal competence was ob-

tained in an earlier study (Morris, 1978),

and 84 percent agreement was reported.

RESULTS

The articulation test scores were exam-

ined prior to and following the pharyn-

geal flap operation. As demonstrated in

Table 2, the articulation scores before sec-

ondary management were poor. Subjects

between the ages of 4"/;, and 8 years im-

165

proved their articulation scores by ap-

proximately 15 percent (average differ-

ence in pre and post scores) following

secondary management. After age 8, the

articulation test scores of the pre- and post-

pharyngeal flap groups were more simi-

lar. It should be noted that the number of

subjects gets smaller across age levels for

the pre-flap group because as age in-

creases, more subjects received pharyn-

geal flaps. Conversely, for the post-flap

group the number of subjects becomes

larger because additional subjects had

pharyngeal flap operations at each age level

studied. Although some individual sub-

jects achieved relatively high articulation

scores, the group data indicate that the ar-

ticulation performance of these subjects was

well below that expected of 8-year-old

children without clefts and slightly below

the norms of children with clefts (Van De-

mark et al, 1979).

The most frequent error types observed

prior to secondary management included

omissions, sound substitutions, and nasal

distortion of consonant sounds (Table 3).

_ Although the number of errors related to

omissions and substitutions decreased with

age, nasal distortion errors did not. Anal-

ysis of the data following pharyngeal flap

management revealed a substantial de-

crease in articulation errors related to na-

TABLE 2. Mean Percentage of Elements Correct

on the 105-Item Iowa Articulation Test Prior toand Following the Pharyngeal Flap Operation

Age N* Before Flap Nt After Flap

4 48 24.5 8 22.14/4 55 28.7 16 35.6

5 51 30.0 26 47.66 48 41.1 50 55.4

7 31 48.3 66 63.48 24 58.2 75 70.59 10 76.3 83 75.510 9 72.4 80 80.9

11 6 79.2 83 82.212 7 61.3 80 84.4

*Ns decrease in column 2 because patients re-ceived pharyngeal flaps at approximately the age level

indicated.{Ns increase in column 4 because of the increase

in the number of subjects with pharyngeal flaps.

166 Cleft Palate Journal, July 1985, Vol. 22 No. 3

TABLE 3. Mean Percentage of Elements Misarticulated on the 105-Item Iowa Articulation TestAccording to Type of Error for all Subjects

Oral Nasal Oral NasalAge N Distribution Distribution Substitution Substitution Omission

Pre* Post* __ pre post pre post pre post pre post pre post

4 48 8 5.0 2.3 15.1 7.5 19.8 20.2 3.0 2.4 26.4 34.4

4/3 55 16 5.9 9.2 14.5 12.4 17.4 17.3 2.6 3.8 22.2 17.5

5 51 26 4.9 9.9 14.5 3.5 16.3 15.4 3.9 1.3 19.8 17.46 48 50 6.6 10.2 12.9 4.9 13.7 12.4 2.1 1.2 12.7 10.4

7 31 66 8.2 11.0 15.4 3.2 8.9 9.1 5.5 7.1

8 24 75 5.0 10.7 13.8 5.5 . 4.8 6.8 1.9 5.9 3.19 10 83 9.3 11.2 11.9 1.9 1.7 5.3 3.4

10 9 80 5.5 9.8 7.0 2.2 2.4 2.9 1.2

11 6 83 5.2 9.2 13.5 1.0 1.2 3.0 1.212 7 80 8.3 11.5 2.9 1.4 2.3

*Pre = pre flap, Post = post flap

TABLE 4. Mean Percentage of Elements Correct on the 105-Item Iowa Articulation Test Following

the Pharyngeal Flap Operation for all Subjects Grouped According to Timing of Primary Palatoplasty

A <22 months 22-28 months 29-34 months 35-46 months >46 months

8° N % N % N % N % N %

4 3 28.7 4 20.8 1 11.4

4/3 3 36.0 9 38.5 3 31.9 1 19.4

5 9 45.3 11 51.2 3 62.8 2 19.2 1 28.1

51/3 5 44.9 3 51.7 - 1 85.2 1 48.5 2 30.96 11 59.7 17 65.5 12 51.0 5 29.8 5 45.57 14 65.5 15 74.0 20 63.0 11 47.5 6 61.4

8 11 79.3 19 75.4 22 69.4 13 59.9 9 64.29 14 76.6 16 81.6 24 78.7 16 64.0 12 72.110 11 86.8 18 84.0 22 81.9 15 76.7 13 73.6

11 8 92.3 18 88.2 23 86.0 17 72.9 16 74.212 7 87.0 20 89.2 21 85.3 16 79.7 15 80.2

sal distortion and an increase in oral dis-

tortion errors.

Timing of initial palatoplasty was also

investigated in order to assess the relation

between the age at which palatoplasty was

performed and articulation proficiency for

patients with pharyngeal flaps (Table 4).

Although the number of subjects in the

early palatoplasty group (under 22 months)

and the older palatoplasty group (over 46

months) was small, inspection of the data

indicated that no readily apparent trend

existed. The younger palatoplasty groups

(under 22 months, 22 to 28 months, and

29 to 34 months) exhibited slightly supe-

rior articulation skills, correctly producing

at least 80 percent of the test items by age

10. The two older groups did not reach

that level of proficiency until 12 years of

age. At age 12, however, the five groups

were similar in speech proficiency with av-

erage scores of 87, 89, 85, 80, and 80 per-

cent respectively. These findings suggest

that timing of primary palatoplasty is not

a critical factor in articulation proficiency

for patients who require a pharyngeal flap

procedure.

Comparison of articulation perfor-

mance between primary palatoplasty

groups is shown in Table 5. In general,

higher articulation scores were obtained by

the Wardill group than the Von Langen-

beck group following pharyngeal flap

management. This trend is particularly

noticeable until age 8, when the Von Lan-

genbeck group performance was similar

to the Wardill group. 'Table 6 illustrates the relation between

articulation performance and the type ofcleft. Subjects with cleft of the hard and

Van Demark and Hardin, LONGITUDINAL EVALUATION 167

TABLE 5. Percent Elements Correct on the 105-Item Iowa Articulation Test Following thePharyngeal Flap Operation for all Subjects

Grouped According to Type of Palatoplasty

A Von Langenbeck Wardall

8° N % correct N % correct

4 8 22.7

4'/2 15 36.75 25 48.5

5/2 9 53.36 11 39.4 38 59.37 25 57.8 41 66.5

8 33 66.4 41 73.39 42 72.4 38 77.8

10 40 78.7 37 82.111 43 _ 79.0 37 85.012 44 84.0 32 81.8

soft palate exhibited articulation skills

slightly superior to subjects with cleft of

the soft palate only; however, the differ-

ences were small and probably not mean-

ingful because of the small sample size in

both groups. Articulation proficiency be-

tween the groups with unilateral and bi-

lateral clefts showed a slight tendency for

subjects with unilateral clefts to have the

better scores longitudinally.

A phoneme analysis was performed for

all subjects following secondary manage-

ment to determine if differences existed

between the group with cleft palate and

the group with cleft lip and palate in the

production of any consonant sounds. Al-

though these data are not presented in this

paper, subjects with cleft lip and palate ex-

hibited substantially more difficulty than

subjects with cleft palate only in produc-

ing alveolar sounds, particularly the /s/ and

/z/ sounds. More errors might be ex-

pected for the groups with cleft lip and

palate if dentition is a factor in articula-

tory production.

Table 7 illustrates the relation between

age at time of pharyngeal flap operation

and articulation proficiency. Although the

sample size of the youngest group (under

48 months at time of operation) is small,

comparison of this group to the older age

groups does not suggest a trend for better

articulation with early secondary manage-

ment. Subjects who had secondary man-

agement between 48 and 60 months tended

to achieve slightly higher articulation scores

than the youngest group and the oldest

group at most age levels. This difference

was small, however, and close inspection

of the data indicates that the absolute dif-

ference between the group with the best

articulation score and the group with the

poorest score decreased with age. Al-

though the older groups may exhibit

poorer articulation skills immediately fol-

lowing pharyngeal flap management than

the younger age groups, rapid improve-

ment in articulation proficiency appears to

occur. By age 12, all age groups were within

approximately six percentage points of each

other. Thus, our data are not supportive

of the hypothesis that early secondary

management (before age 4) results in

higher articulation proficiency.

TABLE 6. Mean Percentage of Total Elements Correct on the 105-Item Iowa Articulation TestFollowing the Pharyngeal Flap Operation for Subjects grouped According to Cleft Type.

a sPO HSSP ULP BLP

8° N % N % N % N %

4 9 22.8 6 21.94}, 1 19.4 3 43.4 12 35.05 3 46.3 4 50.3 16 48.0 3 44.56 5 43.3 7 63.2 29 58.3 9 46.97 6 50.5 13 76.3 39 62.6 25 64.83 5 64.1 14 73.5 35 71.4 21 68.39 6 33.3 13 31.8 39 73.8 25 73.910 4 89.7 14 31.8 38 82.1 24 77.011 6 77.5 11 36.4 40 82.8 25 79.912 7 31.1 11 85.5 39 84.5 24 85.4

SPO = soft palate only, H&SP = hard and soft palate, ULP = unilateral lip and palate and BLP = bilateral

lip and palate

168 Cleft Palate Journal, July 1985, Vol. 22 No. 3

TABLE 7. Mean Percentage of Elements Correct on the 105-Item Iowa Articulation Test for allSubjects Grouped According to Age at Time of Pharyngeal Flap Operation

A <48 months 48-60 months 61-72 months 73-84 months 85-96 months >96 months

__ N- % ON _ON % %

4 6 23.2 2 17.74/3 6 35.3 10 35.8

5 8 37.5 17 55.1 1 8.757g 2 43.2 5 69.7 3 29.9

6 6 58.3 21 71.7 16 _ 45.6 7 21.8

7 7 68.9 18 75.6 16 61.2 23 55.1 2 39.9

8 6 70.7. 19 79.3 16 68.8 18 70.6 14 67.5 5 54.29 4 76.1 14 86.6 15 75.7 21 76.3 13 80.9 19 62.4

10 5 82.0 17 84.5 12 83.5 17 86.8 9 83.3 25 73.311 4 78.3 14 92.6 13 78.1 19 87.3 10 83.1 25 74.512 3 88.5 12 91.2 12 78.1 18 84.9 9 88.7 29 82.4

TABLE 8. Risk Rates of Pharyngeal Flap for Iowa Patients Grouped According to Cleft Type andType of Primary Operation

Von Langenbeck Wardill

TotalCleft Type Youd Patients Risk Tool Paliedts Risk Risk

Patients with Flaps Patients with Flaps

Soft palate .

Only 19 3 16% 38 6 16% 16%Hard and soft

palate 24 15 62% 64 12 19% 31%Unilateral lip :

and palate 67 26 39% 95 31 33% 35%Bilateral lip

and palate 38 19 50% 41 12 29% 39%Totals 148 63 43% 238 61 26% 32%

RISK FACTOR FOR SECONDARY SURGERY

Of particular interest was the signifi-

cance of cleft type as a risk factor for re-

quiring pharyngeal flap management. Risk

was defined as the number of subjects with

a specified cleft type who received a pha-

ryngeal flap operation divided by the total

number of subjects with that cleft type. The

number of patients who have participated

in the longitudinal cleft palate research

project at Iowa is shown in Table 8 and

is grouped according to the type of cleft

and type of primary management. Also

shown is the number of these patients

who have received a pharyngeal flap op-

eration. The results of our analysis sug-

gest that risk of needing a pharyngeal flap

operation is higher for patients with cleft

of the lip and palate than for patients with

cleft of the palate only. Patients with bi-

lateral clefts of the lip and palate are at

higher risk of requiring additional man-

agement than those with a unilateral cleft

of the lip and palate. The risk of requiring

secondary management is higher with clefts

of the hard and soft palate than with clefts

of the soft palate only.

When the type of operation is consid-

ered for all types of cleft, it becomes evi-

dent that fewer subjects who received the

Wardill procedure are in need of second-

ary management compared to those who

had the Von Langenbeck procedure (26%

versus 43%). The data in Table 8 illustrate

that one should question using the Von

Langenbeck procedure, particularly for

patients withclefts involving the hard and

soft palate and bilateral lip and palate.

These differences, however, may reflect the

fact that Von Langenbeck subjects gener-

ally had primary management before 1968,

Van Demark and Hardin, LONGITUDINAL EVALUATION 169

TABLE 9. Mean Rating of Articulation Defectiveness for all Subjects Grouped According to Age at

Time of Pharyngeal Flap Operation

Ave <48 months 48-60 months 61-72 months 73-84 months 85-96 months >96 months

C_ w x N x N X N x N x N x

4 5 6.44/9 5 6.0 8 5.45 6 5.7 17 4.4 1 7.06 5 3.6 19 3.3 12 4.67 6 3.2 16 3.1 14 3.8 18 4.4

8 5 3.2 12 2.7 15 3.2 17 3.5 11 3.5

9 4 2.5 11 2.0 13 3.2 20 3.6 12 3.0 14 4.5

10 4 2.2 15 2.2 11 2.9 15 2.6 9 2.3 16 2.8

11 2 2.0 11 1.7 13 3.2 18 2.3 10 2.5 20 2.4

12 3 4.6 9 1.8 12 4.2 18 2.4 9 2.2 25 2.4

TABLE 10. Mean Rating of Severity of Nasality for all Subjects Grouped According to Age at Time

of Pharyngeal Flap Operation.

A <48 months 48-60 months

-

61-72 months

-

73-84 months

-

85-96 months >96 months

£

_

W

-O

x- N

==

® N x N x N x N x

4 4 3.04'/g 5 2.6 8 4.45 6 2.8 17 2.1 1 7.0

6 5 1.4 19 2.0 12 2.6

7 6 2.5 15 1.2 13 2.0 14 2.0

8 5 3.0 12 1.4 15 2.0 15 2.1 10 1.9

o 3 3.3 11 1.8 12 1.6 16 2.0 12 1.6 12 2.6

10 4 1.0 15 1.6 11 1.6 15 1.7 o 1.6 13 1.9

11 2 1.0 11 1.4 11 1.8 19 1.5 10 1.5 15 1.7

\ 3 1.0 10 1.4 11 2.4 18 1.4 o 1.3 22 1.8

while the Wardill subjects had primary

management after that time.

RELATIONSHIP OF SECONDARY

MANAGEMENT TO ARTICULATION

DEFECTIVENESS, NASALITY, AND

VELOPHARYNGEAL COMPETENCE

Clinical ratings of articulation defective-

ness and nasality were also examined for

subjects grouped according to age at time

of secondary management (Tables 9 and

10). As shown, improvement in ratings of

articulation and nasality occurred for all

groups. Although the number of subjects

in each management age group was small,

a trend for better ratings of articulation

was observed for the groups who received

early pharyngeal flap operations (under 48

months; 48 to 60 months). Little differ-

ence between the groups was apparent in

the severity of nasality.

Clinical judgments of velopharyngeal

competence were examined longitudinally

for all subjects grouped according to the

age at the time of pharyngeal flap man-

agement and are presented in Table 11.

Again, little difference in average judg-

ments of velopharyngeal competence was

evident among the groups. These group

data suggest that timing of secondary

management is not an important factor in

the outcome of velopharyngeal status.

Additionally, the success of the pharyn-

geal flap procedure was evaluated, in part,

by identifying the number of subjects who

demonstrated velopharyngeal competence

at the time of the last examination. Of the

129 patients, 102 received clinical judg-

ments of velopharyngeal competence.

Twenty subjects were judged to demon-

strate marginal velopharyngeal compe-

tence and only seven subjects received

170 Cleft Palate Journal, July 1985, Vol. 22 No. 3

TABLE 11. Mean Rating of Velopharyngeal Competence for all Subjects Grouped According to Ageat Time of Pharyngeal Flap Operation.

A <48 months 48-60 months 61-72 months 73-84 months 85-96 months >96 months

6 N % ON- % No- % No- % No- 4%

4 6 2.0 9 3.0

5 1.6 9 2.0

5 7 1.9 16 1.6 1 3.0

6 5 1.0 20 1.3 14 1.6 9 3.0

7 6 1.2 16 1.1 14 1.2 13 1.4 9 3.0

8 6 1.7 13 1.2 15 1.4 16 1.2 11 1.3 3 3.09 4 1.5 11 1.5 14 1.1 17 1.3 13 1.2 15 1.6

10 5 1.0 16 1.1 12 1.2 15 1.1 9 1.1 17 1.4

11 3 1.0 11 1.1 13 1.2 19 1.1 10 1.3 13 1.5

12 3 1.0 10 1.1 11 1.4 19 1.1 9 1.1 24 1.5

1 = velopharyngeal competence, 2 = marginal velopharyngeal competence, 3 = velopharyngeal incom-petence

judgments of velopharyngeal incompe-

tence.

Six of the 129 subjects exhibited consis-

tent hyponasality following the pharyn-

geal flap procedure. Hyponasality was ev-

ident 1 to 2 years following secondary

management for two subjects, 5 to 7 years

for three subjects, and 11 years after sec-

ondary management for one subject. Three

of the six subjects exhibited hyponasality

for 2 consecutive years and three subjects

exhibited it for 3 consecutive years. Dur-

ing their last examination, only two sub-

jects were judged to have hyponasal voice

quality. Likewise, information about mouth

breathing was available for 114 of the 129

subjects at their last examination. Of the

114 subjects, 55 reported that they were

mouthbreathers, and 48 subjects were

identified by the examining clinician as

mouth breathers.

DIscUssION

The results of this study indicate that one

can expect improvement in articulation

following pharyngeal flap management.

Prior to the pharyngeal flap operation,

subjects seldom, if ever, reached the mean

correct score on the Iowa Pressure Artic-

ulation Test for cleft palate subjects (Van

Demark et al, 1979); after a pharyngeal flap

operation, differences in performance be-

tween flap and nonflap subjects of ap-

proximately 15 percent existed for most

age groups. Differences were smaller at the

older age levels, probably because most of

the older subjects generally exhibited a

marginal velopharyngeal mechanism and

thus often had fairly acceptable articula-

tion but unacceptable nasality. It should

be noted that, as a group, articulation by

the older subjects is still not completely

normal and, as with subjects without flaps,

speech habilitation is less than optimal

(Bardach et al, 1984).

Element analysis of articulation scores

appears to us to be meaningful in the di-

agnostic management of individuals. It has

been well documented that articulation er-

rors occur most predominately on pres-

sure sounds, plosives, fricatives, and affri-

catives, although fricatives and affricatives

are learned relatively late and thus may not

be differentially diagnostic. However, type

of error may be more meaningful and

merits further investigation. Normal chil-

dren seldom exhibit nasal distortions or

emission of air on pressure sounds. The

inability of children with clefts to change

this type of error over time may be the most

significant cue in determining the need for

further management. Our data demon-

strate that there is a decrease in the num-

ber of nasal distortions and an increase in

the number of oral distortions after pha-

ryngeal flap management.

Our data are in disagreement with those

of Riski (1979) who found an approxi-

mately equal proportion of subjects with

clefts of the palate versus clefts of the lip

and palate who required flaps. Our data

indicate that there is a greater risk of re-

quiring secondary management for pa-

Van Demark and Hardin, LONGITUDINAL EVALUATION

tients with bilateral clefts, with the least risk

for patients with clefts of the soft palate

only. The severity of the cleft may influ-

ence the age at initial palatoplasty. In our

institution, subjects with more severe clefts

tended to have later management, and it

is not clear that age at time of initial pal-

atoplasty is a primary factor influencing

the need for pharyngeal flap manage-

ment. Thus, even with a relatively large

sample size, it is difficult to sort out the

influence of the type of cleft, type of pri-

mary surgical management, and age of

primary operation on the need for sec-

ondary management.

Review of the literature still indicates

some confusion as to which operative

management procedure gives better re-

sults. Overall, our data indicate superior

results with the Wardill procedure; how-

ever, some caution should be exercised in

the interpretation of the results since our

Wardill subjects are younger. Some of these

subjects may need secondary management

in their teenage years. The data in Table

7 suggest that one of the reasons for in-

consistency of various reports may be the

make-up of the sample. It can be seen that

differences in risk between the two types

of palatoplasty are very small for subjects

with cleft of the soft palate only and uni-

lateral cleft lip and palate. The Von Lan-

genbeck group, however, demonstrates a

much greater risk of requiring secondary

management for patients with clefts of the

hard and soft palate and bilateral clefts. In

our original research (Van Demark and

Hammerquist, 1978), a slight difference

was found in favor of the Von Langen-

beck procedure for clefts of the soft palate

only. It would appear that if the Von Lan-

genbeck procedure is used, it should only

be used for clefts of the soft palate and

unilateral cleft lip and palate. Another

factor which may influence these results is

the age at the time of initial palatoplasty.

On the whole, Von Langenbeck subjects

had primary management later than the

Wardill subjects.

Data from this study suggest that the age

at which the pharyngeal flap procedure is

performed is not extremely critical; how-

ever, differences in the success of this pro-

cedure may be noted at age extremes. Our

171

initial results (Van Demark and Hammer-

quist, 1978) indicated that subjects who re- _

ceived pharyngeal flaps before 4 years of

age achieved poorer velopharyngeal com-

petence; thus, the number of subjects in

this study having a pharyngeal flap oper-

ation before this age is small. Because of

the longitudinal nature of the project, few

subjects had obvious velopharyngeal in-

competence at the older age levels (1e.,

after 8 to 9 years of age). The majority of

subjects who received secondary manage-

ment after 8 years of age had marginal

mechanisms prior to pharyngeal flap

management, and they usually exhibited

hypernasality but fairly good articulation,

i.e., little audible nasal emission or com-

pensatory articulatory behavior existed. An

increase in the severity of hypernasality and

audible nasal emission, probably related to

adenoid atrophy, had become apparent for

some subjects. Thus, as is demonstrated in

Table 11, the age at time of pharyngeal

flap management does not appear to be a

significant factor in achieving adequacy of

velopharyngeal competence. Likewise, the

articulation scores, severity of articulation

defectiveness, and severity of nasality ap-

pear highly similar, with a trend for sub-

jects with early management to have slightly

better scores.

Recently, attention has been given to the

detrimental effects of pharyngeal flap

management, particularly in regard to na-

sal airway obstruction and sleep apnea.

Forty-eight of our subjects were observed

to be mouth breathers, a surprisingly high

number. Unfortunately, we have not con-

sistently observed the number of individ-

uals with clefts who do not have flaps who

exhibit a mouth-breathing problem, but we

suspect that the incidence is relatively high

and may result, in part, from septal de-

viations. Thus, patients tend to breathe

through the pathway of least resistance,

especially when involved in activity that

requires physical exertion.

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