What is it?
The main function of the palate is to help form sound into recognizable speech. The muscles of the palate contract and force it to touch the back of the throat creating a valve that forces air and sound vibrations out of the mouth past the tongue and lips. When this valve fails, air can leak out through the nose, which makes the speech have a very nasal quality, and can make it very muddled and difficult to understand. Symptoms vary depending on how much of a gap there is, and how much air is leaking through. A similar thing can happen if there is a fistula in the palate that air is leaking through. We call this phenomenon velopharyngeal dysfunction or “VPD”. VPD usually happens if the muscles of the palate or throat do not work correctly, are in the wrong place, or if the palate is too short to touch the back of the throat.
Most patients with VPD are cleft patients. About 1 in 4 cleft patients will have some form of VPD after their initial palate repair. Some children also have what is called a “submucous cleft” palate. With a submucous cleft palate, there isn’t an actual hole in the palate, but sometimes the uvula will appear split. The main issue is that the muscles are in the wrong position. However, most children with a submucous cleft palate have fairly normal speech, and only about 25% will need surgery. Other children born with syndromes or neuromuscular problems that affect how these muscles function can also have VPD (Down’s syndrome, DiGeorge syndrome, Muscular Dystrophy, stroke etc.). Depending on the specific problem, treatments vary. Sometimes it can be hard to determine what is wrong with a child’s speech, as there can be more than one issue happening simultaneously. This is why a speech therapist trained to work with cleft patients is extremely important.
Once it has been determined that there is an issue with your child’s speech, you will be evaluated by our speech therapist. First, they will listen to your child speak, and then decide what further testing is necessary. Typically, this involves fluoroscopy and naso-endoscopy. During fluoroscopy, we have your child sniff some barium contrast, and then watch how their palate moves with x-rays while they are speaking. Naso-endoscopy uses a long thin camera that is inserted in the nose, and allows us to directly watch how the palate and throat move during speech. We will review the results of these tests with the speech therapist and make recommendations. Sometimes, it may be that speech therapy is all that is needed. If so, we will work with you and your child’s school to set up an appropriate regimen. If there is a physical problem with the palate causing air to leak into the nose, then some type of surgery will generally be necessary.
What surgical options are there?
The type of surgery offered depends on the cause of the VPD. If your child has a submucous cleft palate, we will recommend a primary palate repair to place the muscles in their proper position. Sometimes a cleft child may have already had a palate repair, but testing shows that the muscles are not located far enough back in the palate to make a seal with the throat, even though the muscles are working well and the palate is long enough. In these cases, we may recommend a palate re-repair where we move the muscles where they need to be. Sometimes the muscles are working, and are located in the back of the palate, but the palate itself is very short and/or scarred. In these situations, we have two different options: a Furlow Palatoplasty or Buccal Myomucosal flaps.
We tend to use the furlow when it looks as though the muscle still needs some work. The furlow works by creating zig-zag flaps of tissue in the mouth which interdigitate and overlap with each other. This makes the palate longer and also repositions and tightens the muscle. On the other hand, if the muscles are at the back of the palate and working well, and we just need to add length, we tend to use Buccal Flaps. Surgery involves taking a piece of tissue from the inside of each cheek which is kept attached to its blood supply. We then release the soft palate from the hard palate, leaving a hole that needs to be filled. The flaps of tissue are then rotated and sandwiched on each other, and sewn into the hole. This makes the palate considerably longer so that the muscles are then in a position to touch the back of the throat. If overall the palate is working well, but there is a tiny little gap in the center allowing some air to escape, we may consider fat grafting.
Fat grafting involves removing a small amount of fat from your child’s abdomen or buttock via liposuction, preparing the fat, and then injecting it in the back of the palate. This plumps the palate so that it can make a complete seal with the throat. This generally works well for small gaps, but cannot be used for large ones. If we see that the sides of the throat are not moving enough to come together and close around the palate, we generally offer a pharyngoplasty. A pharyngoplasty involves taking tissue from around the tonsils which is overlapped and sewn to the back of the throat. This pulls the throat tighter like a noose and makes the opening around the palate smaller to prevent air from leaking around the sides. The last procedure used is called a Pharyngeal flap or “P flap”.
A P flap works by taking a piece of tissue from the back of the throat, flipping it up, and sewing it to the palate. This acts like a leash and causes a permanent connection between the palate and the back of the throat. As a result, there are only very small holes, or “ports” left on each side of the flap that remain as a connection between the nose and the mouth. During speech, the sides of the throat will hopefully close down these holes to prevent air leakage. However, these ports may make it very difficult to breathe through the nose and can create problems with snoring or sleep apnea. Because of this, we tend to only use this surgery in patients who have a non-functional palate (meaning that the muscles do not work), and who do not already have concerns for sleep apnea. Commonly these are the patients with neuromuscular problems, such as 22q/DiGeorge Syndrome.
Recovery and risk for any of these surgeries are very similar to that of a primary palate repair. After your child is healed from surgery, they will need intensive speech therapy to strengthen and learn how to use their new anatomy. You may notice an initial difference in speech, but often it takes months, and sometimes even a year, to see the full benefit.