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© Borgis - New Medicine 1/2001, s. 33-35
Maria Hortis-Dzierzbicka
Early vs. late cleft palate closure in the light of normal speech development
Department of Paediatric and Adolescent Surgery National Research Institute for Mother and Child, Warsaw, Poland Centre for Craniofacial Disorders
Head: Associate Professor Zofia Dutkiewicz, M.D.
The author presents the different points of view on timing of soft and hard palate closure in cleft palate patients in the light of speech development.
Although debated for decades, the issue of when to perform a primary closure of the cleft palate is still highly controversial. Every theory continues to have an equal number of advocates and adversaries, each of whom quote arrays of arguments to support their positions. Those who favour late operations, when the child is more than one year old, have always been traditionally supported by orthodontists, who invariably claim that early surgical closure of the cleft palate negatively affects maxilla development, which in turn exerts an adverse effect on the esthetic appearance of the face (both en face and in profile), and the maxillary-occlusive relationship. The advocates of late surgery cite numerous examples of hypoplastic, narrow, collapsed maxillas resulting in protruding mandibles, especially when seen in profile, in consequence of pseudoprognathism. As late as 1948, in his classic report Grubber described in detail and in a large series of patients the negative effect of surgical interventions on maxillary growth (3, 10, 13).
This has been always associated with highly traumatic surgical techniques, affecting both the bones and soft tissues, such as the still relatively commonly employed classic Langenbeck´s procedure, with its extensive delamination of mucoperiosteal flap´s in the hard palate. In his comprehensive monograph of 1987 on the effect of surgery on craniofacial growth in unilateral cleft lip and palate, Ross quotes Grubber and ascribes this negative effect rather to the inhibition triggered by scar tissue formed at the surgical site, and especially at the region of the pterygoid tuberosity, than to any immediate effect exerted on the bone itself (13).
Modern methods of palatoplasty, such as those proposed by Malek, Kobus and Dudkiewicz, allow for the avoidance of maxillary growth disorders resulting from extensive soft tissue damage and secondary circulatory disturbances (5). It is thanks to the introduction of these new and less traumatic surgical techniques that when timing the surgery of the palate, the viewpoint of speech pathologists, such as phoniatrists and logopedists, is taken into consideration more and more often, although it is still a slow and difficult process.
Over past decades it has been definitely established that the most important period for speech commences immediately after birth, and not - as was previously believed - in the third year of life, when a normally developing child experiences the „speech explosion ”. As stated by Chapman (2) and Trichet (9), early attempts at vocalization in the second and third month of life are different in cleft palate children than in infants without the defect. Chapman refers to the fact that in this earliest period, called by Trichet (after Koopmans van Beinum and Stelt) the period of acquiring prelinguistic functions, the child substitutes a back sound „g ” for all non-nasal consonants. According to Trichet, a child with cleft palate is unable to articulate properly even a clear „g ” due to the lack of palatopharyngeal closure. Thus, his speech is limited to glottal stops and nasal sounds. When six months old, a child without the defect starts to produce his first frontal consonants, while a child with cleft palate is still limited to the above speech sounds.
In order to ensure proper development of the phonological system, the child with cleft palate should thus be operated on as early as possible, before compensatory articulations and backing become incorporated in the speech system. If this happens, they become extremely difficult, or even impossible, to eliminate, even when a speech therapeutist devotes a lot of work to such a child. In order to allow normal kinaesthetic patterns to operate, normal anatomical conditions within the hard and soft palate should be reconstructed as soon as possible.
The opinion favoured by advocates of the so-called two-stage palate closure should be argued. They attach importance solely to early soft palate closure, before the child is two years old, in order to create a normal palatopharyngeal stop. The closure of the hard palate is delayed - for example by the German or Czech school - until the fifth or sixth year of life, or even later. No plastic palatal plate or obturator is capable of giving the tongue a substitute for contact with living tissue, a palate (including the hard palate) that has been reconstructed as early and as well as possible. Just as the soft palate is necessary for creating adequate pressure in the oral cavity and for producing back sounds, the hard palate is indispensable for alveolar and palatal consonants.
Cosman and Falk (3) emphasise the fact that children with an uncorrected cleft palate encounter difficulties in articulating consonants produced at or before the site of articulation, i.e. friction. Compensatory backing occurs, and „t ” is replaced by „k ”, and „d ” by „g ”. Additionally, children are very unwilling to use obturators.
The so-called „delayed hard palate repair” with an early veloplasty is increasingly rejected. This is confirmed by reports by Scandinavian authors, such as Lohmander (8), Robertson and Jolleys (11). The latter, abandoning delayed hard palate repair in favour of an early one-stage procedure, emphasise in their extensive comparative report the absence of any positive difference in central craniofacial growth in children subjected to late closures. Also Rohrich et al. (12) in their paper written in Oxford evaluating results obtained in two groups of patients subjected either to one-stage three-four flap palatoplasty after Wardill-Killner, or to two-stage procedures consisting of an early closure of the soft palate and a hard palate repair delayed till the fifth year of life, explicity demonstrate more statistically significant speech defects in articulation, nasality, illegibility and frequency of substitutions in patients after delayed hard palate repairs. The investigators found no significant differences in hearing function or maxillo-occlusive disturbances in either group. For many years, early one-stage repairs of unilateral cleft lip and palate have been propagated by Kaplan (6), who, after his Saigon experience, has been operating on these children at 3 or 4 months old using Langenbeck´s method, stressing the psycho-social effect of early surgery. Randall´s material (10) is limited but the author describes the results of early one-stage repairs of the soft and hard palate and emphasizes the beneficial effects of such early procedures on speech and hearing. Malek and Desai (4) describe two-stage early repairs. Malek operates on the soft palate when his unilateral cleft lip and palate patients are less than 3 months old, while the hard palate is repaired in children less than 6 months old. In the same patients, Desai corrects the lip within 48 hours after birth, the palate being repaired after Wardill-Killner with the humular processes of the sphenoid bone being broken away. Both authors comment on the negligible incidence of hypernasality, and thus of indications for secondary pharyngoplasty, as well as the positive effect of their early operations on hearing.
Since 1981, at the National Research Institute a Mother and Child, patients with unilateral cleft lip and palate are operated on at a mean age of 8 months, following the eruption of incisors, i.e. in the period of maxillary growth stabilisation. The surgical technique has been modified twice, starting with the initial modified Langenbeck´s procedure with bilateral delamination of mucoperiosteal flaps, through delamination of one flap at the non-clefted side in the second group, to total elimination of this method and employment of a vomer flap - a technique which is the least dangerous for occlusion (5). In the third group of children operated on using a vomer flap, we have achieved the best maxilla development. In our material, the predominant speech and articulation defect seems to be various types of lisping, resulting from the structure of the defect. Normal palatopharyngeal closure is achieved in almost all patients. The necessity of performing secondary pharyngoplasties has dropped to only a few percent, this chiefly in children operated on in the eighties (7). A significant decrease has also been achieved in the incidence of rudimentary openings in the palate. A detailed comparative presentation of our results in these three groups will be published shortly.
The importance of normal speech development in a child with a facial cleft defect is enormous, from the viewpoint of social integration and future career success. Normal speech is a well-known prerequisite to acquiring the ability to read and write. Thus, speech defects impair the entire intellectual development of the child and affect his or her personality. In their very interesting paper on self-concepts of young school children with visible or non-visible defects, Broder and Strauss (1) quote other authors when they describe considerable social inhibitions and a lack of self-esteem in cleft lip and palate children who live in a world permeated by the „beauty is good ” concept. We must do our best to make their appearance and speech deviate as little as possible from the standards they so much desire. The propagation of cleft surgery performed early in life plays an important role here.
1. Broder H, Strauss RP: Self concepts of early primary school age children with visible or invisible defects, Cleft Palatal J 1989, 26:114-117. 2. Chapman KL: Phonologic processes in children with cleft palate. Cleft Palate - Craniofacial J 1993, 30:64-71. 3. Cosman B, Falk AS: Delayed hard palate repair and speech deficiencies: a cautionary report, CPJ 1980, 17:27-33. 4. Desai SN: Early cleft palate repair completed before the age of 16 weeks: observation on a personal series of 100 children, Br J Plast Surg 1983, 36:300-304. 5. Dudkiewicz Z: Rozszczep wargi i podniebienia, w: Chirurgia glowy i szyi, pod red. L. Krysta, PZWL 1996:252-279. 6. Kaplan I, Dresner J, Gorodischer Ch, Radin L: The simultaneous repair of cleft lip and palate in early infancy, Br J Plast Surg 1974, 27:134-138. 7. Komorowska A, Hortis-Dzierzbicka MA: Wieloetapowa ocena wyników rehabilitacji mowy po jednoetapowej operacji calkowitego jednostronnego rozszczepu wargi i podniebienia wykonanej w wieku 8 miesiecy. Materialy naukowe z II Konferencji Roboczej pt.: „Rozszczep wargi i podniebienia ”, pod red. Z. Dudkiewicz, Warszawa 1996. 7. Lohmander-Agerskov A, Soederpalm E: Evaluation of speech after completed late closure of the hard palate, Folia Phoniatrica 1993, 45:25-30. 8. Psaume J, Malek R, Mousset MR, Trichet Ch, Martinez H: Technique et resultats du traitement total précoce des fentes labio-palatines, Folia Phoniatrica 1986, 38:176-220. 9. Randall P, LaRossa D, Fakhraee M, Cohen MA: Cleft palate closure at 3 to 7 months of age: a preliminary report, Plast Reconstr Surg 1983, 71:624-628. 11. Robertson NRE, Jolleys A: The timing of hard palate repair. Scand J Plast Reconstr Surg, 1974, 8:49-51. 12. Rohrich R, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, Godfrey AM: Timing of hard palate closure: A critical long term analysis. Plast Reconstr Surg 1996:236-246. 13. Ross B: Treatment variables affecting growth in unilateral cleft lip and palate. Part 5: Timing of palate repair, CPJ 1987e, 24:54-63.
New Medicine 1/2001
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