Noncleft Velopharyngeal Insufficiency: Etiology and Need For Surgical Treatment
Altered speech related to velopharyngeal insufficiency is a rare but well-recognised complication of adenoidectomy. Over a 20 year period, 42 patients were referred to the Edinburgh cleft team for investigation of altered speech persisting for more than 12 months after adenoidectomy. We studied the cases to ascertain the incidence, clinical features and causes of altered speech in these patients and to assess the efficacy of a selective treatment policy. All data were prospectively collected when the patients were assessed in a multidisciplinary clinic and investigated by videofluoroscopy. Nasopharyngoscopy was also possible in half of the patients. Overall, 27 patients were male and 15 were female, and their mean age was 6.5 years. The incidence was one in 1200 adenoidectomies. Diagnoses included five submucous cleft palates, six occult submucous cleft palates, 22 cases of velopharyngeal disproportion, seven developmental or neurological causes, one iatrogenic palatal injury and one case that defied diagnosis. In six patients treatment was not required, 13 responded to speech therapy and 23 required surgical intervention. The choice of operation was based on the findings at investigation. Ten patients were treated by a superiorly based pharyngeal flap, 10 underwent a sphincteric pharyngoplasty and three had an intravelar veloplasty. Speech outcome was assessed in 36 cases. Treatment resulted in significantly improved speech in all but one patient and normal speech in 16 patients. Persistently altered speech is a rare complication of adenoidectomy. Preoperative screening by clinical examination will prevent some but not all of such problems. When patients present they should undergo multidisciplinary assessment and multi-modality investigation. A good outcome can be anticipated in most patients.