Cleft palate or cleft lip is a condition in children where the lips aren’t formed properly and this is a very common birth defect that is seen due to improper formation of tissue and due to that lips do not join completely and leaves an opening. Cleft palate may also lead to velopharyngeal dysfunction in which the soft palate does not function properly and the child faces difficulty in speech. In this article, we discuss a surgical technique called Furlow Palatoplasty to improve speech in such children.
These days technology has advanced and there are re-constructive surgeries that can correct such abnormalities. In cleft palate and velopharyngeal dysfunction, the parts of throat and roof of mouth does not function properly due to which the child faces difficulty during speech. In order to correct this difficulty, there is a surgical technique called Furlow Palatoplasty. This is a very commonly chosen technique for treatment of velopharyngeal dysfunction.
Furlow palatoplasty is a very effective surgical technique because it really works in improving speech quality in children. Postoperative speech improvement was noticed after surgical correction.1
Symptoms of Velopharyngeal Dysfunction
The symptoms of velopharyngeal dysfunction (VPD) depend on what type of dysfunction the child has but most of the symptoms are common.
Child faces difficulties in pronouncing few letters like m, n and ng because these sounds comes from nasal and they also face difficulties in pronouncing pressure consonants like P,B,T,D,G,S and K because they cannot build pressure in their mouth. They may learn things wrong way because of the soft palate is not working properly.
Furlow palatoplasty corrects the defect and helps children overcome the speech difficulty.
When is Furlow Palatoplasty Advised?
Below here are some of the instances when furlow palatoplasty is suggested:
- If the palate of the child is short and soft then it may lead to velopharyngeal dysfunction.
- Sub-mucous cleft palate may also cause VPD.
- If the child has any kind of abnormalities of throat or palate then it may lead to VPD.
In order to go for furlow palatoplasty you need to make sure that your child has velopharyngeal dysfunction and so you must check the following for diagnosis of velopharyngeal dysfunction and the type of it.
The following questions help in the identification of issues, required for evaluating the need for Furlow palatoplasty,
- Does the child face difficulty in making sounds with mouth and tongue?
- Does the child find it difficult to co-ordinate the speech?
- Can you properly understand your child’s speech?
- Can the child hear properly?
- Can the child pronounce all the words correctly?
Other diagnosis to evaluate velopharyngeal dysfunction includes:
Nasendoscopy: The child is evaluated for better understanding of the condition. In this procedure a small endoscope is placed in child’s nose and the child is asked to read few things so that they can check if the velopharyngeal muscles of the child are working properly or not.
Video Fluoroscopic Speech Study: X-ray of the child’s throat is taken while reading phrases and talking in order to check the problem deeply.
Evaluation of the child’s speech, behavior and the results of these tests help in determining the need for Furlow palatoplasty.
Velopharyngeal dysfunction is a part of Pierre Robin Sequence, which is associated with glossoptosis, respiratory distress, retrognathia and a cleft palate which if not treated on time may also lead to death from obstruction by the tongue. Treatment with Furlow palatoplasty is planned considering all health parameters and complete diagnosis of the condition.
How is Furlow Palatoplasty Done?
Before looking at procedures of Furlow palatoplasty, let us understand some considerations.
Orthodontic Interventions – It minimizes the severity of the growth disturbance. These are mainly used to realign the premaxilla into a normal position prior to the lip closure. An orthodontic intervention mainly aims at maxillary arch expansion, correction of an often developing class III skeletal growth pattern, and correction of malocclusion.
Timings of Palate Closure – The main goals of palate repairs include normal speech, normal palatal facial growth and normal dental occlusions. Bifid uvula mostly occurs with sub mucous cleft palate. Management of bifid uvula is closely observed to ensure that the speech develops normally.
Sequence of Operations – Cleft palate calls for closure of the lip at an early age from mainly 6 weeks up to 6 months followed by closure of the palate by approximately 6 months later. Prior to the eruption of the permanent canine at the left side, optimal eruption of the teeth at the cleft side and development of normal periodontal structures of the teeth adjacent to the cleft mostly occurs when bone grafting and final fistula closures are performed.
Choices of Operations – Surgical techniques of Furlow palatoplasty mainly depend upon whether the cleft is an isolated cleft palate or a part of unilateral or bilateral cleft lip and palate.
It includes 3 main categories:
- Simple Palatal Closure
- Palatal closure with palatal lengthening, and
- Either of the first two techniques with direct palatal muscle re-approximation.
Von Langenbeck Procedure:
It is the oldest and the simplest procedure which was introduced by Von Langenbeck. This step is very popular as it is a most simple technique in operations. Bipedicle mucoperiosteal flaps were mainly created through incision made along the side of cleft edges and posterior alveolar ridges from the maxillary tuberosities till the anterior level of the cleft. Later on the flaps were mobilized medially with preservation of palatine arteries and closed in layers.
Palatal lengthening – V-Y Pushback:
It basically includes relaxing incisions for making bilateral flaps depending on the greater palatine vessels, the closing of the nasal mucosa in a different layer, fracture of hamulus, V-Y Palatal lengthening and separate muscle closure.
This was mainly designed to lengthen the palate as well as to restore the muscular sling of the levator vili palatini.
This is a single step technique, which consists of the Double-opposing Z-plasties from the nasal and oral surfaces. This technique is mainly used to minimize the requirement of lateral relaxing incisions in order to attain closure.
Two- Flap Palatoplasty:
Main goals of this technique is to achieve closure of the complete cleft without any tension at a very early age bringing in minimal exposure of the raw bony surfaces and creating of a functional soft palate.
Precautions for Furlow Palatoplasty
Furlow palatoplasty mainly does not have any precautions but avoiding exposed raw nasal mucosa will help prevent from further contractions. Instructions regarding diet, feeding and speech related activities must be followed as per medical advice.
Furlow Palatoplasty basically lengthens the palate, while tightening and retro positioning both the levator slings. However, the levator tightening is mostly associated with the improved speech outcomes. Levator tightening is most consistently associated with improved speech outcomes.