The patient is a 19-year-old college student from Guwahati in Assam, India. He was born with a bilateral cleft lip and palate defect. His parents had been extensively counseled regarding the condition. They were educated about the need to follow the correct schedules for surgical repair.
The patient had first undergone cleft lip surgery at 3 months of age. This had been followed by a cleft palate repair at 8 months of age. The two surgeries had been performed at a medical center in a city near his hometown. He had however never undergone a cleft alveolus repair, which is normally performed at 3-1/2 years of age.
There was a good esthetic result from the surgery with minimal scarring of the upper lip. Plastic surgeons also perform this cosmetic surgery in many countries.
Increasing difficulty with speech with the passage of time
The patient has always had problems with clear word-formation since childhood. He has always had difficulty with the pronunciation of certain sounds. His parents felt that there was a nasal quality to his voice. It sounded like he was talking through his nose at times.
The patient had faced a lot of difficulties during his school days. Teachers had constantly complained that they could not understand his speech. He had also been subjected to teasing by his peers. All these factors made him withdrawn and he had very few friends.
Initial visit to a local hospital for surgical consultation
His parents had been counseled by well wishers of the family to get this speech problem addressed. They had visited a local hospital where they were informed that the patient needed surgical repair of his palate.
The mechanism of the velopharyngeal insufficiency was explained to them in detail. They understood that the communication between the oral cavity and nose due to VPI was causing air to escape into his nose during speech. Following this, they had made widespread enquiries regarding the best hospital to get this corrected.
They were then referred to our hospital for surgical management of his condition. Our hospital is a premiere center for speech correction surgery in India. We are a referral hub for palatal defect surgery and jaw reconstruction in India. Our hospital is credited with many surgical innovations in cleft lip and palate rehabilitation.
Velopharyngeal insufficiency and its influence on word formation during the speech
When a patient has velopharyngeal incompetence/insufficiency, the soft palate does not contact the back of the throat. This is mandatory for the creation of certain sounds. Air exits through the oral cavity during the creation of certain sounds. This air escapes into the nasal cavity when there is velopharyngeal insufficiency. The nasal quality to the speech arises because of this escape of air into the nasal cavity.
Initial presentation at our hospital for surgical correction of the palate
Dr SM Balaji, palate repair surgeon and sphincter pharyngoplasty specialist, examined the patient. He noted the quality of speech and explained the causes to the patient and his parents. It was explained to them that the velum was not occluding and this was resulting in the nasal speech.
The patient was then referred to a speech pathologist for assessment was carried out. He was diagnosed with velopharyngeal insufficiency (VPI).
Treatment planning is done and explained to the patient in detail
It was explained to the patient and his parents that the palate surgery also needed to be redone. The palatal repair would be followed by a sphincter pharyngoplasty. This would result in complete normalization of the patient’s speech. Both procedures would be performed in a single surgery.
Successful surgical correction of the velopharyngeal insufficiency
Under general anesthesia, a palatoplasty was first performed using Veau-Wardill Kilner’s technique. The levator palati muscle was joined in the middle. This resulted in a good roof of the mouth palatal repair for the patient.
This was followed by the sphincter pharyngoplasty. Flaps were raised from the palatopharyngeus muscle. These were then attached to the posterior wall of the pharynx. The attachment was at the level of the adenoids in the form of a posterior pharyngeal flap. This resulted in complete correction of the velopharyngeal insufficiency.
A small central opening or “port” was left in the middle for breathing. A suction test was performed at the end of the surgery, which demonstrated good movement of the soft palate. A positive suction test indicates that the patient would have normal speech after rehabilitation following surgery.
Total satisfaction with the results of the surgery
The patient and his parents were very happy with the outcome of the surgery. His parents stated that there was considerable improvement in the quality of his speech following surgery. They were extensively counseled regarding the need for speech therapy for the patient. Speech therapists play an integral role in the successful rehabilitation of these patients.
The patient and his parents expressed a complete understanding of the instructions. His parents stated that this surgery would help the patient gain self-confidence and develop a more active social life.
Patient with air escaping through nose during speech
The patient is a 13-year-old female from Kallakurichi in Tamil Nadu, India. She was born with a bilateral cleft lip and palate deformity. Her parents had been counseled extensively regarding the correct surgical schedule for corrective surgery. They had meticulously followed the instructions provided at the time of her birth.
She had first undergone cleft lip surgery at three months followed by cleft palate surgery at nine months. Cleft alveolus surgery had been performed at 3-1/2 years of age. Results from the surgery were however suboptimal. There was upper lip deformity and she had feeding and speech difficulties. She had undergone three further surgeries to correct her problem, but none of the surgeries were successful.
The patient has always had difficulty with pronunciation of certain words. This made it difficult for people to understand her speech. Teachers had always complained to her parents that it was difficult comprehending her. There had always been a nasal quality to her speech.
Difficulty with employment due to her speech impairment
The patient is from a disadvantaged background and has been facing significant bullying at school. Her peers made fun of her speech difficulties. She has always been good at her academics. However, this bullying had become very frustrating for her and her parents had taken her a local hospital regarding this.
The doctor at the hospital had examined her and diagnosed her to have velopharyngeal insufficiency. This was causing air to escape through her nose when vocalizing sounds like ‘ah.’ Her speech was getting distorted and acquiring a nasal quality because of this. He had referred her to our hospital for corrective surgery.
Initial presentation at our hospital for corrective surgery
Dr SM Balaji, speech correction surgeon and pharyngoplasty specialist, examined the patient and obtained a detailed history. The patient had a palatal fistula. There was also a gross insufficiency of the soft palate, which resulted in air escaping through the nose during speech.
He then referred the patient to a speech pathologist for a speech assessment test. This confirmed his diagnosis of velopharyngeal insufficiency. Plastic surgeons in the United States of America first formulated a surgical protocol for successful treatment of velopharyngeal insufficiency. This is rigorously followed in our hospital.
Intonation of certain sounds results in the palate rising and touching the back of the throat. This pushes air forward and out of the mouth. The soft palate does not contact the throat during speech in velopharyngeal insufficiency. This causes air to escape through their nose during speech.
Treatment planning formulated and explained to the patient and parents
The patient was advised that the palatal fistula had to be closed. It was also explained that she needed a sphincter pharyngoplasty with double layer closure. This would result in correction of velopharyngeal insufficiency. There would be no necessity for bone grafts in speech correction surgery.
It was decided to perform both procedures in a single operation to reduce the financial burden for the patient. The patient and her parents were in agreement with the treatment plan and consented to surgery. Her parents also give a history of recurrent ear infections when she was an infant.
Successful surgical correction of velopharyngeal insufficiency
Under general anesthesia, the patient underwent palatal fistula closure using the Veau-Wardill Kilner technique. This was followed by the sphincter pharyngoplasty, which was performed by taking flaps of tissue from just behind the tonsil on each side. These flaps were then connected together across the back of the throat, thus narrowing the throat opening.
A small, central opening or “dynamic sphincter” was retained in the middle for breathing through the nose. A suction test was performed at the end of the procedure. This demonstrated good movement of the soft palate thus indicating optimum results from the surgery. A positive suction test showed movement of the roof of the mouth. This is indicative of good surgical results.
Total patient satisfaction from the results of the surgery
The patient’s speech was much improved from previous to surgery. She and her parents expressed their happiness at the results of the surgery. They were however instructed that she would need to undergo speech therapy for her speech to normalize completely. The patient will be referred to a speech therapist for further management.
The patient is a 29-year-old male from Theni in Tamil Nadu, India. He is a known case of cleft lip and palate deformity who had been born in Madurai. His parents had been counseled regarding what to expect with an infant with cleft lip and palate deformity.
Surgery performed as per correct surgical protocol for cleft deformity
He had undergone cleft lip surgery at three months of age and cleft palate surgery at nine months of age at a hospital in Madurai. This had been followed by cleft alveolus surgery at the age of 3-1/2 years. These surgeries had resulted in good restoration of function and esthetics for the patient.
He had not faced any feeding problems after his surgery. All his growth parameters had been met on schedule and the patient had thrived well. He had always been good at academics and is now well settled in life.
Persistent difficulty with speech for forming certain sounds
He has however had persistent difficulty with speech. There had always been a hypernasal speech quality with difficulty associated with pronouncing certain sounds. Some of his colleagues at work had found it difficult to understand his speech. This is due to velopharyngeal dysfunction.
His difficulty with speech had been diagnosed to be due to a palatal fistula. This fistula was causing air to escape into the nose during speech. His parents stated that his voice was not clear while pronouncing certain words. There was a clear nasal quality to his voice.
His parents mentioned that they were also looking for a bride to get him married and wanted to correct his speech problem as soon as possible. The patient wanted to undergo speech correction surgery.
Initial presentation at our hospital for correction of his speech problems
Dr SM Balaji, pharyngoplasty specialist, examined the patient and ordered for radiological studies. He further referred the patient for a speech assessment, which stated that the patient’s nasal twang was caused by velopharyngeal insufficiency (VPI).
Velopharyngeal insufficiency and its implications on daily life
Velo refers to the velum or soft palate. It is the part of the roof of the mouth that moves with sounds like “ah.” Pharyngeal refers to the throat. During normal speech with the creation of certain sounds, the palate rises to touch the back of the throat and sends the air out of the mouth.
In the case of a child with velopharyngeal insufficiency, there is deficiency in the posterior extent of the soft palate. This results in the soft palate not contacting the throat during the creation of sounds like “ah.” This results in air escaping through the nose during speech instead of exiting through the oral cavity, thus rendering a nasal quality to the speech.
Treatment planning formulated for the patient
It was decided to perform a Veau-Wardill Kilner sphincter pharyngoplasty for the patient. This would involve taking flaps of tissue from just behind the tonsil from each side. These flaps of tissue are then connected across the back of the throat.
This results in narrowing down of the throat opening. A small central opening or “port” is left in the middle for breathing through the nose.
Successful surgical correction of velopharyngeal insufficiency
Under general anesthesia, the patient underwent a sphincter pharyngoplasty with creation of the small central “port” to facilitate proper nasal breathing. A suction test performed at the end of the surgery resulted in proper action of the soft palate. This indicated complete correction of the velopharyngeal insufficiency.
There was improvement in the tone of voice after surgery. The patient and his family were very happy with the results of the surgery. It was explained to them that he would need speech therapy to completely normalize the quality of his voice.
They expressed understanding of the instructions and said that this would definitely lead to an improvement in the quality of life for the patient.
Parents of girl with cleft repair surgery seek solution for speech problems
The patient is an 11-year-old girl from Cuttack in Orissa, India who was born with a unilateral cleft lip and palate. This is the most common among birth defects in the world. Lower facial growth can be impeded by this deformity. The patient had undergone cleft lip surgery/cleft lip repair at three months of age and cleft palate surgery/cleft palate repair in the upper jaw at 9 months of age. Her cleft alveolus reconstruction had been done at 3-1/2 years of age. All the surgeries had been performed in her hometown. Plastic surgeons also commonly perform this surgery in many countries.
Cleft lip and cleft palate deformities
These are the most common birth defects in the world. Native Americans babies have the highest incidence of cleft deformities in the world while blacks and Hispanics have amongst the lowest rates of occurrence in the world. The percentage of occurrence is somewhere in the middle in India, but the real time numbers are extremely high because of the high birth rate in the country.
Cleft lip and palate deformity can arise from genetic or environmental factors. Infants with clefts are born more often to parents with cleft deformities themselves. A great deal of research is being done around the world to isolate the genes responsible for cleft deformities. Many environmental factors such as maternal use of tobacco, alcohol, drugs or even electromagnetic waves have been credited with the formation of cleft deformities in infants.
Parents dissatisfied with results of the surgery
Her parents were however not satisfied with the results of the surgeries. Her speech had always been compromised and they felt like air was escaping through the roof of her mouth into her nose while speaking. This made it difficult for her to pronounce certain sounds and her parents said it felt like she was speaking from a bottom of a well. She was also having recurrent middle ear infections.
This had led to problems in school with teachers complaining to them that they could not understand her speech. She began to become socially withdrawn and started avoiding going outside. Her parents were very worried as she had no friends and was feeling very lonely.
Patient referred to our hospital for surgical correction
Parents decided to get this problem addressed and visited a big city hospital for consultation. The oral and maxillofacial surgeon at that hospital examined the patient and explained to the parents that her problem needed to be addressed at a specialist cleft lip and palate surgery hospital and referred her to our hospital. He informed them that cleft lip surgery in India is a highly specialized field and cleft palate surgery in India is mainly performed in specialty centers
Initial examination at our hospital
Dr SM Balaji, cleft lip surgeon and cleft palate surgeon, examined the patient and performed a complete clinical and radiological evaluation of the patient. He explained to the parents that the hole in her palate was preventing her from vocalizing certain sounds correctly. He explained that urgical correction would completely correct her velopharyngeal insufficiency.
What is the cause behind velopharyngeal insufficiency?
Velopharyngeal insufficiency refers to the condition where the soft palate does not come in contact with the back of the throat during speech. This causes air to escape into the nose through the back of the throat during speech. When this happens, it causes the speech to develop a prominent nasal twang. A sphincter pharyngoplasty is performed to correct this condition.
Treatment planning for successful resolution of nasal speech
It was explained to the patient’s parents that a sphincter pharyngoplasty would need to be performed for correction of this condition. The parents were in full agreement after the surgical procedure was explained to them in detail. It was then decided to proceed with surgery.
Successful performance of surgery
Under general anesthesia, flaps of tissue were taken from just behind the tonsil on each side. These flaps were next connected together across the back of the throat and sutured together. This narrowed down the opening of the throat with just a small, central opening or port in the middle for breathing through the nose. A positive suction test, which was performed at the completion of the surgery, demonstrated good lifting of the soft palate thus indicating successful surgery.
Parents express total satisfaction with results of the surgery
Improvement in the patient’s speech was immediate and drastic. The patient’s parents were extremely happy that the patient would not be able to speak normally. They had always felt that normalizing the speech problems would enable their daughter to lead a normal life. They were counseled that she would need the help of a speech therapist for further management of her speech problems.
World-renowned surgeon for cleft lip and palate repair
Dr. SM Balaji is a world renowned expert on cleft lip and palate surgical correction. He has over 30 years of experience operating on cleft cases. Many cases of cleft repair done elsewhere, which have failed are often referred to him. His many innovations to existing cleft surgical procedures have to lead to better results. These have become standard operating protocols worldwide.
Young boy with two failed cleft repair surgeries elsewhere
This is a case of a young boy who had undergone cleft surgeries twice elsewhere. Both surgeries had not resulted in closure of the cleft. This had been a cause of anguish to his parents as his food intake was very impaired by the cleft. They had been searching for a long time for a cleft surgeon who could repair their son’s cleft. This search for the best cleft surgeon led them to Dr. SM Balaji.
The treatment plan explained in detail to parents
The patient was first examined and the treatment plan was explained to the parents. The parents agreed to the surgery.
Veau-Wardill-Kilner technique with Orticochea pharyngoplasty
General anesthesia was first administered. The Veau-Wardill-Kilner palatal pushback technique and Orticochea pharyngoplasty were then performed. This resulted in complete closure of the cleft defect. A positive suction test was then demonstrated at the end of the surgery. This would ensure proper speech for the patient.
The patient’s parents presented to Dr SM Balaji six months post-surgery for a checkup. The cleft remained closed and the patient’s speech was much improved. His parents expressed their extreme gratitude.
