THE EFFECT OF ADENOIDECTOMY ON VELOPHARYNGEAL COMPETENCE IN CLEFT PALATE PATIENTS By KENNETH L. PICKRELL, M.D., RAYMONDMASSENGILL,JR., Ed.D., GALEN QUINN, D.D.S. M.S., REXBROOKS,B.S. and MARY ROBINSON,M.A. Divisions of Plastic Surgery, Medical Speech Pathology and Orthodontics, Duke University Medical Center, Durham, North Carolina 27710
cleft palate patients is still controversial. Many, like Williams (1971) and Slaughter and Brodie (I~I), believe that adenoid tissue plays a definite role in velopharyngeal closure and in all cases should be preserved. On the other hand adenoidectomy has been supported as necessary to prevent middle-ear infections (Chalat, 1965; Fahey, 1965).
ADENOIDECTOMYin
FIG.
I
Large oedematous adenoidal masses revealed at cleft palate repair. We believe that these are best curetted out at this time. I34
EFFECT
OF ADENOIDECTOMY
ON VELOFHARYNGEAL
COMPETENCE
135
TABLE
Velopharyngeal function in relation to type of cleft and operation. Adenoidectomy group
Veau I
WPB r---7 cc VP1 3 r
Veau II
97
DPB r---7 cc VP1 2--
Veau III
16
I
-
Veau IV
2
I
--
Cong. short
I_
Total
--
10
-
-
-
VPI
5!6Z --
-
I
-
-
I
-
--
-
-_ 2
VLP
VPR c---7 cc ---
I-
--
31
WPB/IF r---7 cc VP1 --
-
-
-
-_
--
__
--
-
-
-
-
Control group Veau I
-
I-
I
61
--
3-
--
Veau IV
82
--
3-
--
Submucous
2
I
--
18
12
-
2
Veau III
Total
8
-
I
-
--
Veau II
I 8
2
--
-
-
-I
1
-
I
-
-
I
I
WPB= Wardill Pushback. DPB = Dorrance Pushback. WPB/IF = Wardill Pushback and Island Flap. VPR = Veau Palate Repair. VLP = von LangenCC = Complete Velopharyngeal Closure. VP1 = Velopharyngeal back. Incompetence.
In many children with a cleft palate, the adenoids will be found enlarged and oedematous at operation (Fig. I). In such cases we advise and perform a conservative adenoidectomy immediately prior to the palatal repair; only the main mass is curetted out and no attempt is made to remove the lateral adenoid tissue which extends under the palatal shelves. In this study we compared by cinefluorography velopharyngeal closure in 44 cleft palate patients who had an adenoidectomy at the initial operation with that in 43 cleft palate patients who did not. The groups were matched as nearly as possible according to age at the primary operation, which ranged from I to II years. The minimum interval between operation and the fluorographic examination was 18 months and the average interval about 5 years. No patients who had had such secondary procedures as pharyngeal flaps were included. The results are summarised in the Table according to the type of cleft and the operation performed. Veau’s classification is used, since many of the older patients had been thus classified before the newer, more logical classifications were introduced. Ten of the 44 patients in the adenoidectomy group had incomplete closure and the gap ranged from 2 to 18 mm. Fifteen of the 43 control patients had velopharyngeal incompetence and the gap varied from 2 to 23 mm. Because of the variations in the type of cleft and operation, these results fall short of statistical significance and one
BRITISH JOURNAL OF PLASTIC SURGERY 136 cannot conclude that adenoidectomy improves velopharyngeal closure. At the same time there is no doubt that adenoidectomy had not increased the risk of inadequate closure in any way. We also analysed the effect of adenoidectomy when the initial repair was carried out at different ages. Both groups showed that the earlier the operation the higher the incidence of complete closure, but no statistically significant effect of the adenoidectomy emerged.
REFERENCES CHALAT, N. I. (1965). Laryngoscope,
75,426.
Tonsillectomy
and adenoidectomy
and the cleft palate clinic.
FAHEY, D. J. (1965). Otologic care of cleft palate cases. Laryngoscope, 75, 570587. SLAUGHTER, W. B. andBRoDIE, A. G. (1971). “Velar Closure, in Cleft Lip and Palate”, edited by Grabb, W. C., Rosenstein, S. W. and Bzoch, K. R., p. 410. Boston: Little Brown and CO.
WILLIAMS, W. N. (1971).
Application
of radiological measures.
Ibid., p. 767.
cleft palate patients is still controversial. Many, like Williams (1971) and Slaughter and Brodie (I~I), believe that adenoid tissue plays a definite role in velopharyngeal closure and in all cases should be preserved. On the other hand adenoidectomy has been supported as necessary to prevent middle-ear infections (Chalat, 1965; Fahey, 1965).
ADENOIDECTOMYin
FIG.
I
Large oedematous adenoidal masses revealed at cleft palate repair. We believe that these are best curetted out at this time. I34
EFFECT
OF ADENOIDECTOMY
ON VELOFHARYNGEAL
COMPETENCE
135
TABLE
Velopharyngeal function in relation to type of cleft and operation. Adenoidectomy group
Veau I
WPB r---7 cc VP1 3 r
Veau II
97
DPB r---7 cc VP1 2--
Veau III
16
I
-
Veau IV
2
I
--
Cong. short
I_
Total
--
10
-
-
-
VPI
5!6Z --
-
I
-
-
I
-
--
-
-_ 2
VLP
VPR c---7 cc ---
I-
--
31
WPB/IF r---7 cc VP1 --
-
-
-
-_
--
__
--
-
-
-
-
Control group Veau I
-
I-
I
61
--
3-
--
Veau IV
82
--
3-
--
Submucous
2
I
--
18
12
-
2
Veau III
Total
8
-
I
-
--
Veau II
I 8
2
--
-
-
-I
1
-
I
-
-
I
I
WPB= Wardill Pushback. DPB = Dorrance Pushback. WPB/IF = Wardill Pushback and Island Flap. VPR = Veau Palate Repair. VLP = von LangenCC = Complete Velopharyngeal Closure. VP1 = Velopharyngeal back. Incompetence.
In many children with a cleft palate, the adenoids will be found enlarged and oedematous at operation (Fig. I). In such cases we advise and perform a conservative adenoidectomy immediately prior to the palatal repair; only the main mass is curetted out and no attempt is made to remove the lateral adenoid tissue which extends under the palatal shelves. In this study we compared by cinefluorography velopharyngeal closure in 44 cleft palate patients who had an adenoidectomy at the initial operation with that in 43 cleft palate patients who did not. The groups were matched as nearly as possible according to age at the primary operation, which ranged from I to II years. The minimum interval between operation and the fluorographic examination was 18 months and the average interval about 5 years. No patients who had had such secondary procedures as pharyngeal flaps were included. The results are summarised in the Table according to the type of cleft and the operation performed. Veau’s classification is used, since many of the older patients had been thus classified before the newer, more logical classifications were introduced. Ten of the 44 patients in the adenoidectomy group had incomplete closure and the gap ranged from 2 to 18 mm. Fifteen of the 43 control patients had velopharyngeal incompetence and the gap varied from 2 to 23 mm. Because of the variations in the type of cleft and operation, these results fall short of statistical significance and one
BRITISH JOURNAL OF PLASTIC SURGERY 136 cannot conclude that adenoidectomy improves velopharyngeal closure. At the same time there is no doubt that adenoidectomy had not increased the risk of inadequate closure in any way. We also analysed the effect of adenoidectomy when the initial repair was carried out at different ages. Both groups showed that the earlier the operation the higher the incidence of complete closure, but no statistically significant effect of the adenoidectomy emerged.
REFERENCES CHALAT, N. I. (1965). Laryngoscope,
75,426.
Tonsillectomy
and adenoidectomy
and the cleft palate clinic.
FAHEY, D. J. (1965). Otologic care of cleft palate cases. Laryngoscope, 75, 570587. SLAUGHTER, W. B. andBRoDIE, A. G. (1971). “Velar Closure, in Cleft Lip and Palate”, edited by Grabb, W. C., Rosenstein, S. W. and Bzoch, K. R., p. 410. Boston: Little Brown and CO.
WILLIAMS, W. N. (1971).
Application
of radiological measures.
Ibid., p. 767.
