Patients with velopharyngeal insufficiency (VPI) present a unique challenge to the pediatric otolaryngologist. Otherwise straightforward problems such as sleep apnea and chronic tonsillitis become far more complicated in the cleft population due to the risk of VPI, and yet, sleep disordered breathing is increasingly being diagnosed in this group. Several recent studies demonstrated that cleft patients exhibit a significantly higher incidence of sleepdisordered breathing, with syndromic patients carrying an increased risk for obstructive sleep apnea (OSA) [
Adenoidectomy has long been known to carry a risk of worsening velopharyngeal insufficiency in patients with known VPI and may unmask previously undiagnosed VPI, particularly in patients with submucous cleft palate [
In this study we hypothesize that, in carefully chosen patients, tonsillectomy can be safely performed on patients with existing VPI without significant adverse effects to their speech.
All patients seen at the Doernbecher Children’s Hospital Multidisciplinary Velopharyngeal Insufficiency Clinic between 1997 and 2010 were prospectively entered into a database. The database was screened for all patients undergoing tonsillectomy during this time. Inclusion criteria included a previous diagnosis of velopharyngeal insufficiency, a history of tonsillectomy performed at this institution, and adequate pre- and postoperative speech assessment. Exclusion criteria included concordant adenoidectomy, pharyngoplasty or pharyngeal flap, or inadequate speech evaluations for analysis.
Speech assessments were obtained from routine speech analysis by pediatric speech pathologists, on the scale developed at this institution prior to the acceptance of the universal speech parameters. The analysis was translated to a nonparametric scale as indicated below in Tables
Attention was specifically turned to the assessment of two primary parameters for analysis: speech intelligibility and velopharyngeal sufficiency. Pre- and post operative evaluations were compared. For individual patients, a significant change in function was defined to be a change in 2 points on the scale. For the overall group, a two-tailed Wilcoxon rank-sum test was used to evaluate for significance.
A total of 46 patients with known VPI underwent tonsillectomy over this time period. Of these, 23 had both pre- and postoperative speech evaluations that were sufficient for our analysis. See Table
Patient characteristics.
Patient | Sex | Age at tonsil surgery | Tonsillectomy indication | Tonsil size | CP type | Initial cleft repair | Speech intelligibility | VPI severity | ||||
Preop. | Postop. | Diff | Preop. | Postop. | Diff | |||||||
1 | F | 4 | OSA | 3.5 | UC | 2 flap | 4 | 2 | −2 | 3 | 2 | −1 |
2 | M | 4 | OSA | 4.0 | BC | push back | 1 | 1 | 0 | 0 | 2 | 2 |
3 | M | 5 | OSA | 4.0 | UC | 2 flap | 2 | 1 | −1 | 1 | 1 | 0 |
4 | F | 12 | VPI | 3.0 | SM | Unk. | 2 | 2 | 0 | 2 | 2 | 0 |
5 | M | 6 | VPI | 3.5 | None | None | 2 | 2 | 0 | 3 | 2 | −1 |
6 | M | 8 | VPI | 4.0 | UC | 2 flap | 3 | 2 | −1 | 2 | 2 | 0 |
7 | M | 5 | VPI | 3.0 | UC | 2 flap | 3 | 2 | −1 | 1 | 2 | 1 |
8 | M | 8 | OSA | 3.5 | UC | Unk. | 0 | 0 | 0 | 1 | 1 | 0 |
9 | M | 6 | VPI | 3.0 | UC | 2 flap | 3 | 4 | 1 | 4 | 4 | 0 |
10 | M | 7 | VPI | 2.5 | SM | Furlow | 3 | 1 | −2 | 3 | 2 | −1 |
11 | F | 4 | OSA + VPI | 4.0 | None | None | 1 | 4 | 3 | 2 | 3 | 1 |
12 | F | 5 | VPI | 4.0 | UC | 2 flap | 4 | 4 | 0 | 4 | 4 | 0 |
13 | M | 7 | OSA | 4.0 | UC | 2 flap | 3 | 2 | −1 | 1 | 1 | 0 |
14 | F | 7 | OSA | 3.0 | BC | Push back | 1 | 1 | 0 | 2 | 1 | −1 |
15 | M | 7 | Strep+VPI | 4.0 | I | 2 flap | 2 | 1 | −1 | 1 | 2 | 1 |
16 | F | 7 | VPI | 2.5 | None | none | 3 | 3 | 0 | 3 | 3 | 0 |
17 | M | 7 | OSA | 4.0 | UC | 2 flap | 2 | 2 | 0 | 2 | 2 | 0 |
18 | F | 12 | OSA+VPI | 4.0 | I | Furlow | 3 | 2 | −1 | 2 | 1 | −1 |
19 | M | 4 | OSA | 4.0 | I | Unk. | 3 | 2 | −1 | 0 | 1 | 1 |
20 | F | 8 | Dysphagia | 4.0 | I | Unk. | 0 | 0 | 0 | 0 | 1 | 1 |
21 | F | 7 | OSA | 4.0 | UC | Unk. | 1 | 1 | 0 | 1 | 1 | 0 |
22 | F | 8 | VPI | 3.5 | SM | None | 4 | 4 | 0 | 3 | 3 | 0 |
23 | M | 4 | OSA | 3.5 | UC | 2 flap | 2 | 2 | 0 | 2 | 1 | −1 |
Patient characteristics. Cleft type: UC: unilateral complete, BC: bilateral complete, SM: submucous, I: incomplete.
Overall there was no statistically significant difference between pre- and postoperative speech intelligibility (with trend towards improvement,
Ten of the patients underwent both pre- and posttonsillectomy nasal endoscopy, and their data is presented in Table
Nasal endoscopy scores.
Pt. | Indication for tons. | CP type | Initial cleft repair | Protons. endoscopy | Posttons. endoscopy | Speech intelligibility | VPI Severity | ||||
Preop. | postop. | Diff. | Preop. | Postop. | Diff. | ||||||
4 | VPI | SM | Unk. | Palate 9 lat 4 | Palate 9 lat 4 | 2 | 2 | 0 | 2 | 2 | 0 |
5 | VPI | None | None | Palate 7 lat 2 | Palate 9 lat 4 | 2 | 2 | 0 | 3 | 2 | −1 |
6 | VPI | UC | 2 flap | Palate 0 lat 0 | Palate 0 lat 1 | 3 | 2 | −1 | 2 | 2 | 0 |
7 | VPI | UC | 2 flap | Palate 9 lat 2 | Palate 9 lat 1 | 3 | 2 | −1 | 1 | 2 | 1 |
9 | VPI | UC | 2 flap | Palate 1 lat 1 | Palate 2 lat 1 | 3 | 4 | 1 | 4 | 4 | 0 |
12 | VPI | UC | 2 flap | Palate 5 lat 1 | Palate 5 lat 3 | 4 | 4 | 0 | 4 | 4 | 0 |
15 | Recurrent strep + VPI | I | 2 flap | Palate 8 lat 4 | Palate 9 lat 4 | 2 | 1 | −1 | 1 | 2 | 1 |
16 | VPI | None | None | Palate 9 lat 4 | Palate 7/8, lat 1 | 3 | 3 | 0 | 3 | 3 | 0 |
17 | OSA | UC | 2 flap | Palate 8 lat 0 | Palate 8 lat 1 | 2 | 2 | 0 | 2 | 2 | 0 |
22 | VPI | SM | furlow | Palate 4 lat 0 | Palate 3.5 lat 1 | 4 | 4 | 0 | 3 | 3 | 0 |
Patient characteristics. Tons: tonsillectomy. Cleft type: UC: unilateral complete, BC: bilateral complete, SM: submucous, I: incomplete. Unk.: unknown. Endoscopy scores: palate: palatal movement, lat: lateral wall movement. Scores according to the Golding-Kushner Scale, adjusted to 0–10 scale.
Ranking of speech intelligibility.
Speech intelligibility | ||
---|---|---|
0 | Normal | 100% intelligible |
1 | Minimal | 95–99% intelligible |
2 | Mild | 80–94% intelligible |
3 | Mod | 50–79% intelligible |
4 | Severe | <50% intelligible |
Ranking of velopharyngeal insufficiency.
Velopharyngeal insufficiency | |
---|---|
0 | Normal |
1 | Minimal |
2 | Mild |
3 | Mod |
4 | Severe |
The role of tonsils on velum position and function is poorly characterized. The velum position during speech depends on the complex balance of vector forces created by palatal elevators, depressors, and constrictors [
Few studies have characterized the influence of tonsils on speech. A 1994 study by Finkelstein et al. examined tonsil size and position in relation to speech function. They concluded that in most cases markedly enlarged tonsils do not appear to affect velopharyngeal closure as they are typically positioned below the level of velum closure [
On the opposite side of the spectrum, certain cases of VPI may be expected to worsen with tonsillectomy. In some, the tonsils are thought to act as lateral obturators, particularly in patients who have had pharyngeal flaps that are narrow or low placed. In these cases tonsillectomy would not be recommended or may necessitate simultaneous or staged flap augmentation or revision [
In our study, patients with VPI who underwent tonsillectomy had very little overall change in speech parameters. Our findings are consistent with several studies. D’Antonio et al. in 1996 demonstrated improved or unchanged speech parameters in 15 patients at risk for VPI after tonsillectomy [
Similar results have been demonstrated in other groups. In a recent Taiwanese study by Hu et al. comparing management of VPI in the presence of tonsillar hypertrophy, a subset of patients who underwent an isolated tonsillectomy either alone or for staged pharyngoplasty had similar speech outcomes to our study. In their study, 19 of the patients underwent tonsillectomy without a simultaneous velopharyngeal procedure. Of these, 14 patients had no change in function, three patients improved, and two patients worsened after tonsillectomy [
Potential biases of this study include observer bias and selection bias. The evaluators were not blinded to the pre- versus postoperative status in these cases. The selection of patients for surgery was not randomized and was based on clinical judgment. An argument against this bias in this study, however, is the inclusion of the subset who had severe VPI and underwent tonsillectomy as a first stage prior to definitive pharyngoplasty. In these patients it was felt that a procedure to improve speech, which invariably narrows the pharynx, would likely result in sleep-disordered breathing postoperatively. These patients arguably may have been the most “at risk” for worsening speech parameters given the preoperative decision that the patient would need VPI surgery. However, this group did not have significantly different outcomes.
It should be noted that the average tonsil size in this study was large (3−4 + in the majority of patients). Thus, the results must be interpreted with respect to this. Studies of tonsil size and speech characteristics are sparse. In one study of healthy male adults, Mora et al. demonstrated that tonsil size was directly related to the degree of audible speech changes after tonsillectomy, notably, the degree in change of improvement of hyponasality [
Furthermore, we must address the fact that only half of the patients in our VPI database who underwent tonsillectomy had adequate pre- and postoperative speech evaluation with standardized perceptual speech analysis. We excluded those patients with speech assessments that did not quantify the two parameters of interest, namely, speech intelligibility and velopharyngeal competency. Several patients also were lost to followup or had a delay in postoperative evaluation, such that a direct comparison of pre- and postoperative speech parameters would not be useful. Ideally, a study of this design should have standardized time intervals for speech evaluation.
In this study, tonsillectomy without adenoidectomy in patients with VPI and tonsillar hypertrophy did not significantly alter speech intelligibility or velopharyngeal competence. This must be interpreted with respect for adequate clinical judgment. More research is needed to further elucidate the impact of tonsillectomy on patients with or at risk for velopharyngeal insufficiency, particularly given the high prevalence of OSA in this population.