Levator repositioning and palatal lengthening for submucous clefts.

Submucous clefts of the palate may present with velopharyngeal incompetence (VPI) or a history of recurrent otitis media. Many surgeons have favored a pharyngeal flap as primary treatment of the velopharyngeal incompetence associated with this disorder. The increasing number of case reports of sleep apnea and airway compromise associated with pharyngeal flaps prompted the use of levator muscle repositioning with palatal lengthening as initial therapy in 15 patients in an attempt to correct the pathologic anatomy while avoiding the postoperative sequelae. Patients were divided into two groups: group A (N = 8) had surgery before age 2 (11.8 +/- 5.7 months), and group B (N = 7) had surgery after 2 years of age (64.3 +/- 24.2 months). No patient in group A required a secondary operative procedure for velopharyngeal incompetence. Normal speech was obtained in 75 percent (N = 6), and slight velopharyngeal incompetence not requiring secondary correction was obtained in 25 percent (N = 2). Group B obtained less dramatic speech results: normal in 14 percent (N = 1), slight velopharyngeal incompetence in 58 percent (N = 4), and no improvement or severe velopharyngeal incompetence requiring a secondary procedure in 28 percent (N = 2). Patients with preoperative otologic disorders (N = 10) obtained significant improvement in 90 percent of cases (p = 0.002). Early surgical intervention in patients with abnormal speech prior to age 2 appears to result in normal speech in the majority of instances. Late repair with levator repositioning and palatal lengthening provided improved speech in 72 percent of patients.