Improving Care of Cleft-Related Velopharyngeal Incompetence on Humanitarian Missions Using a Multidisciplinary Team Approach
Authors: Gunther Sven , Valerio Ian , Harshbarger Raymond , Kumar Anand R. 
Published: February 2019

Background:
Proper evaluation and analysis of speech surgery outcomes for cleft-related velopharyngeal incompetence in children and young adults performed on humanitarian missions is poorly characterized. The aim of this study is to examine the effect of using a multidisciplinary team on cleft-related humanitarian missions. The effect on patient selection, velopharyngeal mechanism imaging, and speech outcomes after surgery will be highlighted.

Methods:
A review of the Medical Readiness Training Exercise database for craniofacial missions to the Dominican Republic from 2009 to 2011 was performed. A speech pathologist and a craniofacial surgeon evaluated all patients with a diagnosis of cleft palate and speech abnormalities. Patients were screened using speech analysis and selective nasal endoscopy. Data collected included sex, age, diagnosis, speech scores, date, and type of surgical procedure—that is, pharyngeal flap (PF) versus sphincter pharyngoplasty (SP), morbidity, and mortality.

Results:
One hundred twenty-six patients with cleft palate were screened during the study period by a craniofacial surgeon and secondarily by a speech pathologist. Twenty-eight patients were identified with nasal quality speech of whom 12 patients (12/126 = 9.5% of total surgical cases) underwent PF/SP surgery after previous primary repair of a cleft palate defect. The 16 remaining patients (16/28 = 57%) with nonsurgical speech abnormalities were determined that surgery was not going to be beneficial and they were spared unnecessary surgery after speech pathology evaluation and nasal endoscopy. Eight patients were female and 4 patients were male; average age was 13.3 years (range 4–27 years). Seven pharyngeal flaps (58%) and 5 (42%) sphincter pharyngoplasty procedures were performed. The average presurgical speech score was 11.4 (range 6–24). There was a significant decrease in postsurgical speech scores with the average postsurgical speech score of 5.2 (range 0–21, P value = 0.0028). Follow-up evaluation averaged 18 months (range 6–24). Average hospital stay was 2 days for PF/SP surgery. Two patients, both with developmental delay, retained speech scores greater than 6. There were no major complications or reoperations.

Conclusions:
Pharyngeal flap/sphincter pharyngoplasty surgery in young adults resulted in improved speech scores and comprehensibility after speech surgery on Medical Readiness Training Exercise military humanitarian missions. Speech surgery in older patients in relatively austere environments is safe and effective. After comprehensive multidisciplinary team evaluation, 43% of the patients who were screened to have velopharyngeal incompetence were identified as surgical candidates. Fifty-seven percent of patients evaluated by speech pathologist were recommend nonsurgical solution toward improving speech scores sparing them unnecessary surgery. The incorporation of a speech pathologist to the humanitarian mission resulted in identifying surgical candidates who would benefit the most from intervention and improved speech surgery outcomes.