LETTERS TO THE EDITOR Timing of Palatal Closure Should Not not be dependent on age alone. There are be Based on Age Alone _ instances when the hard palate can be suc- In "Delayed Hard Palate Closure: The cessfully closed before 1 year of age and _ Philosophy Revisited" by Drs. Witzel, Sal- other instances when it should not be closed yer, and Ross published in the October until 3 years of age or even later, in order 1984 issue of the Journal, an extensive re- to avoid growth-inhibiting and palate-de- view of the literature covering the pros and forming scar tissue. _ cons for doing early or late palatal closure It is unfortunate that some speech pa- is presented. The readers must conclude, thologists and surgeons still advocate early as the authors do, that the arguments for palatal closure (before 1 year of age), even either side are not conclusive due to the when it has been documented that in some inability of the investigators to control all cases poor speech can result from early the variables which effect speech. Unfor- closure and good speech can result from tunately, the authors also present unsub- late closure. It is time for all specialties to stantiated data to support an opinion, "that agree that there need not be any trade offs the incidence of VPI is significantly greater in objectives and that surgical treatment when the two-stage palate repair is used". needs to be individualized in order to at- They say, "it is likely (and we observe this tain the best results. clinically) that the soft palate may not Samuel Berkowitz, D.D.S., M.S. function as well in the face of an opening 6601 SW. 80th Street in the hard palate where there is leakage South Miami, FL 33143 of air pressure (Shelton and Blank 1984)". It must be stressed that this is an unsup- ported subjective opinion that is not backed Replies to Dr. Berkowitz up by proper diagnostic evaluation, such We wish to thank Dr. Berkowitz for as the use of lateral cephaloradiography, reading our article "Delayed Hard Palate nasopharyngoscopy, or videofluroscopy. Closure: The Philosophy Revisited". The Our own studies, which will be pub- purpose of our essay was to examine the lished in the proceedings of an interna- literature concerning the technique of de- tional conference of the British Craniofa- layed hard palate closure. cial Anomalies Society, held in England in Dr. Berkowitz states that we presented 1983, show that VPI is the function of unsubstantiated data to support an opin- many physiological and anatomical fac- ion. The statement in question simply tors. Among these factors are the depth of summarizes the available published re- nasopharyngeal space, the length and search studies concerning the incidence of thickness of the soft palate, and the action velopharyngeal insufficiency (VPI) in pa- of the pharyngeal and soft palate muscu- tients treated with the two-stage palate re- lature, timed to speech production. This pair technique. same study demonstrates that good speech We do suggest, based on our clinical ob- and good facial palate development and servations, that the soft palate may not occlusion can be obtained simultaneously function as well when there is air leakage if palatal closure (timing and type of pro- through an opening in the hard palate. We cedure) is individualized, that is, related to know of no way to clinically observe soft the size of the cleft space and the amount palate function without using videofluo- of surrounding palatal tissue, and should roscopy or fibreoptics. Our routine clinical 132 LETTERS TO THE EDITOR 133 observation of soft palate function always ety International Meeting, Birmingham, England includes one and in most cases both of these 1983. techniques (Witzel, 1983). The observa- Mary Anne Witzel, Ph.D. tions are qualitatively classified jointly by Hospital for Sick Children a speech pathologist and, depending on the Toronto, Canada technique, either a radiologist or a plastic Kenneth E. Salyer, M.D. surgeon. Lateral cephaloradiographs are Foundation for Craniofacial Deformities not considered to be reliable in the assess- Dallas, TX ment of velopharyngeal function (Wil- liams and Eisenbach, 1981), and we have not subjected patients to this technique Individualizing Treatment since the early 1970s. The statement was The criticism by Dr. Berkowitz of our put forth as one explanation for the re- analysis of the literature is, apparently, ported incidence of VPI in these patients based on his opinion that delayed hard and as a topic for investigation. palate repair would be advantageous for In our article, we made a plea for ad- the speech and facial growth of some in- herence to the scientific method of re- dividuals. His own unsubstantiated theory search and close cooperation among speech is that it is possible to vary cleft palate sur- pathologists, dentists, and plastic sur- gery to suit the individual situation. He was geons, in order to determine the best particularly critical of the speech aspect of treatment techniques. The paper that Dr. the survey, and I believe this illustrates a Berkowitz presented at the British Cranio- far too prevalent occurrence in the liter- facial Society International Meeting in 1983 ature, where a specialist in one discipline does not in its authorship reflect this co- unwisely claims very sophisticated knowl- operation. Furthermore, to our knowl- edge in another. edge, there is no published evidence to Individualization of treatment is a very show that it is possible to predict speech old concept, one which is taken for granted potential in an infant. Individualizing in many situations by most clinical disci- treatment then becomes a guessing game. plines. In orthodontics, for example, a de- Our review pointed out that in six of tailed treatment program for one individ- seven studies speech problems were severe ual may not apply exactly to any other in patients who had treatment by the de- individual. The result, however, is ex- layed hard palate closure technique. pected to be almost identical to all other Therefore, we feel that it is fortunate that results. To dispute the validity of individ- most speech pathologists and surgeons ad- ualization in a clinical situation is tanta- vocate early complete palatal closure. It is mount to supporting sin or decrying not yet time for the specialties of speech motherhood. pathology, dentistry, and plastic surgery It is not enough, however, to state the to agree on treatment methods for pa- obvious and note that all individuals are tients with cleft lip and palate. The time different; one must also add that they are to agree is when we have valid and reliable all almost the same. It is the subtle inter- assessments of the major treatment tech- play of similarities and differences that niques. makes diagnosis and treatment so difficult in the child with cleft lip and palate. The first step is to identify the individ- References ual's problems and determine (from ex- WITZEL MA. Speech problems in craniofacial anoma- perience with similar individuals) what the lies. Communicative Disorders 1983; 8:45. natural history might be. In this context, WILLIAMS WN, EIsENBACH CR. Assessing VP func- that means identifying the speech and tion: the lateral skill technique vs cinefluourogra- phy. Cleft Palate J 1981; 18:45. growth potentials of the infant. Next, we BERKOWITZ S. Neo-natal maxillary orthopedics-a must know all of the treatment options that dissent. Paper presented at the Craniofacial Soci- are available and what precise effect each 134 Cleft Palate. Journal; April 1985, Vol. 22 No. i? will have on the condition. Only then is it may well be a serious speech consequence possible to choose a specific program of to any delay, as our article suggests. treatment. We are not in a position at this I am afraid that Dr. Berkowitz is de- time to accomplish either of these steps, fending an approach which is self-evident although recent studies are improving our and does not require defending, but un- understanding of the problem. i fortunately there is no evidence that it In his letter, Dr. Berkowitz makes two can be accomplished! incredible (and, in my opinion, erroneous) assumptions. First, he claims that it is pos- References sible to predict by observing the width of Ross BR. Variables affecting facial growth in cleft lip the cleft and the amount of surrounding and palate. Transactions of the International Cleft palatal tissue in a neonate whether that Palate Conference, Zurich, 1984 (in press). infant will have a speech or facial growth SCHWARTZ BH, LONG RE, SMITH RJ, GirE DP. Early prediction of posterior crossbite in the complete problem in later years. Schwartz et al (1984) unilateral cleft lip and palate. Cleft Palate J 1984; made a good start at isolating morpholog- 21:76. ical factors related to simple crossbites in R. Bruce Ross, D.D.S. the primary and mixed dentitions. Our Hospital for Sick Children growth studies, some of which were pub- Toronto, Canada lished in the Proceedings of the British Craniofacial Society Meeting 1983, have shown rather conclusively that it is impos- sible to predict final facial morphology and Vowel Oral Air Flow Rates and Air jaw relations even in a 6 year old. Careful Volumes for Vowels monitoring of facial growth up to age 10 The excellent paper by Stathopoulos or 12 will permit a good estimate of the (1984) provides important information on growth pattern and the final relations. I air flow during vowel productions that will listened to Dr. Berkowitz's presentation in be useful in assessment of speech disor- Britain but failed to hear any evidence to ders. I would like to explain what appears support the claims expressed in his letter.