Early, well-designed surgery – performed before the infant reaches critical stages in speech development – can prevent speech impediments and other functional problems related to VPD, as well as avoiding the need for repeated surgeries, according to an introductory article by Mutaz B. Habal, MD, and Jane Scheurle, EdD, of Tampa Bay Craniofacial Center in Tampa, Fla.

"The timing of cleft palate repair is most important in the functional outcome of patients," Habal says.

Patients with VPD have an abnormal opening between the mouth and nasal cavity. This anatomical abnormality leads to functional problems, especially in speech and communication. Although other causes are possible, the most common cause of VPD is failed cleft palate surgery. Even today, surgery may fail to fully close the cleft palate in up to 25 percent of cases.

Some patients undergo additional surgeries in an attempt to correct the inadequate initial repair – sometimes making the problem worse. At their specialty center, Habal's team sees patients with VPD across the age span – including not only infants but also adults dealing with lifelong speech, swallowing, and other problems related to failed cleft palate surgery.

For Habal, a key step in his development as a surgeon was understanding the "critical window of time" for the development of normal speech in infants. Performing surgery before this time – specifically, between age 3 and 6 months – fixes the anatomical problem so that speech can develop normally.

"Following this paradigm of early intervention, the babies develop normal and typical velopharyngeal function, acquire speech and language, and bypass the need for traditional speech resonance diagnostic and treatment therapies," Habal and Scheurle write.

In addition to appropriate timing, other important issues include an individualized approach to surgical planning and an understanding of the critical relationship between hearing and speech. Patients with VPD may have other congenital and acquired defects, as well, leading to problems with hearing, feeding, and socialization that also need to be addressed.

At Tampa Bay Craniofacial Center, the emphasis is on early surgery to repair the cleft palate before the child is 6 months old. (Cleft lip, if present, is repaired even earlier – between one and two weeks.) Close follow-up is essential to monitor the child's hearing, as well as the development of normal communication between the parents and child.

In Habal's experience working with nearly 1,000 infants with cleft palate, this approach has produced excellent results. Only 8 percent of children have required speech therapy, while just one has needed a repeat surgical procedure.

"With these results ... we have come to believe that like early cleft closure, early prespeech, multidimensional intervention that guides the infant’s intraoral, and oropharyngeal muscle habituation coincides with the critical window of time for early neurogenesis and neuromuscular integration," Habal and Scheurle conclude.

"Speech is a learned skill more dependent on cognition than on the type of surgical repair," Habal adds. "Early surgery provides the child with an anatomic repair to help his or her cognition as the child is acquiring the skill of language expression, so the timing is more important than the different repairs done."