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Discussion: The Children’s Hospital of Philadelphia Modification of the Furlow Double-Opposing Z-Palatoplasty 30-Year Experience and Long-Term Speech Outcomes

623 T community of providers who care for children with cleft lip–cleft palate recognizes the contributions to cleft palate surgery realized by successive generations of professionals at The Children’s Hospital of Philadelphia. The pioneering work of Dr. Randall, an early adopter and modifier of Dr. Furlow’s novel original surgical technique,1 continued under the leadership of Dr. LaRossa and subsequent generations of The Children’s Hospital of Philadelphia cleft surgeons and cleft team members, resulting in a widely disseminated surgical technique and a solid body of evidence to substantiate its use.2–5 It has been reported that the Furlow method has been adopted by 42 percent of the surgeon members of the American Cleft Palate-Craniofacial Association as their first choice in primary palatoplasty.6 It is also increasingly used for secondary revision palatoplasty as a first-line treatment of velopharyngeal dysfunction.7,8 Of course, when evaluating any palatoplasty technique, the main outcome measures are speech, fistula rate, and facial growth. The authors here present an interval report on their large experience, with the substance of the update being speech and fistula outcomes. It is far from a straightforward task to determine the speech outcome of primary palatoplasty. The authors have relied on the Pittsburgh Weighted Speech Scale2 as a main outcome measure. They achieved a “competent mechanism in 72.4 percent,” “a borderline mechanism consistent with socially acceptable speech” in 21.5 percent, leaving only 6.1 percent “incompetent.” Using the Pittsburgh Weighted Speech Scale, 93.9 percent of The Children’s Hospital of Philadelphia patients undergoing primary Furlow palatoplasty had resultant socially acceptable speech. Dr. Furlow, in his discussion of a previous update on The Children’s Hospital of Philadelphia experience,4 was critical of the Pittsburgh Weighted Speech Scale, because its methodology lumps together the primary and secondary effects of a structurally incompetent velopharynx (i.e., one that mechanically cannot achieve valve closure). Primary effects of an incompetent velopharynx are nasal air escape and hypernasality, and secondary effects are compensatory behaviors that must be unlearned by speech therapy. His critique was a reminder that the decision about whether primary palatoplasty was successful should keep primary effects in mind. In this respect, it is to their credit that the authors report good outcomes with respect to certain primary effects components of Pittsburgh Weighted Speech Scale composite scores, including hypernasality (nil or mild in >90 percent) and nasal emission (nil or inaudible in >85 percent). It is noteworthy that in this series 21.5 percent of patients had a “borderline mechanism with socially acceptable speech.” Betty Jane McWilliams, who developed the Pittsburgh Weighted Speech Scale, was not reticent in describing difficulties with the “borderline” patient. She observed that “reliability in using scales of these types rests with the raters,” and that “scales are most reliable when groups of listeners participate.” McWilliams was so respectful of the difficulties in the borderline group that in her clinic all borderline decisions were arrived at by comparing the assessments of two or three speech pathologists.9(p314) She echoes Dr. Furlow’s concerns by further stating, “The validity of rating scales is also a matter of concern. Listeners have difficulty separating hypernasality from the other speech characteristics associated with velopharyngeal incompetence.”9 It is not specifically mentioned that more than one rater was used for those with borderline