title: Treatment of velopharyngeal inadequacy in a patient with submucous cleft palate and myasthenia gravis.
abstract: OBJECTIVE
  To describe the clinical course and management of a patient with submucous cleft palate who developed myasthenia gravis (MG) as an adult and suffered recurrent hypernasality. Few reports have described MG patients undergoing pharyngeal flap surgery for velopharyngeal incompetence, and these have described only slight speech improvement in such patients.
  
  
  METHODS
  Case report.
  
  
  METHODS
  The patient underwent primary pushback palatoplasty and superiorly based pharyngeal flap surgery for submucous cleft and short palate at age 7. Hypernasality showed major improvement after initial surgery. At age 19, the patient developed MG that triggered the recurrence of velopharyngeal incompetence.
  
  
  METHODS
  After MG was treated, revision pushback palatoplasty was performed for velopharyngeal incompetence when the patient was 24 years old. Preoperatively and postoperatively, the patient was evaluated by the same speech-language-hearing therapists, each with at least 5 years of clinical experience in cleft palate speech.
  
  
  RESULTS
  After the second pushback palatoplasty, hypernasality and audible nasal air emission during speech decreased to mild.
  
  
  CONCLUSIONS
  Primary pushback palatoplasty and pharyngeal flap surgery were performed for the submucous cleft palate. Revision pushback palatoplasty improved velopharyngeal inadequacy induced by MG. Decreased perceived nasality positively influenced the patient's quality of life. Combined pushback palatoplasty and pharyngeal flap surgery is thus an option in surgical treatment for velopharyngeal inadequacy to close the cleft and the velopharyngeal orifice in cases of cleft palate and MG.
authors.affiliation: Department of Plastic and Aesthetic Surgery, Chiba University Hospital, Japan. rikihisa@faculty.chiba-u.ac.jp
authors.forename: Naoaki
authors.initials: N
authors.lastname: Rikihisa
authors.forename: Akikazu
authors.initials: A
authors.lastname: Udagawa
authors.forename: Shinya
authors.initials: S
authors.lastname: Yoshimoto
authors.forename: Masaharu
authors.initials: M
authors.lastname: Ichinose
authors.forename: Tomoe
authors.initials: T
authors.lastname: Kimura
authors.forename: Sara
authors.initials: S
authors.lastname: Shimizu
mesh_terms: D002648:Child; D002972:Cleft Palate / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D009157:Myasthenia Gravis / Q000150:complications*; D010159:Palate / Q000601:surgery; D010614:Pharynx / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D013064:Speech Disorders / Q000209:etiology; D013524:Surgical Flaps; D014681:Velopharyngeal Insufficiency / Q000209:etiology / Q000601:surgery*; D055815:Young Adult