The Laryngoscope V C 2012 The American Laryngological, Rhinological and Otological Society, Inc. Hypertrophied Tonsils Impair Velopharyngeal Function After Palatoplasty Mosaad Abdel-Aziz, MD Objectives/Hypothesis: When tonsillar hypertrophy obstructing the airway is encountered in a child with a repaired cleft palate and velopharyngeal insufficiency, the surgeon may opt for tonsillectomy to relieve the airway obstruction, with possible effects on velopharyngeal closure. The aim of this study was to assess the impact of hypertrophied tonsils on velo- pharyngeal function in children with repaired cleft palate and to measure the effect of tonsillectomy on velopharyngeal clo- sure and speech resonance. Study Design: Case series. Methods: Twelve children with repaired cleft palate and tonsillar hypertrophy underwent tonsillectomy to relieve air- way obstruction. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech and nasalance scores were measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy. Results: Preoperative impairment of velopharyngeal function was detected. However, significant postoperative improve- ment of speech parameters (hypernasality, nasal emission of air, and weak pressure consonants measured with auditory per- ceptual assessment) was achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Reduction of velopharyngeal gap size was detected after removal of hypertrophied tonsils. Although the improvement of velopharyngeal closure was not significant, three cases demonstrated complete postoperative closure with no gap. Conclusions: Hypertrophied tonsils may impair velopharyngeal function in children with repaired cleft palate, and ton- sillectomy is beneficial for such patients as it can improve the velopharyngeal closure and speech resonance. Secondary cor- rective surgery may be avoided in some cases after tonsillectomy. Key Words: Tonsillectomy, hypertrophied tonsils, cleft palate, velopharyngeal insufficiency. Level of Evidence: 4 Laryngoscope, 122:528–532, 2012 INTRODUCTION Hypertrophied tonsils often affect speech resonance in children, by decreasing oropharyngeal airspace, push- ing the tongue forward, and causing hypernasality, oral breathing, and muffled voice. 1 The upper pole of the enlarged tonsil may interpose between the velum and posterior pharyngeal wall, interfering with proper velo- pharyngeal closure with the possible outcome of velopharyngeal insufficiency. 2–5 Velopharyngeal insuffi- ciency can lead to hypernasality, which renders a child’s speech unintelligible and can affect communication. Chil- dren with hypernasal speech are often considered less intelligent, less pleasant, and less attractive. Such percep- tions can seriously affect the social life of children. 6 Children with cleft palate are more prone to obstruc- tive breathing and sleep apnea, in part due to a small and narrow airway. The effect of adenotonsillar hypertrophy in such patients is more severe than that in normal children. Recently, many reports have documented that obstructive sleep apnea is much more common in cleft palate patients than in noncleft patients. 7–10 However, patients with cleft palate should not undergo adenoidectomy unless abso- lutely necessary, and in such situations, conservative or partial adenoidectomy is performed to avoid the occur- rence of velopharyngeal insufficiency. 8,11,12 Velopharyngeal insufficiency has also been reported after tonsillectomy without adenoidectomy. Although the problem is mostly transient, it can be permanent. 13,14 Thus, some authors sug- gest that tonsillectomy should not be performed in patients with cleft palate to prevent deterioration of velopharyngeal function. 15,16 Surgeons may encounter enlarged tonsils that cause obstructive breathing coexisting with velopharyngeal insufficiency in patients with cleft palate. The aim of our study was to assess the impact of hypertrophied tonsils on the velopharyngeal function in children with repaired cleft palate and to measure the effect of tonsillectomy on velo- pharyngeal closure and speech resonance. MATERIALS AND METHODS The study was conducted on 12 patients with repaired cleft palate who underwent tonsillectomy in the period from January 2006 to July 2010 in the Department of Otolaryngology of Cairo University. The indication for surgery was obstructive From the Department of Otolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt. Editor’s Note: This Manuscript was accepted for publication Octo- ber 24, 2011. The study was carried out in the Department of Otolaryngology, Cairo University, Cairo, Egypt. The author has no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Mosaad Abdel-Aziz, MD, 2 El-Salam St., King Faisal, Above El-Baraka Bank, Giza, Cairo, Egypt. E-mail: mosabeez@yahoo.com DOI: 10.1002/lary.22457 Laryngoscope 122: March 2012 Abdel-Aziz: Tonsil Hypertrophy After Palatoplasty 528