Increased Age At Primary Cleft Palate Repair Is Associated With Worsened Five-Year Speech Outcomes

PURPOSE: Velopharyngeal insufficiency (VPI) is a common complication after primary cleft palate repair, often manifesting clinically as hypernasal speech. Although delayed primary palatoplasty is widely considered a risk factor for VPI, an age threshold at which this risk increases has not been clearly defined. This study aims to evaluate the relationship between age at primary palatoplasty and postoperative speech outcomes at five years of age and to identify a potential age threshold beyond which repair is associated with worse speech outcomes. METHODS: A retrospective review identified all patients who underwent primary cleft palate repair at a single tertiary care institution between 2013 and 2023. Exclusion criteria included patients with submucous cleft palate only, incomplete medical records, and lack of five-year follow-up visit. Data collected included demographics, age at primary repair, Veau classification, and surgical technique. Univariate and multivariate linear regression analyses were performed to identify predictors of increased hypernasality and higher (worse) speech scores at five years of age, as determined by a speech-language pathologist using the Pittsburgh Weighted Speech Score. RESULTS: A total of 108 patients met inclusion criteria. The median age at primary repair was 12.9 months (range: 7.0-52.9); 43.5% were female and 56.5% male. Distribution by Veau classification was: I (11.1%), II (46.3%), III (26.9%), and IV (15.7%). The median overall speech score at five years was 1 (range: 0-19), and the median hypernasality sub-score was 0 (range: 0-4). On multivariate linear regression adjusted for demographic variables, Veau type, and presence of genetic syndromes, increasing age at primary repair was significantly correlated with higher (worse) overall speech scores (p = 0.029) and hypernasality sub-scores (p = 0.021). When age at repair was analyzed categorically, a threshold effect at 15 months emerged: patients repaired after 15 months demonstrated significantly worse overall speech scores at five years (p = 0.031) and a notable but statistically non-significant increase in hypernasality sub-scores at five years (p = 0.076). CONCLUSIONS: Delayed primary cleft palate repair is associated with worse speech outcomes and increased hypernasality at five years of age. Specifically, a 15-month age threshold may be clinically meaningful, with earlier repair associated with better speech scores. These findings support prior literature linking delayed primary repair to worse speech outcomes and further identify 15 months as a potential threshold to inform optimal surgical timing.