Secondary speech surgery: preparation and recovery

This leaflet is for parents/guardians and children who have been seen in a multidisciplinary cleft clinic where surgery has been recommended to improve speech. The aim of these procedures is to reduce the amount of air that escapes through the nose when speaking.

Your surgeon will recommend the approach that is best suited to your child. The most common options include:

• Buccinator flap: The soft palate is separated from the hard palate and moved further to the back of the mouth. A flap of tissue is taken from the lining of the cheek and placed in between the hard and soft palate, lengthening the structure. The flap remains attached to the cheek in order to maintain a good blood supply, which will promote good healing.
• Palate re-repair with/without buccinator flap: This procedure may be used if your child has previously had their cleft palate repaired and it did not heal in a way that was expected (that is, wound break down or the palate is too short). The palate is opened again and the muscles re-aligned. The palate is then repaired once more with or without the addition of a buccinator flap procedure.
• Pharyngoplasty: This operation is most likely to be offered if your child has not been born with a cleft palate but may be experiencing speech concerns related to palate function. Occasionally, this surgery may also be offered to those who have had previous cleft palate surgery. The procedure involves taking two pieces of tissue from the sides of the throat and joining them together to make a ‘speed bump’ on the back of the throat. This bump helps to reduce the gap between the back of the throat and the end of the palate, with the aim of improving speech.

Pre-admission

A few weeks before the operation we will arrange a telephone pre-admission appointment with a specialist cleft nurse. This is a good opportunity for you to ask any questions you may have in order to make you/your child feel as prepared as possible for the upcoming operation. If required, you will also have the opportunity to arrange extra accommodation on site if required during your child’s hospital stay. Expect to stay in hospital for one to four nights after your child’s operation.

You will also be required to attend a pre-admission clinic appointment at the hospital on ward F3. At this appointment a nurse will ask questions about you/your child as well as take some swabs. If you would like, we can arrange for you and your child to see the ward that they will be staying on. Your child may need to attend medical photography to have some photos taken for their medical records.

If you are the parent of a child having surgery, there is a pull-down bed for one parent to stay by your child’s bed throughout the stay. There is open visiting for both parents and siblings. Other visitors may come onto the ward at the set visiting times which are 7:30am-7:00pm every day. We generally advise to keep visiting to a minimum on the day of surgery.

The ward has a kitchen for parents with a fridge, freezer and microwave that you are free to use. Please ensure food kept in the fridge is labelled. The ward will supply food for your child. Parents will need to supply their own food.

Preparing for surgery and admission

Due to the nature of your child’s surgery, a soft diet should be followed for three weeks after the operation. This may differ from your child’s normal diet therefore, in the weeks leading up to your child’s operation it may be helpful if you plan some meals that will be suitable for your child after their surgery. Please see the accompanying leaflet ‘Feeding Advice Following Cleft Palate Surgery’ for more information.

As your child’s mouth will need to be opened wide during the surgery, moisturising the lips will help keep the skin softer, more supple and will reduce soreness and cracking. Two weeks or more before the operation, start applying petroleum jelly to the corners of the mouth twice a day. Please bring this petroleum jelly with you and continue to use throughout your stay.

It is a good idea to bring some toys/activities from home. Some children find it helps if they can pack their own hospital bag, for example, with their favourite cuddly toy, books to read, colouring books and pens.

On the day of surgery

When your child’s surgery date is confirmed you will receive a letter which will inform you of the time you need to arrive on ward F3. It will also give you the required nil by mouth times. Please allow plenty of time to drive to the hospital and to park. It is important that you arrive promptly in order to be seen by the anaesthetist and surgeon before they commence surgery.

Occasionally, a pre-medication may be given one hour before your child goes to theatre. This medicine dries up the inside of the mouth and your child may appear a little flushed looking. It could also make your child sleepy.

You will be able to accompany your child to theatre and one parent will be allowed to stay in the anaesthetic room until he/she is asleep. This usually involves your child breathing some anaesthetic gas through a mask. Later, a tube is passed into the airway to support breathing. A cannula is put into a vein so that some fluid and medication can be given during and after the surgery. For older children the cannula may be inserted whilst they are awake, and the anaesthetic will be administered through this instead of the mask. As a rough guideline your child may be away from you for two to six hours.

This can be a difficult time for parents. Sometimes it helps to have something planned to keep you occupied such as going for a walk, a planned phone call, a cup of tea or coffee, whatever is right for you. When your child is awake you will be called and then both parents are allowed to go to the recovery room. If you leave the hospital during the surgery please provide the nursing staff with a means of contacting you.

After the operation

When your child’s operation is complete they will be a taken to the recovery room. Whilst waking up in the recovery room your child may require some oxygen delivered through a clear face mask. Your child may look slightly puffy and swollen around the nose and eyes. This is normal and will reduce over the next few days.

During the operation, your child will have local anaesthetic put into the affected area and pain relief will be administered via the cannula to reduce post-operative discomfort. Despite this, your child may wake up a little disorientated. There may also be a small amount of blood from the nose and mouth which is normal after this surgery. Occasionally, the anaesthetist may leave a tube (nasopharyngeal airway) in one nostril to support the airway if the palate is swollen after the operation. This usually stays in place for 24 to 48 hours until the swelling has reduced.

Pain relief

It is important that your child has regular pain relief after the operation. Paracetamol and Ibuprofen should be given regularly by mouth using a spoon or syringe. Your child may also be given morphine through a cannula via a pump for the first 24 hours following surgery. It is important for older children to be offered medication in syrup form rather than tablets, as these can be difficult to swallow.

Eating and drinking

Your child will have a sore mouth and throat after the operation and may not want to eat and drink very much. Your child’s swallow may also feel different so they will need time to adjust and have reassurance that this is normal. If your child has had buccinator flap surgery, their cheeks may be swollen which can make it difficult to close the lips properly until the swelling has reduced.

Immediately after surgery your child can be offered sips of water. A straw is not recommended as this could damage the wound. A soft diet can be commenced as tolerated, as discussed previously. Children may want to try an icy drink prior to eating as this might help to numb the mouth.

After any medication, food or drink it is important that your child has some water to keep the mouth and wound clean and free of debris which may cause irritation, infection or wound breakdown.

Discharge home

Your child will be discharged from the hospital when you, your nurse and the surgeon are happy that your child is recovering well. Your child’s pain will need to be well managed on Paracetamol and Ibuprofen. Your child will need to be taking adequate amounts of food and fluid. It may take some time for your child to get back to their usual eating pattern which is to be expected.

Wound care

The stitches inside the mouth will dissolve by themselves in approximately three to six weeks so do not need to be removed.

As mentioned previously, it is important to continue keeping your child’s mouth clean and healthy to minimise infection and wound breakdown. We advise drinking water after food, drink and medication for two weeks to help with this. Your child can recommence regular tooth brushing 24 hours after the operation, though may need some help with this to ensure that the wound is not damaged. Using a smaller toothbrush may also be helpful.

We recommend that your child keeps to a soft diet for three weeks after the operation. Please see guidance in the ‘Feeding Advice Following Cleft Palate Surgery’ leaflet. You can also discuss this further with the cleft nursing team.

We recommend regular pain relief for 7 to 14 days following your child’s operation. This helps them to feel comfortable whilst eating, drinking, speaking and sleeping. We would advise gradually reducing the amount of pain relief after this period.

Your child will require two to three weeks off school following the surgery in order for the wound to heal well and for you to manage food and drink appropriately. Non-contact sports and activities can also restart then. Swimming and vigorous sports such as rugby may need to wait for up to six weeks after surgery.

Follow- up

You should expect to have a telephone call from one of the cleft nurse specialists 7 to 10 days following surgery to see how your child has recovered and check that his/her diet is improving and pain is managed and resolving.

You should receive a letter inviting you to come back to clinic between two to six months following the surgery. This will give the surgeon the opportunity to review the palate and to assess the speech alongside the cleft speech and language therapists.

If you are concerned about your child following surgery, please speak to a specialist cleft nurse on 01223 596272.

Privacy & Dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one to one care is required.