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Charters E, Pelham C, Novakovic D, Madill C, Clark J. Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 25:540-548. [PMID: 35975948 DOI: 10.1080/17549507.2022.2104927] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Following transoral robotic surgery (TORS) for oropharyngeal carcinoma (OPC), velopharyngeal incompetence (VPI) is a known consequence that may contribute to swallowing and speech disorders. As the incidence of OPC increases affecting a younger demographic, a better understanding of VPI is required to support speech and swallowing rehabilitation. METHOD A scoping review was conducted using Arskey & O'Malley's framework. Studies were identified from five databases between 2007 and 2020. The methodological quality was measured with the RevMan Risk of Bias Tool by two independent evaluators. RESULT A total of seven studies met the inclusion criterion. There was a combined total of 306 participants, their average age was 59.2 years. A high risk of bias and degree of heterogeneity across all seven cohort studies was observed. Validated and instrumental evaluations of VPI were present in two papers, with the majority only reporting the presence or absence of VPI. The incidence of VPI reported in each study ranged from 0 to 53%, (median 3.5%). CONCLUSION There are few high-quality studies and considerable heterogeneity in the terminology, inclusion criteria and measurement of VPI. Instrumentation, to date, has been rarely used but is necessary for a normed and validated approach to VPI. Based on this review, there is considerable need for larger studies which instrumentally and longitudinally assess VPI as a consequence of TORS, in order to guide patient education and management prior to, and following their surgery.
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Affiliation(s)
- Emma Charters
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Claire Pelham
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Daniel Novakovic
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
| | - Cate Madill
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jonathan Clark
- Sydney Medical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia
- Sydney Head and Neck Cancer Institute, Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, Australia
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, Australia
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Chen N, Shi B, Huang H. Velopharyngeal Inadequacy-Related Quality of Life Assessment: The Instrument Development and Application Review. Front Surg 2022; 9:796941. [PMID: 35402476 PMCID: PMC8988257 DOI: 10.3389/fsurg.2022.796941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022] Open
Abstract
Objective For the patient-reported outcome (PRO) measures related to patients with velopharyngeal inadequacy (VPI), different quality of life (QOL) instruments have been developed. The present systematic review was designated to identify current VPI-related QOL instrument development, validation, and applicability. Methods Pubmed, Cochrane, Embase, Web of Science, and EBSCO databases were searched in January 2022. “Velopharyngeal” or “palatopharyngeal” and “quality of life” or “life quality” were searched in title, abstract, and keywords. This study followed Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Two investigators independently reviewed abstracts and full texts of the identified literature. An established checklist was used to evaluate the measurement properties of each identified instrument. Results A total of 375 articles and 13 instruments were identified, which can be divided into nine types of families according to their development procedures. Developmental and measurement characteristics, evidence of conceptual model, content validity, reliability, construct validity, scoring, interpretation, respondent burden, and presentation for all instruments were shown. Conclusion The patient's self-report assessment and parent-proxy assessment are both valuable. The conclusion that any QOL instrument is absolutely the best for patients with velopharyngeal inadequacy could not be drawn. Understanding the development and characteristics of different QOL instruments, including their reliability, validity, aim, target, language, and resource, should be important before application in clinic or research.
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Affiliation(s)
- Nan Chen
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Hanyao Huang
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Autologous Fat Grafting in Velopharyngeal Insufficiency Gives Complete and Stable Speech Recovery in Patient Under 7 years. J Craniofac Surg 2021; 33:e8-e14. [PMID: 34510057 DOI: 10.1097/scs.0000000000007845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT The authorspresent a retrospective observational cohort study of 47 French speaking consecutive patients treated with retropharyngeal wall filling with autologous fat graft from 2006 to 2019 in a single tertiary center, to assess with a long-term follow-up, the best tailored treatment to recovery speech for velopharyngeal insufficiency, and to stress the importance of early treatment with minimally invasive procedure with retropharyngeal wall fat grafting. In preoperative setting, a clinical and instrumental evaluation with aerophonoscope is completed by a palatal closure assessment with nasal endoscopy. All patients were classified according with Borel Maisonny score pre- and post-operatively. Sixty three fat injections were performed. In 4 cases a pharyngeal flap was performed after fat graft for an insufficient speech result. The authors had no complications. Patients with less than 7 years of age obtained a complete recovery of their velopharyngeal incompetence (P = 0.03) compared to older patients. In conclusion, the authors can state that this tailored surgical technique needs a multidisciplinary approach. Many variables can affect postoperative results: fat reabsorption, concurrently performed surgery, pattern of pharyngeal closure, hearing impairment. None of these factors affected our result. Early treatment plays a crucial role to achieve better results. Patients with less of 7 years showed a better result in this functional treatment.
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Ecuadorian Spanish translation and validation of the VELO quality of life instrument. Int J Pediatr Otorhinolaryngol 2020; 138:110312. [PMID: 32882600 PMCID: PMC7649090 DOI: 10.1016/j.ijporl.2020.110312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/08/2020] [Accepted: 08/09/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Adapt the Spanish translation of VPI Effects on Life Outcome (VELO) instrument into Ecuadorian Spanish; test the resulting instrument for reliability and validity. METHODS A cross-sectional, prospective design, set at a humanitarian mission within a community hospital. Linguistic validation: native Ecuadorian-Spanish speakers modified the Spanish VELO to Ecuadorian Spanish. Cognitive interviews were conducted with children with cleft palate (CP) and their parents (n = 50), guiding instrument modifications. An expert panel reviewed changes, resulting in the VELO-Ecuadorian dialect (VELO-Ec). INSTRUMENT ASSESSMENT 88 participants with CP (88 parents, 46 children) and 33 non-cleft controls (33 adult, 11 children) completed the VELO-Ec, Spanish-Pediatric Voice Handicap Index (pVHI), and Spanish-Intelligibility in Context Scale (ICS). Internal consistency was assessed with Cronbach's alpha; test-retest reliability was assessed by calculating the intraclass correlation coefficient (ICC); standard error of measurement (SEM) was calculated. Concurrent validity was assessed with Pearson correlations of VELO-Ec with pVHI and ICS. Discriminant validity assessment used an established ICS cutoff. Construct validity was assessed by grouping patients by parent report of hypernasality and early vs. late cleft repair (>24 months) using the Wilcoxon Rank-Sum test. RESULTS VELO-Ec showed excellent internal consistency (alpha 0.96) and test-retest reliability (ICC = 0.85, 95% CI 0.68-0.93, SEM 5.71). It had strong concurrent validity, correlating with ICS (r = 0.75, p < 0.001) and pVHI (r = -0.79, p < 0.001). Discriminant validity was strong with better VELO-Ec scores among subjects with normal vs. abnormal ICS score (median 95 & 61, p < 0.001). Strong construct validity was identified: those with parent-reported hypernasality had worse VELO-Ec scores than those without (median 59 & 75, p < 0.001). Those with repair before or after 24 months had similar VELO-Ec scores (p = 0.882). CONCLUSION The VELO-Ec is a valid and reliable measure of VPI-related quality of life, useful to clinicians and researchers treating Ecuadorian CP patients, especially in areas with limited resources such as on humanitarian missions.
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Acum M, Mastroyannopoulou K, O'Curry S, Young J. The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review. Cleft Palate Craniofac J 2020; 57:990-1007. [PMID: 32174163 DOI: 10.1177/1055665620911328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway. DESIGN A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery. RESULTS Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress. CONCLUSIONS Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.
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Affiliation(s)
- Michelle Acum
- Cambridgeshire and Peterborough NHS Foundation Trust, Elizabeth House, Fulbourn Hospital, Cambridge, United Kingdom.,University of East Anglia, Norwich, United Kingdom
| | - Kiki Mastroyannopoulou
- Norfolk and Norwich University Hospital, University of East Anglia, Norwich, United Kingdom
| | - Sara O'Curry
- Psychological Medicine for Children, Young People and their Families, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Judith Young
- University of East Anglia, Addenbrooke's Cambridge University Hospital Trust, Cambridge, United Kingdom
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Lindeborg MM, Shakya P, Pradhan B, Rai SK, Gurung KB, Niroula S, Rayamajhi B, Chaudhary H, Gaire B, Mahato N, Rana L, Rokaya P, Shrestha N, Shrestha R, Tamang J, Joshi HD, Gaha P, Khorja DK, Mitnick CD, Rai SM, Shaye DA. Nepali Linguistic Validation of the Velopharyngeal Insufficiency Effects on Life Outcomes Instrument: VELO-Nepali. Cleft Palate Craniofac J 2020; 57:967-974. [PMID: 32054301 DOI: 10.1177/1055665620905173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To translate and validate the velopharyngeal insufficiency (VPI) effects on life outcomes (VELO) instrument into Nepali, and test its internal consistency and validity. DESIGN Quality-of-life instrument translation and validation. SETTING Community served by Nepal's craniofacial referral hospital. PARTICIPANTS Twenty-three postpalatoplasty children with VPI, 19 family guardians of VPI cases, and 29 non-VPI controls. INTERVENTIONS The VELO instrument was translated to Nepali by 2 independent bilingual translators, reconciled, backward-translated, compared, and modified using patient cognitive interviews. All VPI children, guardians, and controls completed the VELO-Nepali. MAIN OUTCOME MEASURE(S) The VELO internal consistency was evaluated using Cronbach α coefficient. Concurrent validity and discriminant validity were assessed using 2-sample t test: assuming unequal variances. RESULTS The VELO was translated and optimized using cognitive interviews. The VELO-Nepali demonstrated excellent internal consistency, with Cronbach α coefficients of 0.93, 0.94, and 0.90 for VPI cases, guardians of VPI cases, and non-VPI controls, respectively. The VELO-Nepali exhibited strong discriminant validity between VPI cases (x¯ = 45.4, standard deviation [SD] = 22.1) and non-VPI controls (x¯ = 84.9, SD = 12.3), (P < .001). The VELO-Nepali showed strong concurrent validity with similarities in VPI case scores (x¯ = 45.4, SD = 22.1), and guardian scores (x¯ = 52.9, s = 22.8; P = .473). CONCLUSION The translated VELO-Nepali demonstrates strong internal consistency, discriminant validity, and concurrent validity, and can assess quality of life for Nepali VPI patients. This instrument represents the first VPI quality of life assessment validated in Nepali, and supports the feasibility of its implementation in other low- and low-middle-income countries.
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Affiliation(s)
- Michael M Lindeborg
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Michael Lindeborg and Pramila Shakya are co-first authors
| | - Pramila Shakya
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal.,Michael Lindeborg and Pramila Shakya are co-first authors
| | - Bhawani Pradhan
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Shiba Kala Rai
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | | | - Suman Niroula
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Badri Rayamajhi
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Hema Chaudhary
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Bhagwati Gaire
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Naina Mahato
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Lila Rana
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Phana Rokaya
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Nilam Shrestha
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Renuka Shrestha
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Januka Tamang
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Hemanta Dhoj Joshi
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Pushpa Gaha
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Dhana Kumari Khorja
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Shankar Man Rai
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | - David A Shaye
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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Poff C, Horton J, Boerner R, Marston AP, Nguyen SA, White DR. Publishing trends in velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2020; 129:109761. [PMID: 31760335 DOI: 10.1016/j.ijporl.2019.109761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/24/2019] [Accepted: 10/26/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study seeks to describe publishing trends for VPI over a 33-year span with regard to treating specialty, methods of assessment, related diagnoses, and methods of treatment for each specialty. METHODS A PubMed search was performed on "velopharyngeal insufficiency" using medical subject headings terms from 1985 to 2017. Publisher specialty, method(s) of VPI assessment, associated diagnosis/diagnoses, and method(s) of VPI treatment per specialty and combined across specialties were analyzed. Respective publications were totaled in 11-year intervals and two-way analysis of variance was used to compare change over time within specialties and across specialties. RESULTS 763 publications were included for analysis. The total number of publications on VPI increased from a total of 6 in 1985 to a peak of 67 in 2015. The specialties that showed the largest increase in relative frequency of publication were Otolaryngology (p < 0.001), Plastic Surgery (p < 0.001), and Multidisciplinary (p < 0.001). Publications on endoscopic (p < 0.001) evaluation of VPI have significantly increased over time relative to magnetic resonance imaging and lateral cephalometry. Across all specialties, publications that feature pharyngoplasty (p < 0.001), palatoplasty (p < 0.001), and pharyngeal flap (p < 0.001) as methods of VPI treatment have significantly increased over time. CONCLUSION There is a trend towards endoscopy for diagnostics and a multidisciplinary approach when managing patients with VPI. The specialty that showed the largest increase in the relative frequency of publication was Otolaryngology. Surgical methods of treatment continue to be described at increasing frequency relative to more conservative treatments.
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Affiliation(s)
- Charles Poff
- Medical University of South Carolina, College of Medicine, USA.
| | - Joshua Horton
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan Boerner
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander P Marston
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - David R White
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Impieri D, Tønseth K, Hide Ø, Feragen K, Høgevold H, Filip C. Autologous fat transplantation to the velopharynx for treating mild velopharyngeal insufficiency: A 10-year experience. J Plast Reconstr Aesthet Surg 2019; 72:1403-1410. [DOI: 10.1016/j.bjps.2019.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/17/2018] [Accepted: 03/30/2019] [Indexed: 02/07/2023]
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Health-related quality of life in patients with cleft palate: Reproducibility, responsiveness and construct validity of the Dutch version of the VELO questionnaire. Int J Pediatr Otorhinolaryngol 2019; 119:141-146. [PMID: 30708181 DOI: 10.1016/j.ijporl.2019.01.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/13/2018] [Accepted: 01/19/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Recently, the Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) questionnaire, which evaluates the impact of speech and swallowing difficulties on health-related quality of life (HRQoL) in patients with VPI (Skirko et al., 2012), was translated to Dutch (Bruneel et al., 2017). The purpose of this study was to evaluate the reproducibility, responsiveness and construct validity of this Dutch version of the questionnaire. METHODS To evaluate the reproducibility, 50 parents and 14 children with cleft palate re-completed the questionnaire after two weeks. Thirty-five parents and 8 children with cleft palate completed the VELO questionnaire after one year for the evaluation of the responsiveness. The correlation between age and the VELO questionnaire (construct validity), and the internal consistency (Cronbach's α) were re-determined based on the responses of 73 parents and 24 children. RESULTS Based on descriptive statistics, results of the Wilcoxon signed rank-test, and the absolute (SEM) and relative (ICC) consistency, the questionnaire showed good reproducibility. VELO scores did not significantly differ after one year, neither when performing separate analyses for the intervention (speech therapy) and the non-intervention group. Correlations indicated higher HRQoL, as perceived by the parents, with increasing age. The reverse was the case for the youth report. Cronbach's α showed excellent internal consistency for both reports. CONCLUSIONS The VELO questionnaire showed good reproducibility and internal consistency. Moreover, results reconfirmed the age effect on VELO scores. To understand the implications of the results regarding the questionnaire's responsiveness, future research should focus on the identification of factors influencing the patient's evolution in HRQoL.
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Huang H, Chen N, Yin H, Skirko JR, Guo C, Ha P, Li J, Shi B. Validation of the Chinese Velopharyngeal Insufficiency Effects on Life Outcomes Instrument. Laryngoscope 2019; 129:E395-E401. [PMID: 30671957 DOI: 10.1002/lary.27792] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
| | - Nan Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children and Office of Educational AdministrationWest China Second University Hospital, Sichuan University Chengdu China
| | - Heng Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
| | - Jonathan R. Skirko
- Pediatric Otolaryngology (ENT) and Pediatric Facial Plastic SurgeryUniversity of Utah and Primary Children's Medical Center Salt Lake City Utah U.S.A
| | - Chunli Guo
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
| | - Pin Ha
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral Maxillofacial Surgery West China Hospital of Stomatology, Sichuan University, Chengdu, China;West China Second University Hospital, Sichuan University Chengdu China
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