Velopharyngeal insufficiency: current concepts in diagnosis and management

Radical Overlapping Intravelar Veloplasty during Primary Cleft Palate Repair Results in Decreased Secondary Speech Surgery

BACKGROUND

There is growing evidence that performing a radical intravelar veloplasty (IVV) improves speech outcomes. The aim of this study was to determine the impact of a radical IVV during primary palatoplasty on the rate of secondary speech surgery.

METHODS

This study was a retrospective review of primary palatoplasty using an IVV performed by a single surgeon from the years 2000 to 2023. In 2008, the surgeon changed technique to involve a more radical IVV. The radical overlapping IVV involves release of the palatopharyngeus from the posterior hard palate and from the lateral tendinous insertion of the tensor veli palatini, release of the levator veli palatini to the levator tunnel, and overlapping of the palatopharyngeus-levator unit across the midline after retropositioning. This separated the patients into a before and after technique change group. The rate of secondary speech surgery was compared between the 2 periods.

RESULTS

An IVV was performed during straight line repairs 333 and 272 times during the first and second periods, respectively. The second radical overlapping IVV group had significantly ( P < 0.05) fewer secondary speech surgery procedures at 43 (15.81%) compared with 83 (24.92%) among the first conservative IVV group ( P < 0.05).

CONCLUSION

Precise anatomical dissection, extensive release, retropositioning, and overlap of the velar musculature during IVV results in significantly fewer secondary speech surgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Streamlined Preoperative Evaluation of Velopharyngeal Dysfunction: A Single-Session Protocol for Speech MRI and Carotid MRA

ObjectiveTo evaluate the feasibility and utility of a dual-imaging protocol integrating speech magnetic resonance imaging (MRI) and carotid magnetic resonance angiography (MRA) for assessment of velopharyngeal dysfunction (VPD).DesignProspective case series.SettingSingle tertiary care institution.PatientsSix pediatric patients with VPD.Main Outcome Measure(s)Image quality, velopharyngeal and vascular assessment, and impact on surgical decision-making.ResultsSpeech MRI consistently provided key velopharyngeal metrics, including levator veli palatini orientation and velopharyngeal gap size. Carotid MRA successfully mapped the vascular course, identifying one case of carotid medialization. Integration of both studies streamlined preoperative planning, influencing surgical technique selection and posterior pharyngeal flap design in cases with vascular anomalies.ConclusionA dual-imaging VPD protocol provides comprehensive anatomical and vascular data in a single nonsedated session. This approach enhances diagnostic accuracy, improves surgical planning, and reduces patient burden by eliminating the need for separate imaging sessions and repeated anesthesia exposure.

Management of Velopharyngeal Dysfunction (VPD) Following Cleft Palate Repair: A Comprehensive Decision-Making Process Based on Severity and Structural Deficiencies

ObjectiveTo describe a comprehensive decision-making process for surgical correction of structural Velopharyngeal Dysfunction (VPD) following cleft palate repair and evaluate its efficacy.DesignRetrospective study.SettingTertiary care hospital.Patients300 consecutive patients with unilateral or bilateral cleft lip and palate (CLP) or isolated cleft palate (CP) diagnosed with clinical VPD following cleft palate repair between 2009 and 2014. Of these 206 patients had structural VPD and underwent surgical correction.InterventionsSurgical corrections were carried out according to the comprehensive two stage decision making process developed by the investigators. Step 1 of decision-making involved visualisation of the VP sphincter function by nasoendoscopy. This was followed by step 2 which involved per-operative identification of scarring, tissue loss, hypoplasia and other structural deficiencies in the soft palate and septal mucoperiosteum. The choice of operation was then made from a repertoire of interrelated and escalating surgical procedures consisting of palate revision and pharyngoplasties ranging from most anatomical to the least.Main outcome measuresEvidence of postoperative restoration of VP function on nasoendoscopy, evaluation of speech for hypernasality, understandability, acceptability and symptoms of obstructive sleep apnea.ResultsComplete VP closure was demonstrated in 94% of patients treated using this algorithm. There was significant improvement in all speech parameters (p < 0.00001).ConclusionOur comprehensive decision-making process is designed to effectively correct structural VPD according to the severity of structural and functional deficiencies in the soft palate and avoid over treatment.

Efficacy of Posterior Pharyngeal Wall Injection for Velopharyngeal Dysfunction in Adults

OBJECTIVE(S)

Posterior pharyngeal wall (PPW) injection is often employed to treat velopharyngeal deficiency (VPD). We sought to analyze the impact of PPW injection on severity of dysphagia and dysphonia.

METHODS

Retrospective chart review was conducted of patients undergoing PPW injection from 2018 to 2023 at a tertiary laryngology center. Effects on Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), soft palate closure on modified barium swallow, and auditory-perceptual measures of hypernasality and audible nasal air emission were analyzed.

RESULTS

67 PPW injections were performed in 29 patients (11 female). Mean age was 59.4 ± 17.0 years. Etiologies were head and neck cancer (n = 23) and neurologic conditions (n = 6). 30 PPW injections were performed concurrent with intervention on the upper esophageal sphincter (25 dilations, 3 myotomies, 2 botulinum toxin injections), and 8 with a glottic procedure (6 vocal fold injections, 2 thyroplasties). Change scores were 3.87 (-6.85 to -0.89, p = .012) for VHI-10 and -3.00 (-4.75 to -1.25, p = 0.001) for EAT-10. These were statistically different from 0 for the whole cohort but not in the subset of patients undergoing concurrent voice and/or swallow surgery. Soft palate closure scores tended to be better (but not statistically significant) on MBS after PPW injection. Hypernasality and audible nasal air emission both improved after injection.

CONCLUSION

PPW injection appears to have a therapeutic effect on dysphagia/dysphonia in patients with VPD; however, many patients have multifactorial impairment. Additional study is needed to determine benefit of PPW when performed in conjunction with other procedures in this complex patient population.

LEVEL OF EVIDENCE

4 (Case series) Laryngoscope, 135:605-613, 2025.

Levator Veli Palatini Muscle Ratio Is a Clinically Significant Anatomic Predictor for Velopharyngeal Surgical Need

ObjectiveVelopharyngeal insufficiency (VPI) poses challenges for normal speech production, often necessitating surgical intervention. Determining optimal candidates for surgery remains complex and requires a nuanced understanding of underlying anatomic factors contributing to VPI. This study aimed to identify anatomic predictors that drive surgical recommendations for VPI.DesignProspective observational cohort study.SettingPediatric tertiary care hospital.MethodsMagnetic resonance imaging data were acquired from 150 children (aged 4-17) to identify anatomic predictors of VPI and surgical need. Fourteen velopharyngeal variables were measured in the oblique coronal and midsagittal imaging planes. Calculations included differences in levator veli palatini (LVP) muscle angles of origin, mean extravelar length, differences between left and right extravelar segments, the VP Needs ratio, and a newly developed LVP ratio. Multivariate logistic regression models with k-fold cross validation were utilized to identify anatomic profiles predictive of VPI and receiving a surgical recommendation.ResultsThe models demonstrated high accuracy, sensitivity, and specificity. Among anatomic variables, the LVP ratio emerged as the strongest determinant of surgical need (β = 11.256, p < .001). Notably, an increase in the LVP ratio of 0.10 is associated with a 3.08-fold increase in the likelihood of receiving a surgical recommendation. LVP ratios above 1.0 were significant for both VPI classification and surgical need.ConclusionsThe LVP ratio significantly differentiates individuals with VPI and is predictive of surgical need for VPI management. Inclusion of the LVP ratio into clinical evaluations may refine patient stratification, enabling more precise surgical decision-making tailored to individual anatomic variations.

Management of Persistent Hypernasality After Pharyngeal Flap by Revision Palatoplasty With Use of MRI to Aid Surgical Decision Making

OBJECTIVE

Describe surgical decision making and outcomes in a series of patients with persistent VPI after pharyngeal flap placement that were all treated with revision palatoplasty.

DESIGN

Retrospective, case series.

PARTICIPANTS

Five patients with nonsyndromic cleft palate and persistent hypernasality following a pharyngeal flap. On MRI, 3 patients presented with an incohesive levator veli palatini muscle, and 4 patients had a pharyngeal flap that was below the palatal plane.

INTERVENTIONS

One patient underwent straight-line intravelar veloplasty (IVVP), 2 patients underwent pharyngeal flap take-down and IVVP, and 2 patients underwent pharyngeal flap take-down and palate lengthening with buccal myomucosal flaps.

MAIN OUTCOME MEASURE

Pre- and postoperative resonance.

RESULTS

Four of five patients (80%) achieved normal resonance 12 months postoperation.

CONCLUSIONS

Revision palatoplasty may be an effective approach for treating patients with persistent hypernasality following a pharyngeal flap. MRI may aid in surgical selection based on patient-specific anatomical findings.

Indications for Furlow Double-Opposing Z-Plasty in Patients with Velopharyngeal Insufficiency following 2-Flap Palatoplasty

BACKGROUND

Various surgical methods have been developed for treating velopharyngeal insufficiency (VPI); however, the choice of surgical treatment is controversial. The pharyngeal flap, which is commonly used, has a high success rate but frequently leads to airway complications. Furlow double-opposing Z-plasty (DOZ) does not deform the velopharyngeal port; therefore, it is expected to show good speech outcomes while reducing airway complications if an appropriate indication is noted. This study aimed to identify indications for DOZ in cases of VPI after palatoplasty.

METHODS

Nonsyndromic patients who underwent palatoplasty were prospectively followed from 2008 to 2016, and those diagnosed with VPI were treated with DOZ. Preoperative facial computed tomography (CT) and postoperative nasometric assessment results were examined. Surgical indication was set based on a 30% threshold value for postoperative nasalance.

RESULTS

Comparing the preoperative CT measurements of both groups, high need ratio (NR), wide width of the nasopharynx (WNP), and long velopharyngeal depth (VPD) were contributing factors to VPI occurrence ( P < 0.05). Analyzing preoperative CT and postoperative speech evaluation results, a linear relationship was observed between preoperative NR, WNP, and VPD and postoperative nasalance. In cases where NR was less than 0.81, WNP was less than 27.64 mm, and VPD was less than 20.34 mm, DOZ showed favorable outcomes ( P < 0.05).

CONCLUSIONS

Preoperative CT evaluation should be performed in patients with VPI. When WNP, VPD, and NR values are small, DOZ can achieve sufficient correction of VPI and reduce the risk of airway complications. In cases where the indication range is exceeded, the pharyngeal flap is considered.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Velopharyngeal dysfunction and speech-related characteristics in craniofacial microsomia: a retrospective analysis of 223 patients

This study aimed to document the prevalence, severity, and risk factors of velopharyngeal dysfunction (VPD) in craniofacial microsomia (CFM) and to analyse differences in VPD-related speech characteristics between CFM patients without cleft lip and/or palate (CL/P), CFM patients with CL/P, and CL/P patients without CFM (control). A total of 223 patients with CFM were included, of whom 59 had a CL/P. Thirty-four CFM patients had VPD, including 20 with a CL/P. VPD was significantly more prevalent in CFM with CL/P than in CFM without CL/P (odds ratio (OR) 4.1, 95% confidence interval (CI) 1.9-8.7; P < 0.001). Multivariate logistic regression showed a significant association between CL/P and VPD in CFM patients (OR 7.4, 95% CI 2.1-26.3; P = 0.002). The presence of VPD was not associated with sex, the laterality or severity of CFM. Speech problems related to VPD appeared to be similar among the different groups (CFM without CL/P, CFM with CL/P, CL/P without CFM). As 15.2% of all CFM patients and 8.5% of CFM patients without CL/P had VPD, it is proposed that all patients with CFM, with or without CL/P, should be assessed by a speech and language therapist for the potential risk of VPD.

Does Notching Along the Nasal Velar Surface During Nasopharyngoscopy Predict Discontinuity of the Underlying Levator Veli Palatini Muscle?

To determine the sensitivity and specificity of velar notching seen on nasopharyngoscopy for levator veli palatini (LVP) muscle discontinuity and anterior positioning.

Nasopharyngoscopy and MRI of the velopharynx were performed on patients with VPI as part of their routine clinical care. Two speech-language pathologists independently evaluated nasopharyngoscopy studies for the presence or absence of velar notching. MRI was used to evaluate LVP muscle cohesiveness and position relative to the posterior hard palate. To determine the accuracy of velar notching for detecting LVP muscle discontinuity, sensitivity, specificity, and positive predictive value (PPV) were calculated.

A craniofacial clinic at a large metropolitan hospital.

PARTICIPANTS

Thirty-seven patients who presented with hypernasality and/or audible nasal emission on speech evaluation and completed nasopharyngoscopy and velopharyngeal MRI study as part of their preoperative clinical evaluation.

Among patients with partial or total LVP dehiscence on MRI, presence of a notch accurately identified discontinuity in the LVP 43% (95% CI 22-66%) of the time. In contrast, the absence of a notch accurately indicated LVP continuity 81% (95% CI 54-96%) of the time. The PPV for the presence of notching to identify a discontinuous LVP was 78% (95% CI 49-91%). The distance from the posterior edge of the hard palate to the LVP, known as effective velar length, was similar in patients with and without notching (median 9.8 mm vs 10.5 mm, P = 1.00).

The observation of a velar notch on nasopharyngoscopy is not an accurate predictor of LVP muscle dehiscence or anterior positioning.

Models for Predicting Velopharyngeal Competence Based on Speech and Resonance Errors and Velopharyngeal Area Estimation

OBJECTIVE

To develop tools for predicting velopharyngeal competence (VPC) based on auditory-perceptual assessment and its correlation with objective measures of velopharyngeal orifice area.

DESIGN

Methodological study.

PARTICIPANTS AND METHODS

Sixty-two patients with repaired cleft palate, aged 6 to 45 years, underwent aerodynamic evaluation by means of the pressure-flow technique and audiovisual recording of speech samples. Three experienced speech-language pathologists analysed the speech samples by rating the following resonance, visual, and speech variables: hypernasality, audible nasal air emission, nasal turbulence, weak pressure consonants, facial grimacing, active nonoral errors, and overall velopharyngeal competence. The correlation between the perceptual speech variables and velopharyngeal orifice area estimates was analysed with Spearman's correlation coefficient. Two statistical models (discriminant and exploratory) were used to predict VPC based on the orifice area estimates. Sensitivity and specificity analyses were performed to verify the clinical applicability of the models.

RESULTS

There was a strong correlation between VPC (based on the orifice area estimates) and each speech variable. Both models showed 88.7% accuracy in predicting VPC. The sensitivity and specificity for the discriminant model were 92.3% and 97.2%, respectively, and 96.2% and 94.4% for the exploratory model.

CONCLUSION

Two predictor models based on ratings of resonance, visual, and speech variables and a simple calculation of a composite variable, SOMA (Eng. "sum"), were developed and found to be efficient in predicting VPC defined by orifice estimates categories based on aerodynamic measurements. Both tools may contribute to the diagnosis of velopharyngeal dysfunction in clinical practice.

Bilateral Buccal Flap Revision Palatoplasty to Correct Velopharyngeal Dysfunction: Perceptual Speech, Acoustic, and Aerodynamic Outcomes

BACKGROUND

The purpose of this study was to analyze perceptual, acoustic, and aerodynamic changes in speech and velopharyngeal function after bilateral buccal flap revision palatoplasty (BBFRP) in patients with repaired cleft palate.

METHODS

Ten consecutive patients ages 4 to 18 years with velopharyngeal dysfunction treated with BBFRP by a single surgeon were evaluated. Using a visual analog scale, nine blinded speech-language pathologists independently rated hypernasality, hyponasality, audible nasal emission, and speech acceptability. Measurements of the acoustic speech signal were used to quantify changes in hypernasality and nasal emission. The pressure flow technique was used to determine changes in velopharyngeal gap size.

RESULTS

Complete records were available for eight patients. After surgery, hypernasality decreased ( P < 0.001) and speech acceptability increased ( P < 0.001) significantly. Audible nasal emission was significantly reduced ( P < 0.001). Postoperative acoustic measures showed a reduction of nasal emission and nasalization. Velopharyngeal gap size significantly decreased after BBFRP ( P < 0.001), correlating with lower visual analog scale ratings of hypernasality ( P = 0.015). Hyponasality did not change significantly after surgery ( P = 0.964). No patient developed sleep-disordered breathing.

CONCLUSION

BBFRP resulted in a measurable improvement in hypernasal speech, audible nasal emission, and speech acceptability without significant changes in hyponasality or risk of obstructive sleep apnea.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Can MRI Replace Nasopharyngoscopy in the Evaluation of Velopharyngeal Insufficiency?

OBJECTIVE

To investigate whether flexible nasopharyngoscopy, when performed in addition to magnetic resonance imaging (MRI), influences the type of surgery selected or success of surgery in patients with velopharyngeal insufficiency (VPI).

DESIGN

Cohort study.

SETTING

A metropolitan children's hospital.

PATIENTS

Patients with non-syndromic, repaired cleft palate presenting for management of VPI.

INTERVENTIONS

MRI and nasopharyngoscopy or MRI alone for preoperative imaging of the velopharyngeal mechanism.

MAIN OUTCOME MEASURES

(1) Surgical selection and (2) resolution of hypernasality. All speech, MRI, and nasopharyngoscopy measurements were performed by raters blinded to patients' medical and surgical history.

RESULTS

Of the 25 patients referred for nasopharyngoscopy, 76% completed the exam. Of the 41 patients referred for MRI, the scan was successfully completed by 98% of patients. Completion of nasopharyngoscopy was significantly (p=0.01) lower than MRI. Surgical selection did not significantly differ (p=0.73) between the group receiving MRI and nasopharyngoscopy and the group receiving MRI alone, nor was there a significant difference between these groups in the proportion of patients achieving resolution of hypernasality postoperatively (p=0.63). Percent total velopharyngeal closure assessments on nasopharyngoscopy and MRI were strongly correlated (r=0.73).

CONCLUSIONS

In patients receiving MRI as part of their preoperative VPI evaluation, the addition of nasopharyngoscopy did not result in a difference in surgical selection or resolution of hypernasality. Routine inclusion of nasopharyngoscopy may not be necessary for the evaluation of velopharyngeal anatomy when MRI is available.

Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates

Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.

Velopharyngeal Inadequacy-Related Quality of Life Assessment: The Instrument Development and Application Review

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.

Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques

BACKGROUND

The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors.

METHODS

A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age.

RESULTS

Mean perceptual scores improved significantly postoperatively (p < .0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p < .001, p < .02], [audible nasal emissions: p < .002, p < .05], [velopharyngeal function: p < .001, p < .05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p < .001) or sphincter pharyngoplasty (66.7%, p < .001). No significant difference was identified in success rate based on syndrome or cleft status.

CONCLUSION

Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed.

Using Active-Phonation Cone-Beam Computed Tomography to Evaluate Pediatric Patients With Suspected Velopharyngeal Dysfunction, a Pilot Study

ABSTRACT

Velopharyngeal dysfunction (VPD) is described as the incomplete closure of the velopharyngeal port during a speech production. Nasopharyngoscopy and/or multiplanar videofluoroscopy have been utilized for decades to assess the degree and nature of the dysfunction. Cone-beam computed tomography (CBCT) is presented as an additional diagnostic tool, allowing for clear visualization of the affected structures and the ability to obtain accurate measurements (within 100 microns) of the involved anatomy and defect. This prospective pilot study aims to test the feasibility of using "active-phonation" CBCT to assess suspected VPD in the pediatric and young adult populations and compare the results to nasopharyngoscopy; the current standards of care.Six patients, ages 6 to 26 years, with suspected VPD, defined as the inability to completely close off the nasal airway during an oral speech, seen at an urban medical outpatient craniofacial care center, served as subjects for this pilot study. Each patient received a comprehensive speech evaluation and participated in both active-phonation CBCT and nasopharyngoscopy.Both active-phonation CBCT and nasopharyngoscopy revealed incomplete closure of the velopharyngeal port during a speech in all 6 patients (100%). Two patients (33%) were unable to tolerate a complete nasendoscopic examination. There was no difference between CBCT or nasopharyngoscopy in determining the presence of VPD and noting the severity on a 3-point scale, (P = 0.61) as judged by 4 experienced clinicians.As a functional imaging modality, active-phonation CBCT is a useful adjunct tool for accurate diagnosis of VPD and may be more easily tolerated during a thorough VPD assessment than nasopharyngoscopy. It also provides quantitative data that is useful to augment treatment optimization and surgical planning in this population. Further studies are needed to validate these results.

Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function

ABSTRACT

Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

Surgical Management of Velopharyngeal Insufficiency Due to Unilateral Oropharyngeal Agenesis in a Patient With Stickler Syndrome

Velopharyngeal insufficiency (VPI) results from defects interfering with closure of the velopharyngeal port. It can lead to many issues ranging from nasal regurgitation to severe speech abnormalities. Treatment is tailored to patient-specific etiology and severity, often involving surgical correction. A rare, and therefore seldom, described cause of VPI is isolated unilateral agenesis of the soft palate. We describe the case of a 2-year-old patient with Stickler syndrome possessing a unique anatomic presentation of this pathology, managed successfully with a unilateral pharyngeal flap.

Innovative Molecular and Cellular Therapeutics in Cleft Palate Tissue Engineering

Clefts of the lip and/or palate are the most prevalent orofacial birth defects occurring in about 1:700 live human births worldwide. Early postnatal surgical interventions are extensive and staged to bring about optimal growth and fusion of palatal shelves. Severe cleft defects pose a challenge to correct with surgery alone, resulting in complications and sequelae requiring life-long, multidisciplinary care. Advances made in materials science innovation, including scaffold-based delivery systems for precision tissue engineering, now offer new avenues for stimulating bone formation at the site of surgical correction for palatal clefts. In this study, we review the present scientific literature on key developmental events that can go awry in palate development and the common surgical practices and challenges faced in correcting cleft defects. How key osteoinductive pathways implicated in palatogenesis inform the design and optimization of constructs for cleft palate correction is discussed within the context of translation to humans. Finally, we highlight new osteogenic agents and innovative delivery systems with the potential to be adopted in engineering-based therapeutic approaches for the correction of palatal defects. Impact statement Tissue-engineered scaffolds supplemented with osteogenic growth factors have attractive, largely unexplored possibilities to modulate molecular signaling networks relevant to driving palatogenesis in the context of congenital anomalies (e.g., cleft palate). Constructs that address this need may obviate current use of autologous bone grafts, thereby avoiding donor-site morbidity and other regenerative challenges in patients afflicted with palatal clefts. Combinations of biomaterials and drug delivery of diverse regenerative cues and biologics are currently transforming strategies exploited by engineers, scientists, and clinicians for palatal cleft repair.

Characteristics of velopharyngeal dysfunction in 22q11.2 deletion syndrome: a retrospective case-control study

Objective

To identify and describe the dynamic features of velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome relative to patients with non-syndromic cleft palates.

Study design

Retrospective case-control study.

Setting

Pediatric tertiary care center.

Subjects and methods

A total of 30 children (aged 9–16 years) with VPD were included in this study. Fifteen children with a definitive diagnosis of 22q11.2 deletion syndrome requiring surgical VPD repair were included in the 22q11.2 deletion syndrome group. Fifteen age- and sex-matched children with non-syndromic cleft palate requiring surgical VPD repair were included in the non-syndromic cleft palate group for comparison. Velar displacement, lateral pharyngeal wall displacement, and lateral pharyngeal wall motion pattern data were extracted from preoperative Multiview Videofluoroscopy imaging studies of all children and compared across groups.

Results

Lateral pharyngeal wall displacement was found to be reduced in the 22q11.2 deletion syndrome group (U = 29.50, p = .001, r = .63). However, measures of velar displacement were not observed to differ between groups. Similarly, lateral pharyngeal wall motion pattern distributions were not found to differ across these two groups.

Conclusions

Velopharyngeal dysfunction in patients with 22q11.2 deletion syndrome showed differences in dynamic velopharyngeal function when compared to non-syndromic cleft palate patients. The current findings provide initial insights into the unique aspects of velopharyngeal dysfunction for patients with 22q11.2 deletion syndrome. These findings may guide further efforts directed toward understanding the dynamic velopharyngeal characteristics of this population and potentially optimize surgical management and functional outcomes.

Revision Surgery of the Cleft Palate

Cleft palate repairs often require secondary surgeries and/or revisions for a variety of reasons. The most common causes are symptomatic oronasal fistulas and velopharyngeal insufficiency. Complications from primary surgery, such as wound dehiscence, infection, and hematomas, contribute to the relatively high rate of revision surgery. Prevention of postoperative complications that may lead to fistula or velopharyngeal insufficiency is key, and many techniques have been described that have reportedly decreased the incidence of secondary surgery. Management varies depending on the nature of the fistulous defect and the type of velopharyngeal insufficiency. Numerous surgical options exist to fix this deficiency.

Brazilian-Portuguese Linguistic Validation of the Velopharyngeal Insufficiency Effects on Life Outcome Instrument

BACKGROUND

The purpose of this study was to conduct a linguistic validation of the velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for use in Brazilian-Portuguese patients with VPI.

METHODS

The original English version of the VELO instrument was translated into Brazilian-Portuguese, back-translated, and adapted among the Brazilian patients (n = 21) with VPI and their parents, based on the standardized guidelines for the cross-culture adaption process. Discrepancies in the forward and backward translation steps were computed. Comprehension rates were captured for each debriefing interview. The content validity index (CVI) per item (I-CVI) and of the scale (S-CVI universal agreement [S-CVI/UA] and averaging [S-CVI/Ave]) were calculated.

RESULTS

Reconciliation of the 2 forward translations and the comparison between the back translation and the original VELO version resulted in some item wordings with discrepancies which were reviewed by the research team (translators, expert committee, and original developers of instrument). Three rounds of cognitive interviews also led to some revisions of wording. Comprehension rates of patients and their parents were 60% to 100%, 80% to 100%, and 100% in the first, second, and third rounds of cognitive interviews, respectively. The I-CVI, S-CVI/AU, and SCI/Ave for the Brazilian-Portuguese VELO version were 0.83 (or higher), 0.83 (or higher), and 0.97, respectively.

CONCLUSIONS

The linguistic validation process of the VELO instrument created a cross-culturally equivalent Brazilian-Portuguese version for use in Brazilian-Portuguese speaking patients with VPI.

Age and Preoperative Velar Closure Ratio Are Significantly Associated With Surgical Outcome of Furlow Double-Opposing Z-Plasty in Palatal Re-Repair

PURPOSE

The patient selection criteria for Furlow double-opposing Z-plasty in palatal re-repair remain obscure. This study investigated whether patients' preoperative characteristics significantly affected the surgical outcome of Furlow double-opposing Z-plasty in palatal re-repair.

MATERIALS AND METHODS

We designed and implemented a case-control study nested in a cohort, which could be divided into 2 stages. In the first stage, a retrospective cohort study was performed to collect basic information and the preoperative status of the patients who would undergo Furlow double-opposing Z-plasty to correct velopharyngeal insufficiency after primary cleft palate repair. Eight predictor variables were included: age, gender, primary surgical technique, velopharyngeal closure pattern, velar movement, lateral pharyngeal wall movement, levator muscle orientation, and preoperative velar closure ratio. The outcome variable was postoperative velopharyngeal function described as velopharyngeal competence or velopharyngeal insufficiency. In the second stage, a case-control analysis was performed to explore the potential factors affecting the surgical outcome. Univariate and multivariate analyses were applied to examine the relationship between the predictor variables and surgical outcome.

RESULTS

The sample was composed of 83 patients and resulted in 54 velopharyngeal competence outcomes and 29 velopharyngeal insufficiency outcomes after surgery. Two predictors showed statistical significance: age and preoperative velar closure ratio. The possibility of postoperative velopharyngeal insufficiency in patients older than 14.5 years was 6 times higher than that in patients younger than 14.5 years. The possibility of postoperative velopharyngeal insufficiency in patients with preoperative velar closure ratios of 0.9 or greater was one fifth that in patients with preoperative velar closure ratios between 0.8 and less than 0.9.

CONCLUSIONS

The results of this study suggest that age and preoperative velar closure ratio are significantly associated with postoperative velopharyngeal insufficiency. Age was a risk factor in achieving good surgical outcomes, and the preoperative velar closure ratio remained a protective factor.

Evaluation of velopharyngeal function using high-speed cine-magnetic resonance imaging based on T2-weighted sequences: a preliminary study

The objective was to introduce a new technique for visualizing the three-dimensional (3D) movements of velopharyngeal-related muscles using high-speed cine-magnetic resonance imaging (MRI) based on T2-weighted sequences. The evaluation of phonation- and water swallowing-related events was performed in 11 healthy subjects. Specifically, whether cine-MRI could precisely visualize normal velopharyngeal function during these two events was examined. The 3D movements of the soft palate, superior pharyngeal constrictor muscles, and levator veli palatini muscles were visualized in all 11 subjects. A noteworthy finding was that the magnetic resonance signals of the superior constrictor pharyngeal muscles and the levator veli palatini muscles were significantly higher during phonation and during water swallowing than at rest. This initial study suggests that the 3D movements of velopharyngeal-related muscles can be successfully and precisely visualized without side effects. The magnetic resonance signal changes seen in the superior pharyngeal constrictor and levator veli palatini muscles using the technique described here should be useful to develop better methods of evaluation of velopharyngeal function.

The effect of hypertrophied tonsils on the velopharyngeal function in children with normal palate

OBJECTIVE

Tonsillar hypertrophy may affect velopharyngeal closure and speech resonance. The aim of this study was to assess the impact of hypertrophied tonsils on velopharyngeal function in children with normal palate and to measure the effect of tonsillectomy on velopharyngeal closure and speech resonance.

METHODS

Eighty seven children with hypertrophied tonsils and normal palate were subjected to tonsillectomy for indications other than speech problems. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech (APA) and nasometric assessment of nasalance was measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy.

RESULTS

Thirteen patients were excluded from the study because of associated adenoid hypertrophy. The mean baseline of APA scores showed insignificant changes postoperatively. However, significant postoperative changes of nasometric parameters were detected, and the overall postoperative nasalance score was improved for nasal and oral sentences. Also, improvement of velopharyngeal closure was observed postoperatively with accession of palatal mobility and significant increase in coronal closure pattern.

CONCLUSION

hypertrophied tonsils may impair velopharyngeal function in children with normal palate by hindering palatal elevation. Tonsillectomy is a beneficial procedure for such patients as it can improve the velopharyngeal closure and speech resonance.

Acquired Velopharyngeal Dysfunction: Survey, Literature Review, and Clinical Recommendations

PURPOSE

The aim of this study was to describe the clinical assessment recommendations for acquired velopharyngeal dysfunction (AVPD) and, through a literature review and online survey, summarize current practice patterns for evaluation and treatment pathway determination for this target population.

METHOD

An online survey to query current assessment procedures and treatment pathway recommendations for AVPD was developed. Following survey results, a literature review was completed to determine evidence-based recommendations for assessment procedures and intervention recommendations based on assessment findings. Literature search terms included the following: acquired velopharyngeal dysfunction, hypernasality, non-cleft velopharyngeal dysfunction, velopharyngeal dysfunction, velopharyngeal dysfunction AND iatrogenic, velopharyngeal dysfunction AND neurogenic, velopharyngeal dysfunction AND assessment OR evaluation, velopharyngeal dysfunction AND treatment OR intervention, velopharyngeal dysfunction AND practice patterns OR clinical guidelines, velopharyngeal insufficiency. Inclusion criteria were limited to practice patterns/recommendations for assessment and/or treatment recommendations for AVPD, English language articles published between 2000 and 2017, and peer-reviewed journals. Studies regarding solely congenital or cleft palate velopharyngeal dysfunction and intervention outcome studies were excluded. Forty articles met inclusionary criteria.

RESULTS

The online survey results indicated lack of consensus for AVPD assessment and treatment recommendation protocols, with 93% of respondents indicating the need for a clinical guide for developing treatment recommendations. The majority of recommendations were filtered into an algorithm for clinical decision making.

CONCLUSIONS

Clinical uncertainty among speech-language pathologists surveyed and the paucity of published clinical guidelines for assessing individuals with AVPD indicate the need for additional clinical research for this disorder, one that is heterogeneous and distinct from those with congenital velopharyngeal dysfunction. The proposed evidence-based clinical worksheet may assist in determining management for patients with AVPD and may serve as a starting place for validation of a clinical guideline.

Primary augmentation pharyngoplasty with calcium hydroxylapatite for treatment of velopharyngeal insufficiency: Surgical and speech outcomes

INTRODUCTION

Augmentation pharyngoplasty (AP) is a technique that may effectively treat velopharyngeal insufficiency (VPI), while avoiding typical short and long term surgical risks. This study seeks to determine if children with VPI treated by AP with calcium hydoxylapatite (CaHa) demonstrate clinically significant improvement in speech outcomes.

METHODS

Retrospective review (2012-2016) of prospectively collected database of children with VPI, cared for at a single tertiary children's hospital. Preoperative speech assessment, nasometry, and video nasendoscopy were used to identify patients with VPI treated by AP with CaHa. Demographics, surgical/speech outcomes, complications, novel surgical technique and follow-up were recorded. Main outcome measures included pre and postoperative nasality and perceptual speech assessments, based on the Pittsburgh Weighted Values for Speech (PWS).

RESULTS

17 patients treated with AP with CaHa, as initial primary treatment for VPI, were identified. 8 patients had cleft palate, 9 patients had isolated VPI. Mean age at treatment was 6.6 years, with no operative complications. Mean nasality scores before and after surgery were 3.2 vs. 0.5 (p < 0.001). Mean PWS before and after surgery were 9.7 vs. 2.1 (p < 0.001). Based on the PWS scoring, 4/8 of cleft patients (50%) and 8/9 of isolated patients (89%) achieved a competent/borderline competent nasopharyngeal valve. 17/17 of patients (100%) had improvement in nasality. Mean length of follow-up was 32.8 months (range 10-64 months).

CONCLUSION

In this largest series of patients to date, AP with CaHa is a safe, minimally invasive, enduring treatment for VPI in properly selected patients. Nasality and speech scores significantly improved, especially in patients with isolated VPI.

Speech outcomes following Sommerlad primary palatoplasty: Results of the Ghent University Hospital

OBJECTIVE AND SUBJECTS

Speech outcomes were described for 16 patients with cleft palate (mean age: 5.4 years) following Sommerlad primary palatoplasty performed by a single surgeon of the Ghent University Hospital. These speech outcomes were compared with those of an age and gender matched control group without cleft palate (mean age: 5.3 years).

METHODS

Speech intelligibility/distinctiveness, resonance, nasal airflow and articulation, were perceptually evaluated. Additionally, nasalance values and the NSI 2.0 were determined.

RESULTS

In seven patients, speech intelligibility/distinctiveness was disordered. Hypernasality was present in twelve participants, whereas nasal emission and nasal turbulence were perceived in thirteen and five patients respectively. Both perceptual and instrumental speech evaluations were significantly poorer in the patient group in comparison to the control group.

CONCLUSIONS

Patients still present with both obligatory and compensatory speech disorders following Sommerlad's palatoplasty. In the future, a Dutch speech assessment protocol will be developed in order to standardize follow-up of these patients and to allow for within-center and inter-center comparisons.

Treatment of Stress Velopharyngeal Incompetence With Injection of Hyaluronic Acid

Stress velopharyngeal incompetence (VPI) is a challenging clinical entity that can be managed by a variety of surgical and nonsurgical approaches. We describe the case of a clarinetist who presented with nasal air escape while playing. She had successful improvement in her symptoms after targeted injection of a hyaluronic acid compound to her posterior pharyngeal wall. Our objective is to describe the safety and efficacy of this technique, to emphasize the multidisciplinary management of patients with stress VPI, and to review the importance of both nasopharyngoscopy and videofluoroscopy in their evaluation.

The Role of the Velopharyngeal Sphincter in the Speech of Patients with Cleft Palate or Cleft Lip and Palate Using Perceptual Methods

BACKGROUND:

The velopharyngeal sphincter (VPS) plays the main role in speech formation. The cleft palate, due to the damage of the soft palate, leads to dysfunction of the velopharyngeal sphincter thus causing speech disorder.

AIM:

To establish a link between the nasal air escape and the perceptual symptoms in the speech of patients with cleft palate or cleft lip and palate using auditory-visual perceptual procedures for determining the influence the velopharyngeal dysfunction has on speech.

MATERIAL AND METHODS:

Twenty patients with speech disorders, out of which 10 have cleft palate or cleft lip and palate (experimental group), participated in the perceptual assessment by means of Czermak mirror fogging test for assessing the nasal air escape and Pittsburgh Weighted Speech Scale (PWSS) for assessing the probable nature of the velopharyngeal sphincter.

RESULTS:

The respondents with a considerable nasal air escape have a higher velopharyngeal inability, that is, probably incompetent nature of the velopharyngeal sphincter. There is a strong correlation between the nasal air escape and the probable nature of the velopharyngeal sphincter (the coefficient of linear correlation r = 0.9756). The calculated p-value is p = 0.000002.

CONCLUSION:

The perceptual speech symptoms and the nasal air escape provide unique insight into the state and role the velopharyngeal sphincter has in speech.

Velopharyngeal insufficiency treated with levator muscle repositioning and unilateral myomucosal buccinator flap

PURPOSE

Velopharyngeal insufficiency (VPI) is common (20-30%) after cleft palate closure. The myomucosal buccinator flap has become an important treatment option for velopharyngeal insufficiency; however, published studies all use bilateral buccinator flaps. This study assesses outcomes with a unilateral myomucosal buccinator flap that might result in less operating time and might prevent the need of a bite block and an extra procedure for division of the flap pedicle at a later stage.

MATERIALS AND METHODS

Forty-two consecutive patients who underwent a unilateral myomucosal buccinator flap procedure were retrospectively reviewed. Overall clinical judgment of speech, speech analysis, and velopharyngeal closure were evaluated by a multidisciplinary cleft palate team.

RESULTS

Median follow-up was 1.2 years. In 83% of patients, overall clinical judgment of optimal speech was obtained and thus no further velopharyngeal surgery was necessary. In 7 patients, further surgery was necessary, of whom 57% (4/7) had bilateral cleft lip-palate. Mean level of intelligibility improved significantly as evaluated by speech pathologists (2.5 ± 0.9 vs 3.5 ± 0.9; P < 0.0001) and by parents (2.1 ± 0.9 vs 3.2 ± 0.7; P < 0.0001). Mean level of resonance improved significantly (0.7 ± 0.9 vs 2.0 ± 1.0; P < 0.0001), and velopharyngeal closure improved in 83% postoperatively.

CONCLUSION

The unilateral myomucosal buccinator flap seems to be an effective and safe procedure and should become part of the armamentarium of cleft surgeons.

Lateralization of the Pharyngeal Flap for Treatment of Lateral Velopharyngeal Gap

Pharyngeal flap is usually used for treatment of velopharyngeal insufficiency (VPI); it is bridged between the posterior pharyngeal wall and the soft palate traversing the central part of the velopharyngeal port. The aim of this study was to assess the efficacy of lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap. Fifteen patients with VPI due to lateral velopharyngeal gap were subjected to closure of the gap by pharyngeal flap that was lateralized to fill the gap. Preoperative and postoperative assessment of velopharyngeal functions including flexible nasopharyngoscopy, auditory perceptual assessment (APA), and nasometric assessment were performed. Postoperatively, flexible nasopharyngoscopy showed complete velopharyngeal closure in all the patients, with significant improvement of speech parameters as measured by APA. Also, nasalance score showed significant improvement for oral and nasal sentences that was measured by nasometry. Lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap is an effective method; it improves the velopharyngeal closure and the speech of the patients.

Surgery for velopharyngeal insufficiency: The outcomes of the University Hospitals Leuven

OBJECTIVES

We reviewed the outcomes of patients who underwent a velopharyngoplasty and subsequent speech therapy for velopharyngeal insufficiency (VPI) to determine possible prognostic variables.

METHODS

During the period 2002-2010, 91 patients with VPI underwent a velopharyngoplasty (either the Honig velopharyngoplasty, the modified Honig velopharyngoplasty or the Hynes pharyngoplasty). Of these, 62 had complete data for long-term evaluation of speech outcome and analysis of variables potentially influencing this outcome. Speech outcome was assessed using five criteria that were evaluated pre- and postoperatively: hypernasality, nasal emission, facial grimacing, retro-articulation and glottal stops. The former two variables were transformed into a semi-objective nasality index (NI), the latter three variables were assembled to form a subjective articulation index (AI). Prognostic variables for outcome that were studied included age at velopharyngoplasty, associated 22q11.2 deletion syndrome, intervention type, primary or secondary surgery and pre-intervention speech therapy.

RESULTS

Before surgery, based on the NI, 15 patients had mild VPI and 44 patients had moderate to severe VPI. Postoperatively at 12 months, 46 patients had a good speech outcome (normal or mild VPI), 13 patients had moderate VPI and no more severe VPI was observed. The overall success rate of 78% after one year increased to 90% in the long-term (median 27 months) with further speech therapy. Patients without the diagnosis of 22q11.2 deletion syndrome had better speech outcomes than patients with the syndrome. No statistically significant effect of the age at velopharyngoplasty on speech outcome was found. No cases of sleep apnea syndrome were reported.

CONCLUSIONS

Our protocol of patient tailored surgical interventions and further postoperative speech therapy results in good speech outcomes, with no or only mild remaining VPI for the majority of patients. The correction of VPI is more difficult for the subgroup of patients with 22q11.2 deletion syndrome.

Furlow palatoplasty for previously repaired cleft palate with velopharyngeal insufficiency

OBJECTIVE

Velopharyngeal insufficiency (VPI) is a common complication after cleft palate repair, it may be due to lack of levator sling reconstruction and/or palatal shortening. Furlow palatoplasty has the advantages of retro-positioning of levator palati muscles and palatal lengthening. The aim of this study was to assess the efficacy of Furlow palatoplasty in the treatment of VPI in patients who undergone previous palatoplasty.

METHODS

Twenty-three children with post-palatoplasty VPI were included in the study. Furlow technique which was not used in the primary repair, has been used as a secondary corrective surgery. Preoperative and postoperative evaluation of velopharyngeal function was performed, using auditory perceptual assessment (APA) and nasometry for speech, and flexible nasopharyngoscopy for velopharyngeal closure.

RESULTS

Significant improvement of APA and nasalance score for oral and nasal sentences was achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure in 19 patients (82%) postoperatively.

CONCLUSION

Furlow palatoplasty is considered a useful treatment option for VPI in patients with previously repaired cleft palate, it improves the speech and velopharyngeal closure.

Comparação entre cirurgia do retalho faríngeo e esfincteroplastia: análise nasométrica e aerodinâmica

OBJETIVO: comparar o efeito do retalho faríngeo e da esfincteroplastia sobre a hipernasalidade da fala e o fechamento velofaríngeo no tratamento de indivíduos com insuficiência velofaríngea residual, por meio de avaliação instrumental. MÉTODOS: foram avaliados 30 pacientes, com fissura de palato±lábio reparada, submetidos à correção cirúrgica da insuficiência velofaríngea (15 com retalho faríngeo e 15 com esfincteroplastia), avaliados antes e, no mínimo, 1 ano após a cirurgia. A hipernasalidade foi estimada a partir dos escores de nasalância (correlato físico da nasalidade) obtidos por meio da nasometria, durante a leitura de 5 sentenças contendo, exclusivamente, sons orais, considerando como limite de normalidade o escore de 27%. O fechamento velofaríngeo foi aferido a partir da medida da área velofaríngea obtida por meio da técnica fluxo-pressão e foi classificado em: 0-4,9mm2=adequado; 5-19,9mm2=marginal e, >20mm2=inadequado. Diferenças entre as duas técnicas foram consideradas estatisticamente significantes ao nível de 5%. RESULTADOS: antes da cirurgia, os valores médios de nasalância foram de 43±8,4% e 45±14,2% e de área velofaríngea foram 51±35,4mm2, e 69±29,2mm2, para os grupos retalho faríngeo e esfincteroplastia, respectivamente. Após a cirurgia, os valores médios de nasalância reduziram para 27±10,1% e 31±14,2% e de área velofaríngea para 3,6±5,5mm2 e 24±32,7mm2 para os grupos retalho faríngeo e esfincteroplastia, respectivamente. A redução dos valores de nasalância e área velofaríngea foi estatisticamente significante nos dois grupos. CONCLUSÃO: estes resultados sugerem que o retalho faríngeo foi mais eficiente do que a esfincteroplastia na eliminação da hipernasalidade e adequação do fechamento velofaríngeo nos pacientes estudados.

Ressonância da fala após tratamento cirúrgico da insuficiência velofaríngea secundária à cirurgia ortognática

OBJETIVO:investigar o efeito da cirurgia corretiva da insuficiência velofaríngea sobre a ressonância da fala de indivíduos nascidos com fissura palatina que passaram a apresentar hipernasalidade, após a cirurgia ortognática.MÉTODOS:foram analisados os resultados da ressonância de 23 pacientes com fissura labiopalatina corrigida cirurgicamente que apresentavam ressonância oronasal equilibrada antes da cirurgia ortognática e foram submetidos à correção cirúrgica da insuficiência velofaríngea, devido ao aparecimento de hipernasalidade após a cirurgia ortognática. Os pacientes foram submetidos à avaliação perceptivo-auditiva da fala para classificação da hipernasalidade, em três situações: 3 dias antes e 5 meses, em média, após a cirurgia ortognática e, 13 meses, em média, após a cirurgia corretiva da insuficiência velofaríngea. A hipernasalidade foi classificada utilizando-se escala de 4 pontos: 1=ausência de hipernasalidade; 2=hipernasalidade leve; 3=moderada e 4=grave. Os escores de hipernasalidade nas três situações estudadas foram comparados por meio do teste de Friedman, com nível de significância de 5% e, posteriormente, pelo teste de Tukey para comparações múltiplas.RESULTADOS:do total de 23 pacientes, houve eliminação do sintoma de fala após a correção da insuficiência velofaríngea em 83% (19/23), sendo os escores médios de nasalidade antes da cirurgia ortognática=1, após a cirurgia ortognática=3 e após a correção da insuficiência velofaríngea=1. Houve diferença estatisticamente significante entre as três situações estudadas (p<0,001).CONCLUSÃO:a cirurgia corretiva da insuficiência velofaríngea foi um tratamento efetivo na grande maioria dos casos que apresentaram hipernasalidade secundária à cirurgia ortognática, com retorno à condição de normalidade.

The Furlow Palatoplasty for Velopharyngeal Dysfunction: Velopharyngeal Changes, Speech Improvements, and Where They Intersect

Objective

We investigated how Furlow palatoplasty changes velopharyngeal morphology and speech characteristics, as well as how the anatomical and clinical results might be related. We hypothesized that Furlow palatoplasty would result in measurable velar elongation, tightening of the genu angle, and retropositioning of the levator sling and that the achievement of these modifications might be associated with clinical speech improvement.

Design

Retrospective analysis of preoperative and postoperative videofluoroscopic and speech data.

Setting

Tertiary care center.

Patients/Participants

A total of 29 patients with velopharyngeal insufficiency in the setting of previous cleft palate repair or submucous cleft palate.

Interventions

Furlow palatoplasty for treatment of velopharyngeal insufficiency.

Outcome Measures

Lateral videofluoroscopy and perceptual speech examination were conducted preoperatively and postoperatively in order to measure velopharyngeal dimensions and speech quality. We describe anatomical and speech changes associated with the Furlow palatoplasty and undertake an exploratory analysis of the relationship between surgical changes to the velopharynx and clinical outcomes.

Results

Furlow palatoplasty results in significant velar elongation, increased acuity of the genu angle, and retropositioning of the levator sling. Postoperative speech improvement was identified on the three subscales of resonance, nasal emission, and stops/plosives. Speech improvement and the absence of need for reoperation were most consistently associated with tightening of the genu angle.

Conclusions

Furlow palatoplasty lengthens the palate, while both tightening and retropositioning the levator sling. These changes reflect transverse recruitment of lateral velar tissues, along with transverse tightening and anterior release of the muscle fibers, respectively. Levator tightening is most consistently associated with improved speech outcomes.

Instrumental assessment of velopharyngeal function and resonance: a review

The purpose of this literature review is to describe and discuss instrumental assessment techniques of the velopharyngeal function in order to diagnose velopharyngeal disorders and resonance characteristics. Both direct and indirect assessment techniques are addressed, in which successively nasopharyngoscopy, videofluoroscopy, magnetic resonance imaging (MRI), cephalometric radiographic analysis, computed tomography (CT), ultrasound, acoustic and aerodynamic measurements are considered. Despite the multiple instrumental assessments available to detect and define velopharyngeal dysfunction, the ideal technique is not yet accessible. Therefore, a combination of different quantitative parameters can possibly form a solution for a more reliable determination of resonance disorders. These multi-dimensional approaches will be described and discussed. The combination of quantitative measurement techniques and perceptual evaluation of nasality will probably remain necessary to provide sufficient information to make appropriate decisions concerning the diagnosis and treatment of resonance disorders.

LEARNING OUTCOMES

The reader will be able to describe and discuss currently available instrumental techniques to assess the velopharyngeal mechanism and its functioning in order to diagnose velopharyngeal disorders. Additionally, he will be able to explain the possible advantages of the combination of several types of complementary measurement techniques.

Submucous Cleft Palate: A Systematic Review of Surgical Management Based on Perceptual and Instrumental Analysis

Objective

Submucous cleft palate (SMCP) is a congenital condition associated with abnormal development of the soft palate musculature. In a proportion of cases, this results in velopharyngeal insufficiency (VPI), the treatment for which includes pharyngeal flap surgery, pharyngoplasty, and palate reconstruction. The aim of this paper is to determine whether there is superiority of one or more types of surgical procedure over the others in improving speech in patients with VPI secondary to SMCP.

Methodology

Nine databases, including MEDLINE and EMBASE, were searched between inception and January 2013 to identify articles published relating to the surgical management of SMCP. Only studies that reported outcome measures for postoperative speech were included in the systematic review.

Results

Twenty-six studies analyzing the outcomes of surgery for VPI in patients with SMCP met the inclusion criteria. In these studies, speech outcomes were measured either in a binary fashion (i.e., normal speech or evidence of VPI) or using scales of VPI severity. Of the 26 studies, only two utilized blinded speech assessment, and 12 included both preoperative and postoperative speech assessment.

Conclusions

The review found little evidence to support any specific surgical intervention. This is in large part due to the inclusion of mixed etiologies within study populations and the lack of unbiased validated preoperative and postoperative speech assessment. Further methodologically rigorous studies need to be conducted to provide a secure evidence base for the surgical management of SMCP.

A Delphi survey on diagnosis and management of stress velopharyngeal insufficiency in wind musicians

The aim of this study was to identify current trends in clinical assessment and management of stress velopharyngeal insufficiency (VPI) in wind musicians. This was an online two-round Delphi survey of health practitioners familiar with assessing and treating musicians with stress VPI. Fourteen specialists (seven otolaryngologists and seven speech-language pathologists) from four countries participated in the Delphi survey. From the first round questionnaire, 32 items were identified as being causes, assessment tools, diagnostic indicators, and treatment methods for stress VPI. The second round questionnaire revealed that prolonged exposure to high intra-oral pressures was important in determining the cause of stress VPI. The most important assessment tools for stress VPI were case history and nasendoscopy. The most important indicator for stress VPI was self-reported symptoms. There was no clear agreement identified on the management methods for stress VPI for musicians. However, the trend followed by most of the survey participants was a combination of conservative management approaches (including rest or watch and wait, speech-language pathology intervention, velopharyngeal muscle training, and changes to the instrument or reed), and then, if symptoms persist, to use injection pharyngoplasty or pharyngeal flap. This survey demonstrates that no standard management protocol currently exists for musicians diagnosed with stress VPI, but provides current trends in the assessment and management which can be used in future guidelines for health professionals who treat wind musicians.

Surgical outcome of pharyngeal flap surgery and intravelar veloplasty on the velopharyngeal function

PURPOSE

To investigate the postoperative outcomes of pharyngeal flap surgery (PF) and secondary palatoplasty with intravelar veloplasty (IV) in the velopharyngeal insufficiency management regarding nasalance scores and velopharyngeal area.

METHODS

Seventy-eight patients with cleft palate±lips submitted to surgical treatment for velopharyngeal insufficiency, for 14 months on an average, were evaluated: 40 with PF and 38 with IV, of both genders, aged between 6 and 52 years old. Hypernasality was estimated by means of nasalance scores obtained by nasometry with a cutoff score of 27%. The measurement of velopharyngeal orifice area was provided by the pressure-flow technique and velopharyngeal closure was classified as: adequate (0.000-0.049 cm²), adequate/borderline (0.050-0.099 cm²), borderline/inadequate (0.100-0.199 cm²), and inadequate (≥0.200 cm²).

RESULTS

Absence of hypernasality was observed in 70% of the cases and adequate velopharyngeal closure was observed in 80% of the cases, in the PF group. In the IV group, absence of hypernasality was observed in 34% and adequate velopharyngeal closure was observed in 50% of the patients. Statistically significant differences were obtained between the two techniques for both evaluations.

CONCLUSION

PF was more efficient than the secondary palatoplasty with IV to reduce hypernasality and get adequate velopharyngeal closure.

Cadaveric study of the posterior pedicle nasoseptal flap: a novel flap for reconstruction of pharyngeal defects and velopharyngeal insufficiency

BACKGROUND

The posterior pedicle nasoseptal flap has been the workhorse for endoscopic reconstruction of medium to large cranial base defects, with excellent outcomes and minimal flap failures. The authors present the anatomical foundations for the use of the nasoseptal flap for reconstruction of soft palate and pharyngeal defects and for surgical treatment of velopharyngeal insufficiency in a cadaveric model.

METHODS

Posterior pedicle nasoseptal flaps were endoscopically harvested and transposed to the naso/oropharynx in seven cadavers. The reach and relationships of the flap with nasopharyngeal and oropharyngeal structures were documented.

RESULTS

A total of nine nasoseptal flaps (bilateral in two specimens) were transposed into the nasopharynx and oropharynx. The most anterior aspect of the flap was visualized transorally several millimeters inferior to the soft palate in all specimens. Six flaps were sutured transorally to the posterior pharyngeal wall and three were sutured to defects of the soft palate. The width of a fully harvested flap (entire septal mucosa) was more than twice the width of the posterior nasopharyngeal/oropharyngeal wall in all specimens. Nasoseptal flaps were easily tailored endoscopically and transorally with standard instrumentation to fit the defects.

CONCLUSIONS

In a cadaveric model, the nasoseptal flap can be transposed into the nasopharynx and upper oropharynx and is a potential alternative for pharyngeal reconstruction and surgical treatment of velopharyngeal insufficiency in patients in whom traditional flaps are not available. The application of this technique for reconstruction of pharyngeal and velar defects is novel, and further studies evaluating clinical outcomes are needed.