Management Of Velopharyngeal Dysfunction Research Articles

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 2: Speech Fundamentals and Perceptual Speech Assessment.

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. The gold standard for diagnosis is auditory-perceptual speech evaluation by a specialized speech-language pathologist. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism, (2) fundamental speech terminology and principles of perceptual speech assessment for VPD, and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 2, the authros begin with the concepts and terminology required to understand the perceptual speech assessment of VPD, including resonance, articulation, and the differentiation between consonants and vowels. We review the types of speech samples used for evaluation such as single-word articulation tests, syllable repetition, sentence repetition, and spontaneous connected speech. Finally, we discuss the auditory-perceptual speech assessment for VPD, including the assessment of resonance, nasal air emission, articulation, and voice quality. The use of rating scales like the Pittsburgh Weighted Speech Scale (PWSS) and the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) is highlighted. In addition, the significance of intraoral examinations, visual-tactile-auditory evaluations, and the assessment of voice quality are covered. Most textbook chapters discussing this topic assume a foundational knowledge of speech-language pathology, which a surgical trainee may lack. This study aimed to bridge the gap between surgical training and speech pathology, providing a comprehensive resource to enhance the understanding and management of VPD.

What's New in Cleft Palate and Velopharyngeal Dysfunction Management: An Update.

After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.

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

To describe a comprehensive decision-making process for surgical correction of structural Velopharyngeal Dysfunction (VPD) following cleft palate repair and evaluate its efficacy. Retrospective study. Tertiary care hospital. 300 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. Surgical 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. Evidence of postoperative restoration of VP function on nasoendoscopy, evaluation of speech for hypernasality, understandability, acceptability and symptoms of obstructive sleep apnea. Complete VP closure was demonstrated in 94% of patients treated using this algorithm. There was significant improvement in all speech parameters (p < 0.00001). Our 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.

"Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction."

Velopharyngeal dysfunction is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of velopharyngeal dysfunction (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of velopharyngeal dysfunction. Here, we investigate the effectiveness of buccal myomucosal flaps in the treatment of velopharyngeal dysfunction. A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016-2021. Pre- and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which velar closing ratio was obtained. A total of 25 patients underwent buccal myomucosal flap procedures for velopharyngeal dysfunction at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% vs 50%, p<0.001) and improved speech scores (p<0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea. :' Treatment of velopharyngeal dysfunction with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been utilized for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomic velar muscle correction for patients with a larger preoperative velopharyngeal gap.

Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients.

Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients. An academic tertiary pediatric care center. Retrospective cohort study. Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL). The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS). 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05). Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.

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

BackgroundThe 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.MethodsA 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.ResultsMean 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.ConclusionOperative 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.Graphical abstract

Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes.

The Furlow palatoplasty is a proven procedure in the management of secondary velopharyngeal dysfunction in patients with cleft palate. But the selection of cases, the degree of clinical success, and the preoperative predictors of the same are less established. This study is an effort to retrospectively look at outcomes, in a large series of velopharyngeal dysfunction cases treated with the Furlow palatoplasty alone. Retrospective analysis of preoperative and postoperative speech and videofluoroscopic data. Tertiary care center. Ninety-two patients who were diagnosed with velopharyngeal dysfunction post primary cleft palate repair. Furlow palatoplasty for velopharyngeal dysfunction post primary cleft palate repair. Variables analyzed were perceptual speech parameters and, closure ratios obtained from lateral video-fluoroscopic images. Overall, 81.5% had postoperative improvements in their lateral video-fluoroscopic parameters, 63% improved their nasality scores, and 65.2% had improved speech intelligibility. A simple linear regression was done to predict the postoperative closure ratio. Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative closure ratio. The Furlow palatoplasty alone led to complete resolution, or significant improvement of velopharyngeal dysfunction in a majority of patients, despite the cohort having a wide range of severity in terms of degree of dysfunction. The predictive formula will be validated in a further study.

Core Outcome Set for Reporting Outcomes of Interventions for Velopharyngeal Dysfunction: Final Results of the COS-VPD Initiative

Objective To date, the recording of outcomes of interventions for velopharyngeal dysfunction (VPD) has not been standardized. This makes a comparison of results between studies challenging. The aim of this study was to develop a core outcome set (COS) for reporting outcomes in studies examining the management of VPD. Design A two-round Delphi consensus process was used to develop the COS. Patients, Participants The expert Delphi panel comprised patients and caregivers of patients with VPD, surgeons and speech and language therapists specializing in cleft palate, and researchers with expertise in VPD. Interventions A long list of outcomes was derived from the published literature. In each round of a Delphi survey, participants were asked to score outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations scale of 1 to 9, with 1 to 3 labeled “not important,” 4 to 6 labeled “important but not critical,” and 7 to 9 labeled “critical.” Main outcome measure Consensus criteria were specified a priori. Outcomes with a rating of 75% or more of the panel rating 7 to 9 and 25% or fewer rating 1 to 3 were included in the COS. Results A total of 31 core outcomes were identified from the Delphi process. This list was condensed to combine topic areas to produce a final COS of 10 outcomes, including both processes of care and patient-reported outcomes that should be considered for reporting in future studies of VPD. Conclusions Implementation of the COS-VPD will facilitate consistency of outcomes data collection and comparison of results across studies.

1. Surgical Management of Velopharyngeal Dysfunction in Patients with Cleft Palate: A Systematic Review

1. Surgical Management of Velopharyngeal Dysfunction in Patients with Cleft Palate: A Systematic Review

Protocol for the development of a core outcome set for reporting outcomes of management of velopharyngeal dysfunction

IntroductionVelopharyngeal dysfunction (VPD) is present in up to 40% of patients following cleft palate repair. Children with VPD display hypernasal speech, nasal air emission and are at a high risk...

Management of velopharyngeal dysfunction in patients with 22q11.2 deletion syndrome: A survey of practice patterns

ObjectiveTo determine demographics and practice patterns of surgeons treating velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome (22q11.2DS). MethodsAn anonymous electronic survey study was administered to the surgical membership of the American Cleft Palate-Craniofacial Association and the Society for Ear Nose and Throat Advances in Children. The survey queried surgeon demographics and differences in management practices for submucous cleft palate (SMCP), pharyngoplasty algorithms, and self-reported complications for nonsyndromic versus 22q11.2DS patients. Results126 surveys were returned from 9 international regions with the majority from the United States (73%), followed by Western Europe (9.5%) and Canada (7.9%). Plastic surgery was the most common specialty (61.9%), followed by otolaryngology (27.8%). 88.1% reported fellowship training, and 33% completed multiple fellowships. Prior to proceeding with pharyngoplasty in 22q11.2DS patients, surgeons required the following assessments: speech evaluation (79.4%), velopharyngeal imaging (51.6%), cardiac evaluation (50.0%), carotid artery MRI (29.4%), and cervical spine x-rays (11.1%). Nasoendoscopy was the most common modality used for imaging the velopharynx. Overall, providers managed patients with 22q11.2DS similarly to nonsyndromic patients, with several significant exceptions including that they were more likely to perform SMCP repair alone as a first approach in nonsyndromic patients (p = 0.031) and posterior pharyngeal flap without SMCP repair in those with 22q11.2DS (p = 0.017). ConclusionsPractice patterns for the management of VPD in patients with 22q11.2DS vary across providers. Further collaborative studies are needed to develop optimal treatment paradigms for VPD in patients with 22q11.2 DS.

What's New in Cleft Palate and Velopharyngeal Dysfunction Management?

After studying this article, the participant should be able to: 1. Have a clear understanding of the evolution of concepts of velopharyngeal dysfunction, especially as it relates to patients with a cleft palate. 2. Explain the subjective and objective evaluation of speech in children with velopharyngeal dysfunction. 3. On the basis of these diagnostic findings, be able to classify types of velopharyngeal dysfunction. 4. Develop a safe, evidence-based, patient-customized treatment plan for velopharyngeal dysfunction founded on objective considerations. Velopharyngeal dysfunction is improper function of the dynamic structures that work to control the velopharyngeal sphincter. Approximately 30 percent of patients having undergone cleft palate repair require secondary surgery for velopharyngeal dysfunction. A multidisciplinary team using multimodal instruments to evaluate velopharyngeal function and speech should manage these patients. Instruments may include perceptual speech analysis, video nasopharyngeal endoscopy, multiview speech videofluoroscopy, nasometry, pressure-flow, and magnetic resonance imaging. Velopharyngeal dysfunction may be amenable to surgical or nonsurgical treatment methods or a combination of each. Nonsurgical management may include speech therapy or prosthetic devices. Surgical interventions could include palatal re-repair with repositioning of levator veli palatini muscles, posterior pharyngeal flap, sphincter pharyngoplasty, or soft palate or posterior wall augmentation. Treatment interventions should be based on objective assessment and rating of the movement of lateral and posterior pharyngeal walls and the palate to optimize speech outcomes. Treatment should be tailored to specific anatomical and physiologic findings and the overall needs of the patient.

Craniofacial structure variations in patients with palatal anomalies and velopharyngeal dysfunction.

Cephalometric evaluation of craniofacial and craniopharyngeal morphology is important for understanding the factors affecting velopharyngeal dysfunction (VPD) in patients with palatal anomalies. In this study, 366 patients with VPD were retrospectively stratified into cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP groups. Lateral cephalometrics were used to assess craniofacial, craniopharyngeal, and velopharyngeal anatomy. The average craniofacial morphology in patients with VPD differed significantly according to the type of palatal anomaly. The non-CP and OSMCP groups differed from the CLP, CP, and SMCP groups in nasopharyngeal size and shape as depicted by a larger ANS-Ptm-Ve angle, a smaller S-N-Ba and NBa-PP angles, and a shorter linear value of S-Ar in the non-CP group. The CLP and CP groups had shorter ANS-Ptm, shorter Ptm-P, and smaller SNA and SNB angles. VPD patients with overt clefts have different skeletal and nasopharyngeal shapes compared to non-CP and OSMCP. Velopharyngeal function assessment should include the size and shape of the nasopharyngeal space in addition to the size and the activity of the velum and posterior and lateral walls of the nasopharynx. This should enable a more precise understanding of VPD pathology, and lead to improvements in the posterior pharyngeal flap technique in order to obtain better postoperative speech outcomes after surgical management of velopharyngeal dysfunction.

The Buccinator Mucomuscular Flap: An In-Depth Analysis and Evaluation of Its Role in the Management of Velopharyngeal Dysfunction.

A significant proportion of patients with cleft palate experience persisting velopharyngeal dysfunction (VPD) after primary surgery. Pharyngoplasty is the most common procedure to correct inadequate velopharyngeal closure. Although it is often effective, it poses a risk for postoperative airway obstruction. The mucomuscular buccinator flap is a more recent alternative: In the largest case series to date, we outline its use and evaluate its effectiveness in managing persistent VPD. Over 9 years, 103 buccinator flap procedures were performed by the Cambridge group to improve velar function. Clinical records were retrospectively assessed: 60 patients were analyzed by two expert speech and language therapists external to the group using the Cleft Audit Protocol for Speech-Augmented. In a subset of patients, the buccinator flap was interpolated between the limbs of a large mucosal Z-plasty. Consensus listening was undertaken, and interrater reliability was calculated for 24.17% of the cohort. The remaining samples were assessed by a single listener following calibrated consensus listening. There was a significant reduction in VPD (P < .001). Preoperatively, 68.5% of patients demonstrated marked VPD, falling to 24.1% postoperatively. The buccinator procedure demonstrated significant improvement for three of four individual speech parameters: hypernasality, passive cleft speech characteristics, and audible nasal emission. Overall, 13.5% of patients required further corrective speech surgery. The buccinator mucomuscular flap reliably and effectively improves velar function in the management of VPD and has low complication rates. We therefore recommend the use of the buccinator flap in primary surgical management of persisting VPD.

Surgical Considerations and Choices in the Management of Velopharyngeal Dysfunction

Determining the type of secondary surgical management to treat velopharyngeal dysfunction requires the incorporation of surgical indications and principles to the perceptual, acoustic/airflow, and imaging results of a comprehensive evaluation by a speech-language pathologist. In addition, how the specific type of surgical technique (primary and/or secondary) may affect velopharyngeal function also should be considered. The purpose of this paper is to consider three standard techniques commonly employed in speech surgery—Pharyngeal Flap; Sphincter Pharyngoplasty; and Furlow Double Opposing Z-Plasty—and provide examples of the specific imaging parameters that support the choice of surgical technique. In addition, information is provided regarding the characteristics of different primary surgical techniques for cleft palate which can influence velopharyngeal closure, given that the most common cause of velopharyngeal dysfunction seen in the clinic is a patient with a history of repaired cleft palate.

Surgical management of velopharyngeal dysfunction

Velopharyngeal insufficiency can be a postoperative sequela or congenital. Velopharyngeal insufficiency is defined as a degree of nasality that interferes with resonance quality and comprehensibility. The diagnosis and preoperative evaluation is contingent on collaborative evaluation between the surgeon and speech-language pathologist. A thorough history and a complete head and neck examination including a videotaped nasopharyngoscopy optimize planning. Although each patient varies greatly in their presentation, we provide a review of the most commonly implemented procedures to improve velopharyngeal insufficiency and the best way to recognize which will likely improve a patient’s condition based on preoperative evaluation.

A Novel Patient-Controlled Bidirectional Palatal Lift Appliance

Palatal lift appliances have a role in management of velopharyngeal dysfunction for immobile palates of adequate length where surgery is contraindicated. Conventional appliances involve acrylic/wire work adjustment over successive appointments until they can be tolerated without gagging. A novel appliance has been developed where the lifting plate is incrementally distalized by the patient and vertically adjusted to optimize soft palate positioning. The design, construction, and utility of the appliance, which was developed in Dundee Dental Hospital, are described. The subject was a 12-year-old boy with a variant of Moebius syndrome and velopharyngeal dysfunction. Previous pharyngoplasty had been carried out and further surgery was contraindicated. The appliance is constructed and fitted and the flexible spring arm is vertically adjusted to lift the soft palate. The screw is turned incrementally at home, extending the lifting plate posteriorly. Videofluoroscopy allows visualization of the appliance and soft palate positioning. The procedure improved soft palate positioning, as demonstrated by videofluoroscopy, and objective speech outcomes. The appliance was well tolerated and led to improved speech outcomes for the patient. Adjustments were quick and easy for both clinician and patient. Further studies are needed to definitively determine the efficacy of the appliance.

The buccinator mucomuscular flap: An in depth analysis and evaluation of its role in the management of velopharyngeal dysfunction

The buccinator mucomuscular flap: An in depth analysis and evaluation of its role in the management of velopharyngeal dysfunction

Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals

To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. The survey was distributed through E-mail lists for the American Cleft Palate-Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and "improved" speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.

Velopharyngeal Insufficiency and Cleft

Management of orofacial clefts requires a comprehensive approach to address the multifaceted aspects of possible aesthetic and functional deficits. Many children with cleft palate with or without cleft lip continue to have speech abnormalities that can affect socialization, education, and childhood development. An interdisciplinary cleft team ideally manages most orofacial clefts and can include members from the fields of facial plastic surgery, otolaryngology, speech and language pathology, pediatrics, nursing, audiology, genetics, oral surgery, orthodontics, dentistry, and social work. These teams follow a relatively established timeline and algorithm for each of the discrete steps of orofacial cleft treatment. Cleft lip repair is often performed after 3–5 months of age. Palatoplasty is delayed after 8–14 months of age. Speech and language pathology assessment and therapy are targeted as the vocabulary develops (2–5 years old). This special issue deals with the cleft surgeon and speech therapists role in treatment of velopharyngeal dysfunction (VPD), which is often related to velopharyngeal insufficiency (VPI). This lack of coordinated closure of the soft palate to the posterior pharyngeal wall is often a sequela of cleft palate, even after primary repair. One paper from this issue titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” reports on cephalometric differences between the skull base and velopharyngeal anatomy in patients with unilateral cleft lip and palate compared to normal controls. These data contribute to the existing literature of abnormal skull base anatomy and inclination in children with velocardiofacial syndrome, which often associated with VPD. The next paper titled “Noncleft velopharyngeal insufficiency: etiology and need for surgical treatment” analyzes those children with VPD without obvious orofacial clefting, and assesses the etiologies and potential treatment options. This allows for comparison to the traditional orofacial cleft-related VPD management. The velopharyngeal workup is often a coordinated assessment by the cleft surgeon and speech pathologists. It can include subjective assessment, which is the subject of the next two papers. First, the next paper titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” assesses the relationship between two speech assessment tools, Lyapunov exponents, and Nasalance scores in the presence of hypernasal speech. Furthermore, an additional paper titled “Assessment of single-word production for children under three years of age: comparison of children with and without cleft plate” presents a case-control testing of a single word assessment tool in children less than 3 years of age with cleft palate, which indentified speech differences in error patterns, consonants, articulation, and accuracy between children with and with clefts. Objective assessment of VPD also can include either fluoroscopic speech examination or nasopharyngoscopy to characterize the pattern of VPD and target a surgical goal. The next paper titled “Objective assessment of hypernasality in patients with cleft lip and palate with the nasalView system: a clinical validation study” assesses the validity and reliability of a new tool for hypernasality testing called NasalView. Speech and language therapy is instituted to address typical compensatory speech patterns seen in children with cleft palate (e.g., glottal stops). If hypernasal speech is not responsive to speech and language therapy, secondary speech surgery is warranted to address hypernasality in this time period. Surgical options may include a superiorly based pharyngeal flap, dynamic sphincter pharyngoplasty, or posterior pharyngeal wall augmentation. Occasionally, a palate-lengthening procedure (Furlow double-opposing Z-plasty) is performed. These procedures can limit nasal air emissions, but potential obstructive sleep apnea from excessive nasal obstruction is a risk. The risk of sleep apnea after surgically treating the velopharynx may be decreased if the tonsils and adenoids are addressed preemptively. Before pharyngeal flap surgery, some surgeons perform tonsillectomy to limit the potential variability of speech and airway changes that comes with fluctuating tonsillar hypertrophy, tonsillitis, or upper respiratory infections. The use of tonsillectomy in the face of VPI in children with cleft palate is somewhat controversial and is the topic of the last paper “Speech outcomes after tonsillectomy in patients with known velopharyngeal insufficiency”. The guest editors are pleased to present a collection of papers dealing with management of the speech-related difficulties in children with orofacial clefts. In this era of the expanding role of evidenced-based medicine, the effectiveness of treatments can only be monitored and improved by assessment with valid and consistent outcome measures, which are reviewed in this issue. Travis T. Tollefson David White James Brookes Steven Goudy