Posterior Pharyngeal Wall Augmentation Research Articles

Posterior pharyngeal wall augmentation in post-adenoidectomy velopharyngeal insufficiency

PurposeTo assess the efficacy of posterior pharyngeal wall augmentation using septal or conchal cartilages with other bulks—according to the persistent gap and the individual anatomy of each patient—in improving velopharyngeal function in patients who acquired persistent velopharyngeal insufficiency (VPI) post-adenoidectomy.MethodsObservational descriptive prospective case series of 24 patients (their ages ranged between 3 and 26 years) who developed persistent VPI post-adenoidectomy (more than 3 months) although they had normal speech resonance before adenoidectomy.ResultsThe present study demonstrated that statistically significant improvement in auditory perceptual assessment (APA) was found regarding all obligatory speech disorders and unintelligibility of speech. Significant improvement was observed in the degree of velar mobility, size of the persistent gap, and the gap distance between velum and posterior pharyngeal wall at rest and during phonation in post-operative evaluation versus pre-operative. A significant change was observed in the closure pattern of the velopharyngeal port (VPP) as all patients turned to coronal closure.ConclusionsPosterior pharyngeal wall augmentation could be used in VPI post-adenoidectomy up to 7 mm and lead to better speech outcomes. Also, it revealed that using conchal and/or septal cartilage as a graft regardless of the patient’s age is a safe procedure.

Management of noncleft velopharyngeal insufficiency.

Velopharyngeal insufficiency in the absence of an overt cleft-palate is a less common and often missed cause of a resonance disorder. The purpose of this manuscript is to provide the reader with an overview of the clinical assessment. Highlight the need for multidisciplinary involvement. Discuss the process of decision-making related to a repair and finally comment on the preoperative, intra-operative, and postoperative considerations. With the advent of small calibre videonasendoscopes, evaluation of the size, location, and closure pattern of the velopharyngeal gap has improved the surgeons' ability to provide a tailored repair. Evolutions in technique including posterior pharyngeal wall augmentation and buccal flap advancement in palatal lengthening have all increased the options available to the patient and treating team. Multidisciplinary assessment by trained specialist from speech and language pathology and surgery remain the cornerstone in the evaluation and management of this patient cohort. Many have a chromosomal anomaly that should be tested for and managed accordingly. These patients are often diagnosed late and have developed additional compensatory speech disorders that often need to be addressed following repair of the palate. Targeted thoughtful assessment will allow for a greater likelihood of successful repair.

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults

ObjectiveThe study aims to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in adults with velopharyngeal valve insufficiency (VPI). MethodsThe study included 23 patients with VPI (grade I, II, III), with ages ranging from 19 to 45 years. Six patients had previously undergone simple palatoplasty for cleft palate, 8 patients had previously undergone adenotonsillectomy and 9 patients had previously undergone uvulopalatopharyngoplasty (UPPP). The procedure was done by implanting a piece of autologous tragal cartilage in the posterior pharyngeal wall. Patients were followed up for 24 months postoperatively. The evaluation of percent of speech intelligibility and grade of the closure of the velopharyngeal valve using video-nasopharyngoscopy was evaluated preoperatively and postoperatively. ResultsHighly statistically significant improvement in the grade of the closure of the velopharyngeal valve (P = 0.009) and percent of intelligibility (P = 0.001) was found after surgery. There were no postoperative airway obstruction or sleep apnea. ConclusionAugmentation of the posterior pharyngeal wall using tragal cartilage is an effective, safe and physiological surgical procedure in the management of VPI in adults who suffered hypernasality following palatal and oropharyngeal surgeries.

Optimizing speech outcomes for cleft palate.

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate. The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics. According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

Management of Speech and Swallowing Disorders in Children with Oral Clefts

Cleft lip and palate are common congenital anomalies with significant implications for feeding, swallowing, and speech. If a cleft palate goes unrepaired, a child will have difficulty distinguishing nasal and oral sounds. Even following cleft palate repair, approximately 20 to 30% of nonsyndromic children have persistent hypernasal speech. This often occurs due to velopharyngeal dysfunction (VPD), a term describing failure of the soft palate and pharyngeal walls to seal the nasopharynx from the oropharynx during oral consonant production. The gold standard for diagnosis is perceptual examination by a trained speech pathologist, although additional diagnostic tools such as nasendoscopy are often used. Treatment options for VPD range from speech therapy to revision palatoplasty, sphincter pharyngoplasty, pharyngeal flap, and pharyngeal wall augmentation. Palatal prosthetics may also be considered for children who are not surgical candidates. Further research is needed to improve selection of diagnostic and treatment interventions and optimize speech outcomes for children with a history of oral cleft. This review contains 1 figure, 3 videos, and 58 references. Key words: Cleft lip and palate, hypernasal resonance, levator veli palatine, nasal emission, nasendoscopy, palatoplasty, pharyngeal flap, posterior pharyngeal wall augmentation, sphincter pharyngoplasty, velopharyngeal dysfunction

Assessment of outcomes and complications of posterior pharyngeal wall augmentation with dermal fat graft in patients with Velopharyngeal Insufficiency (VPI) after primary cleft palate repair: A pilot study

IntroductionMaterials used for posterior pharyngeal wall augmentation have been associated with important complications (exogenous materials) or variable and unpredictable durability (exogenous and endogenous materials); therefore, introducing a different material for augmenting the posterior pharyngeal wall seems necessary for reviving this relatively forgotten technique.The purpose of this study was to emphasize on the use of a material associated with minimal complications and maximum recovery and durability in correcting VPI and the use of evaluative adjuncts such as nasoendoscopy and videofluoroscopy to assess surgical outcomes. MethodsIn a pilot study, 24 patients underwent posterior pharyngeal wall augmentation with dermal fat graft harvested from the low crease abdominal region. Early and late complications, autologous graft durability in posterior pharynx, and speech improvement were assessed. ResultsThere was a significant improvement in hypernasality, nasal emission, and nasal grimace after posterior pharyngeal wall augmentation with dermal fat graft (p<0.0001). The authors observed no significant life-threatening complication. The most evident short-term complication was snoring, which occurred in five patients, and all relieved uneventfully. ConclusionThe authors believe that augmenting the posterior pharyngeal wall with dermal fat graft is effective in improving hypernasality in patients with moderate velopharyngeal gap size and relatively adequate velar motion. This method has minimal complication profile because of autologous tissue application.

Surgery for Velopharyngeal Dysfunction: A Systematic Review of Interventions and Outcomes.

This systematic review sought to evaluate the consensus in the literature regarding the surgical management of VPD and to determine whether a particular procedure results in superior speech outcome or less morbidity Design: A systematic review was carried out according to PRISMA-P guidelines. Systematic review software was used to facilitate 3-stage screening and data extraction by 2 reviewers. University teaching hospital. Studies that reported perceptual speech assessment or obstructive sleep apnea (OSA) in patients who had undergone surgery for VPD were included in the review. Four categories of surgery for VPD were examined-pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior pharyngeal wall augmentation. Perceptual speech assessment, need for further surgery, and occurrence of OSA were the outcomes of interest. Eighty-three relevant studies were identified, comprising data on 4011 patients. Pharyngeal flap was the most common procedure (64% of patients). Overall, 70.7% of patients attained normal resonance and 65.3% attained normal nasal emission. There was no notable difference in speech outcomes, need for further surgery, or occurrence of OSA across the 4 categories of surgery examined. Heterogeneous groups of patients were reported upon and a variety of perceptual speech assessment scales were used. There is a lack of consensus in the literature to guide procedure selection for patients with VPD. The development of a standardized minimum data set to record postoperative speech, OSA, and patient-reported outcomes is required.

Investigation of the speech results of posterior pharyngeal wall augmentation with fat grafting for treatment of velopharyngeal insufficiency

PurposeThe purpose of this study was to evaluate the speech results of posterior pharyngeal wall augmentation (PPWA) with fat grafting both in the early and late postoperative period, and to clarify the impact of the procedure concomitant with speech therapy. Materials and methodsThis is a prospective case-control study. The study involved 87 cleft palate ± cleft lip patients with velopharyngeal insufficiency (VPI) who has been treated with PPWA. Patients were separated into two groups according to age; the first group consisted of 49 pediatric participants between 6 and 12 years of age and the second group consisted of 38 adolescent participants between 13 and 18 years of age. Preoperative velopharyngeal function and articulation were compared postoperatively at the following time points: the 3rd month, 12th month, 18th month and 24th month. The velopharyngeal function was evaluated with regards to the velopharyngeal closure type and velopharyngeal closure amount, by using the pediatric flexible nasoendoscopy and the nasometer methods. In the nasometer evaluation, nasalance sores were measured by using nonsense syllables and meaningful sentences. The Ankara Articulation Test (AAT) (Ege et al., 2004) was used to detect compensatory articulation products secondary to VPI. Consonant production error types and frequencies were determined according the guidelines stated in the study of Hardin-Jones et al. (2009). These were Pharyngeal Fricatives – Posterior Nasal Fricatives/Stop Production, Glottal Stop Production, Middorsum Palatal Stop Production, Nasal Frictional Production, Posterior Nasal Frictional Production/Phoneme Specific Nasal Emission, use of Nasal Consonants for Oral Consonants, and Replacement of Trills. All the participants received concurrent speech therapy four times, twice in the post-operative period between 1 and 3 months and twice between 3 and 6 months. ResultsPPWA improved the speech performance from the 18th month to 24th month of the postoperative period. AAT assessment of the first group after 24 months comparing the post-PPWA with the preoperative data showed a highly significant decrease with regard to compensatory production errors and hypernasality; however, in the second group, the same comparison revealed a highly significant decrease in regard to the degree of hypernasality and a significant difference in terms of glottal articulation and pharyngealization of fricatives. A circular closure pattern was observed in 17 individuals with cleft palate at a rate of 70.6%. ConclusionPPWA with concurrent speech therapy is an acceptable surgical method to correct VPI and to improve speech performance.

POSTERIOR PHARYNGEAL WALL AUGMENTATION WITH MUSCULAR FLAP VERSUS MUSCULOMUCOSAL FLAP FOR CORRECTION OF VELOPHARYNGEAL INCOMPETENCE

This study was aimed to evaluate and compare the posterior pharyngeal wall augmentation using muscular flap versus musculomucosal flap for correction of velopharyngeal incompetence (VPI). Patients and methods: this study was conducted on twenty children (13 males and 7females) complaining from VPI with age ranging between 6.5 and 13 years with a mean of age 8.7 years. All patients were treated surgically using posterior pharyngeal wall augmentation. Patients were classified into two equal groups according to the type of flap technique used for posterior pharyngeal wall augmentation. Group I included10 patients (7 males and 3 females) were treated by muscular flap. Group II included10 patients (6 males and 4 females) were treated by musculomucosal flap. The preoperative and postoperative assessments for patients with VPI included clinical examination of the voice, nasopharyngoscopy and computed tomography (CT) scans. Results: Regarding clinical presentation (hypernasality and nasal regurgitation of fluid), all patients in both groups had no nasal regurgitation of fluid or food which represents 100%. As regard the overall nasalance results (Nasal sentence) measured by nasometry in both groups there was noticeable improvement. But when comparing overall nasalance results between both groups there was no significant difference .Competence and borderline closure was achieved in 65% for patients of both groups. The VP gap size reduction was achieved in both groups, however there was no significant difference regarding reduction of median VP gap size. Conclusion: At the end, as there no significant difference in the results of both groups: the myomucosal flap technique for posterior pharyngeal wall augmentation is simple and easier than the muscular flap technique and the posterior pharyngeal wall augmentation is a good technique for treatment of VPI

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for velopharyngeal valve insufficiency after repair of cleft palate in pediatric patients

PurposeThe aim of this study was to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in patients with velopharyngeal valve insufficiency (VPI) after simple palatoplasty for cleft palate.Patients and methodsThis study included 18 patients with postpalatoplasty VPI (grade 2 or 3), with ages ranging from 5 to 14 years. Patients were followed up for 24–48 months postoperatively. Percent of speech intelligibility and grade of closure of velopharyngeal valve with nasopharyngoscope were evaluated preoperatively and postoperatively.ResultsStatistically significant improvement in grade of closure of velopharyngeal valve (P=0.001) and percent of intelligibility (P=0.001) was found after surgery.ConclusionAugmentation of the posterior pharyngeal wall using tragal cartilage is a safe technique, with generally good surgical and phoniatric outcomes in the management of pediatric patients with grades 2 and 3 VPI after simple palatoplasty to overcome hypernasality.

Factors prognostic for phonetic development after cleft palate repair.

Palatoplasty is aimed to achieve normal speech, improve food intake, and ensure successful maxillary growth. However, the velopharyngeal function is harder to control than other functions. Therefore, many studies on the prognostic factor of velopharyngeal insufficiency have been conducted. This study aimed to evaluate the relationships between speech outcomes and multimodality based on intraoral and preoperative three-dimensional computerized tomographic (CT) findings. Among 73 children with cleft palate who underwent palatoplasty between April 2011 and August 2014 at Kyungpook National University Hospital (KNUH), 27 were retrospectively evaluated. The 27 cases were non-syndromic, for which successful speech evaluation was conducted by a single speech-language pathologist (Table 1). Successful speech evaluation was defined as performing the test three times in 6-month intervals. Three intraoral parameters were measured before and immediately after operation (Fig. 1). On axial- and coronal-view preoperative facial CT, 5 and 2 different parameters were analyzed, respectively (Figs. 2 and 3). Regression analysis (SPSS IBM 22.0) was used in the statistical analysis. Two-flap palatoplasty and Furlow's double opposing Z-plasty were performed in 15 and 12 patients, respectively. The operation was performed 11 months after birth on average. Children with a higher palatal arch and wider maxillary tuberosity distance showed hypernasality (p < 0.05; Table 2). The useful prognostic factors of velopharyngeal function after palatoplasty were palate width and height, rather than initial diagnosis, treatment method, or palate length. Therefore, a more active intervention is needed, such as orthopedic appliance, posterior pharyngeal wall augmentation, or early speech training.

ÇOCUKLARDA DAMAK YARIĞI ONARIMI SONRASI GÖRÜLEN VELOFARİNGEAL YETMEZLİK TEDAVİSİ

Velopharyngealcomplex separates the oral and nasal cavity closing towards the posterior pharyngeal wall. Velopharyngeal insufficiency (VFI) is often observed after cleft palate repair. Various surgical techniques including; Furlow palatoplasty, pharyngeal flap, Sphincter pharyngoplasty. and the posterior pharyngeal wall augmentation The most commonly used techniques are Furlow palatoplasty, pharyngeal flap, Sphincter pharyngoplasty and posterior pharyngeal wall augmentation. The surgical treatments of velopharyngeal insufficiency is aimed to form a more appropriate structure or function of velopharyngeal mechanism. The purpose of this study was to evaluate the efficiencies of the surgical techniques used for the treatment of velopharyngeal insufficiency seen after cleft palate repair

Posterior pharyngeal wall augmentation.

Posterior pharyngeal wall augmentation is a useful technique in selected patients with velopharyngeal insufficiency who have a small central velopharyngeal gap. Options for augmenting this region include using posterior pharyngeal wall flaps to create bulk and implanting various materials to fill in the central deficiency. Autologous and nonautologous implant materials are available and may be implanted through an incision or directly injected into the posterior pharyngeal wall. Previously described materials for implantation include cartilage, fat, fascia, silicone, acellular dermis, polytetrafluoroethylene, and calcium hydroxyapatite. Patient evaluation and surgical techniques for posterior pharyngeal wall augmentation are described.

Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency.

This study aimed to describe syndromes where preoperative imaging may be essential in determining the course of the carotid arteries before velopharyngeal insufficiency (VPI) surgery and therefore affect surgical planning. Records of children who underwent surgery for VPI between May 1, 2012, and October 30, 2013, at a tertiary care pediatric otolaryngology center were reviewed. Data collected included age at operation, preoperative and postoperative nasometry values, presence of underlying genetic disorders, and imaging findings. Twenty-five patients underwent 33 surgeries for VPI, with 1 posterior pharyngeal wall augmentation, 6 Furlow palatoplasties, 11 sphincter pharyngoplasties, and 15 pharyngeal flaps. Medialized carotid vasculature was identified in 5 of 25 patients (20%). Seven syndromic patients were identified, with 3 patients having 22q11.2 deletion syndrome. All patients (100%) with 22q11.2 deletion syndrome had medialized carotid arteries. Of the 4 additional syndromic children, 2 (50%) had medial internal carotid arteries, with 1 patient diagnosed with neurofibromatosis 1 and another with Prader-Willi syndrome. Both patients underwent Furlow palatoplasty. Whereas 22q11.2 deletion syndrome is recognized as an entity where a medial carotid is often present, other syndromic children may also demonstrate vascular variability. Although a larger study is needed to confirm an increased prevalence in these patients, clinicians may need a higher degree of suspicion while performing the physical examination. If examination findings are suggestive or the disease process may lend itself to this abnormality, vascular imaging can be considered as part of presurgical planning to help guide surgical technique and prevent complications.

Posterior Pharyngeal Wall Augmentation with Acellular Dermis Implant for Velopharyngeal Insufficiency

Objectives: Review outcomes for children with velopharyngeal insufficiency (VPI) after posterior pharyngeal wall augmentation with an acellular dermis implant. Methods: Retrospective case series of children with VPI who underwent augmentation pharyngoplasty from 2002-2011 at a tertiary care children’s hospital. The posterior pharyngeal wall was augmented with rolled acellular dermis inserted in the subfascial plane. Pre- and postoperative nasometry, speech nasal endoscopy, and caretaker and clinician perceptual evaluation were reviewed. Results: Twenty-four children with VPI (average age 8.8 ± 4.0 yrs) who underwent augmentation pharyngoplasty were identified. The majority of these children had a small gap noticed on speech nasal endoscopy. Of the 24 children, 5 were lost to follow-up and were not assessed in the postoperative period. Average follow-up for the remaining 19 patients was 17.6±20.9 months. Fifteen of the 19 patients (79%) had some improvement in VPI symptoms as determined by clinical perceptual evaluation, but only 8 children (42%) demonstrated complete resolution after the operation. One implant extruded. No major complications related to the surgical procedure were identified. Conclusions: We present a novel technique to treat VPI using an acellular dermis implant to augment the pharyngeal wall. Although this approach does not successfully treat all children with VPI, no major complications were seen in this series. Vital tissue that may be used for future speech surgery is preserved if this treatment option fails.

Cerclage and sphincter pharyngoplasty techniques for management of velopharyngeal insufficiency: How I do it?

AbstractThe activities of swallowing and speaking depend upon the ability to achieve adequate closure of the velopharyngeal (VP) port. Swallowing and speaking are complex motor skills that involve the coordination of diverse groups of muscles between the nasopharynx and oropharynx. Various conditions can affect VP closure function including an adenoidectomy operation. Defects in the VP sphincter can affect the patient’s speech in many ways–for example, induction of hypernasality, decreased speech intelligibility, and nasal emissions. Three main surgical approaches to VP corrective surgery can be used–namely, pharyngoplasty, pharyngeal flap, and posterior pharyngeal wall augmentation. The author of this study designed a new procedure called cerclage sphincter pharyngoplasty to be added for correction of VP insufficiency. Maximum benefit can be achieved when the surgical technique takes advantage of the remaining native VP closure. As pharyngeal flaps are not functional and have multiple drawbacks and because posterior pharyngeal wall augmentation is successful only in case of minor defects, the author focuses on functional techniques used for correction of different closure patterns and grades–namely, cerclage and sphincter pharyngoplasty.

Parental perceptions of posterior pharyngeal wall augmentation using autologous fat for treating velopharyngeal dysfunction

Posterior pharyngeal wall augmentation using autologous fat to treat velopharyngeal dysfunction (VPD) is an alternative surgical procedure to more commonly used invasive procedures such as the pharyngeal flap. However, limited research exists on this technique. The aim of this study was to qualitatively investigate parental perceptions of posterior pharyngeal wall augmentation using autologous fat when treating velopharyngeal dysfunction. Furthermore, this research aimed to examine parent's perspectives of their child's speech and quality-of-life following this procedure. A qualitative collective case study methodology was used in the form of semi-structured interviews with seven participants. These were then analysed using constant comparative analysis. Four distinct themes emerged: post-surgical outcomes; speech-language pathology, not just medicine; factors for successful post-operative speech and resonance; and long-term sustainability and worthiness of the procedure. Six out of seven participants expressed positive post-operative speech and resonance results. Five further expressed long-term satisfaction up to 6 years post-operatively. Overall the majority of participants were satisfied that this procedure provided their child with long-term successful speech outcomes. The participants also discussed the importance of receiving speech-language pathology services alongside surgery and the positive impact of the procedure on their child's quality-of-life including social interactions, confidence, friendships, as well as eating and drinking.

Velopharyngeal Dysfunction

Velopharyngeal dysfunction (VPD) is a generic term which describes a set of disorders resulting in the leakage of air into the nasal passages during speech production. As a result, speech samples can demonstrate hypernasality, nasal emissions, and poor intelligibility. The finding of VPD can be secondary to several causes: anatomic, musculoneuronal, or behavioral/mislearning. To identify the etiology of VPD, patients must undergo a thorough velopharyngeal assessment comprised of perceptual speech evaluation and functional imaging, including video nasendoscopy and speech videofluoroscopy. These studies are then evaluated by a multidisciplinary team of specialists, who can decide on an optimal course for patient management. A treatment plan is developed and may include speech therapy, use of a prosthetic device, and/or surgical intervention. Different surgical options are discussed, including posterior pharyngeal flap, sphincter pharyngoplasty, Furlow palatoplasty, palatal re-repair, and posterior pharyngeal wall augmentation.

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

Use of Porous Polyethylene Implant for Augmentation of the Posterior Pharynx in Young Adult Patients With Borderline Velopharyngeal Insufficiency

In the current study, we evaluated the efficiency of using porous polyethylene implant to correct velopharyngeal insufficiency (VPI) in young adult patients. Ten male patients with VPI, aged 21 to 27 years, underwent posterior pharyngeal wall augmentation with porous polyethylene implant. The evaluations for VPI on all patients in the study included speech evaluation of nasality and articulation, mirror test, nasopharyngoscopy, and magnetic resonance (MR) imaging. Evaluation of the methods for correcting VPI was done preoperatively and 6 months after surgery, and the results were compared. According to preoperative speech evaluation, 7 patients had severe hypernasal speech and 3 patients had moderate hypernasal speech. Follow-up evaluations demonstrated that 7 patients had normal speech without hypernasal resonance. Although all patients had nasal escape on mirror test preoperatively, only 2 had nasal escape postoperatively. When the preoperative and postoperative results of the Multi-Dimensional Voice Programme were analyzed, there was a statistically significant improvement in all parameters. The distance between the posterior pharyngeal wall and the velum during phonation observed preoperatively had disappeared in the postoperative period in all of the patients' sagittal-plane MR scans. In the axial views of the MR scans, the velopharyngeal gap area calculated preoperatively was reduced in the postoperative period. We conclude that posterior pharyngeal wall augmentation with porous polyethylene implant is an effective method in the correction of mild VPI in adult patients.