Treatment Of Velopharyngeal Insufficiency Research Articles

An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis.

Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature. This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications. The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases. Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.

Comparative analysis of speech outcomes in the treatment of velopharyngeal insufficiency: Traditional superior-based pharyngeal flap and pharyngeal flap combined with radical intravelar veloplasty

Comparative analysis of speech outcomes in the treatment of velopharyngeal insufficiency: Traditional superior-based pharyngeal flap and pharyngeal flap combined with radical intravelar veloplasty

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy.

To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes. A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI. A single academic center between January 2015 and January 2022. Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI. Simultaneous conversion Furlow palatoplasty and tonsillectomy. Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications. Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p = 0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p = 0.16). Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps.

The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.

Effect of Velopharyngeal Insufficiency on Long-Term Patient-Reported Sleep-Related Impairment in Patients With Cleft Palate

Objective: Velopharyngeal insufficiency (VPI) surgery in patients with cleft palate increases the risk for airway obstruction acutely. However, the long-term effects of VPI surgery on airway obstruction are unknown. In this work, we prospectively evaluated patient-reported sleep-related impairment scores as a screening tool for airway obstruction in patients with cleft palate (CP). Methods: Patients with CP > 14 years of age from 2 institutions were prospectively administered the Patient Reported Outcomes Measurement Information Systems sleep-related impairment short form. Patient characteristics, medical, and surgical histories were reviewed. Multivariable linear regression analyses were performed to assess the contribution of independent variables to sleep-related impairment scores. Results: Forty-four patients (mean age 20.5 ± 4.7 years) were included. Twenty-three patients (52.3%) were diagnosed with VPI. Seventeen patients (38.6%) underwent VPI surgery, of whom 14 patients (82.4%) were treated with sphincter pharyngoplasties at a mean age of 7.7 ± 4.1 years. Multivariable linear regression models to control for variables that could influence sleep-related impairment such as body mass index (BMI) ≥25 were developed to evaluate the contribution of VPI and VPI treatment. The diagnosis of VPI (β = .52, P = .004), VPI surgery (β = .48, P = .008), and sphincter pharyngoplasty (β = .47, P = .011) were found to independently predict sleep-related impairment in each of the respective regression models. Conclusions: A history of VPI, any type of VPI surgery, or sphincter pharyngoplasty were separately and independently predictive of patient-reported sleep-related impairment long-term. These data suggest that longitudinal airway obstruction screening in patients with cleft palate and VPI deserves consideration.

Customized Surgical Treatment of VPI with Pharyngeal Flaps Using Flexible Video Nasopharyngoscopy and Multiplanar Video Fluoroscopy

Objective: Speech is achieved through velopharyngeal competence—described as the complete closure of the velopharyngeal sphincter (VPS). Failure of complete closure of the VPS results in velopharyngeal insufficiency (VPI), which may severely interfere with intelligibility and quality of speech. VPI correction is not a one-size-fits all procedure, and this warrants the importance of customization that suits the individual patient’s anatomic and functional pathology. The purpose of this study is to determine whether customization of pharyngeal flaps—using a dynamic pre-procedural assessment—can achieve reliable and successful outcomes in the surgical treatment of VPI, despite differences in surgeon approach and technique. Methods: A total of 171 cases of VPI with pharyngeal flap surgery were reviewed between the ages of four and eighteen years. Four surgeons performed four different surgical techniques. All cases were evaluated preoperatively by a multidisciplinary team and underwent speech pathology evaluation, nasometry, multiplanar videofluoroscopy (MPVF) and flexible video nasopharyngoscopy (FVNP). Individualized preoperative planning was performed based on the findings. Results: 158 patients (92%) demonstrated overall successful correction of VPI with mean nasalance within normal limits following the surgical procedure. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a non-significant association between surgical technique and unsuccessful corrections. Conclusion: The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing superior pedicle pharyngeal flaps, high rates of success can be achieved when adequate surgical planning is based on imaging findings. Corresponding Author: Kongkrit Chaiyasate, 3555 W 13 Mile Rd #120, Royal Oak, MI, 48073, [email protected], 248-890-2515

Influence of speech aid prosthesis with speech therapy on speech outcomes in adult patients with persisting velopharyngeal insufficiency: A retrospective analysis

Statement of problemProsthetic intervention with a speech aid prosthesis (SAP) along with speech therapy has been reported to improve speech outcomes in patients with persisting velopharyngeal insufficiency (VPI). However, little is known regarding the impact of this treatment on different speech parameters over time in adult patients with VPI. PurposeThe purpose of this retrospective study was to evaluate the change in speech parameters after rehabilitation with an SAP and speech therapy in adult patients with VPI using subjective and objective tests. Material and methodsPatients above 16 years of age who had received prosthetic treatment for VPI and had complete speech assessment records between 2017 and 2020 were included in the analysis. After completion of the prosthetic treatment, speech therapy comprising 2 sessions per week of 45 minutes was provided by a speech pathologist. Speech evaluation was performed using tests that included speech intelligibility calculation, nasal pinch test, audible nasal air emissions, acoustic analysis, and the nasalance check. Assessments were done at 4 time intervals: T0: without an SAP; T1: 1 week with an SAP; T2: 1 month with an SAP; and T3: 3 months with an SAP. A descriptive analysis was followed by a comparison between groups using the Friedman test for subjective assessments and repeated measures ANOVA for objective tests (α=.05). ResultsOf 10 individuals who had received an SAP, 5 participants, 2 men and 3 women with a mean age of 38 years were included in the analysis. Statistically significant improvement in mean scores was observed from T0 to T3 concerning speech intelligibility (P<.001), hypernasality (P<.001), audible nasal air emission (P<.001), mean fundamental frequency (P=.034), shimmer percentage (P=.004), and nasalance (P=.004). Improvement in jitter percentage was not statistically significant (P=.218). ConclusionsAn SAP along with speech therapy should be considered as a conservative and effective treatment option for addressing speech issues in adult patients with VPI.

How Early Can We Predict the Need for VPI Surgery?

This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years. Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics. Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

Velopharyngeal Insufficiency Treatment in Cleft Palate Patients: Umbrella Review.

Velopharyngeal insufficiency may occur as a result of an anatomical or structural defect and may be present in patients with cleft lip and palate. The treatment options presented in the literature are varied, covering invasive and non-invasive methods. However, although these approaches have been employed and their outcomes reviewed, no conclusions have been made about which approach is the gold-standard. This umbrella review aimed to synthesize the current literature regarding velopharyngeal insufficiency treatments in cleft lip and palate patients, evaluating their effectiveness based on systematic reviews. A standardized search was carried out in several electronic databases, namely PubMed via Medline, Web of Science, Cochrane Library, and Embase. The quality of the included studies was evaluated using AMSTAR2 and degree of overlap was analyzed using Corrected Covered Area. Thirteen articles were included in the qualitative review, with only 1 in the non-invasive method category, and 12 in the invasive method category. All reviewed articles were judged to be of low quality. In symptomatic patients, treatment did not solely comprise speech therapy, as surgical intervention was often necessary. Although there was no surgical technique considered to be the gold standard for the correction of velopharyngeal insufficiency, the Furlow Z-plasty technique and minimal incision palatopharyngoplasty were the best among reported techniques.

Treatment of VPI with Customized Pharyngeal Flaps: One Size Does Not Fit All.

Background:Failure of complete closure of the velopharyngeal sphincter results in velopharyngeal insufficiency (VPI), which may severely interfere with speech. The pharyngeal flap remains a common procedure for correcting VPI. We aimed to study whether customization of pharyngeal flaps using a dynamic preprocedural assessment can result in successful outcomes in the surgical treatment of VPI, despite variations in surgical technique.Methods:This is a retrospective review of patients between the ages 4 and 18 years old with VPI who underwent surgical correction by one of four surgeons at our institution. All four surgeons used a superiorly based pharyngeal flap (SBPF) with slight variations in operative technique. All patients also received an evaluation by the speech and language pathologist that included nasometry, multiplanar videofluoroscopy, and flexible videonasopharyngoscopy. Individualized preoperative planning was performed based on the findings.Results:In total, 158 patients (92%) demonstrated overall successful correction of VPI, defined by a normal post-operative mean nasalance. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a nonsignificant association between surgical technique and unsuccessful corrections.Conclusions:The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing SBPF, high rates of success can be achieved when adequate surgical planning is based on imaging findings.

Precision Pharyngeal Flap: An Individualized, Patient-Specific Surgery for the Treatment of Velopharyngeal Insufficiency.

The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author. Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined. Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P < 0.01). Postoperative nasalance scores revealed sufficient postoperative resonance rating in 96% of patients. No patients experienced postoperative complications (bleeding, airway obstruction, and surgical wound dehiscence). Individually configured pharyngeal flaps designed based on preoperative nasopharyngoscopic examination coupled with precise surgical techniques led to the high surgery success rate for VPI treatment.

Role of Speech Aid Prosthesis as Diagnostic and Therapeutic Aid for Velopharyngeal Insufficiency Defect: A Case Report

Soft palate tumors pose the challenge during reconstructive and rehabilitating procedures. Surgical resection of these tumors leads to velopharyngeal insufficiency (VPI). The primary effects of VPI are hypernasality and air-flow escape, while the secondary effects are abnormalities in speech articulation. Surgical revision along with speech therapy is a common approach to the treatment of VPI. Prosthetic management by means of speech aid prosthesis helps to reduce resonance, nasal emission and consonants errors. This clinical report describes the different stages of rehabilitation of velopharyngeal insufficiency defect following resection of malignant melanoma of left posterior alveolar ridge and soft palate. The speech aid prosthesis helped to rehabilitate the velopharyngeal insufficiency defect and aided in the diagnosis of extent of speech function improvement by perceptual and objective methods.

Optimizing Safety in Velopharyngeal Insufficiency Surgery for Children with 22q11.2 Deletion Syndrome

22q11.2 microdeletion syndrome (22q11.2DS) is a common genetic condition associated with structural and functional velopharyngeal anomalies. However, not all patients with 22q11.2DS presenting for treatment will have an established diagnosis and/or have been evaluated for critical medical comorbidities including congenital cardiovascular anomalies, bleeding diatheses, hypocalcemia, and cervical spine instability. When considering surgical management for patients with velopharyngeal insufficiency (VPI), it is imperative to be aware of the clinical features of 22q11.2DS to avoid serious morbidity and mortality. This is illustrated here with 2 case examples. First, a 10-year-old male with 22q11.2DS presented at 6 years old for treatment of VPI associated with submucous cleft palate. Preoperative computed tomographic angiography revealed right carotid artery tortuosity and retropharyngeal displacement, while intraoperative Doppler ultrasound confirmed carotid artery medialization at the base of the proposed flap. Consequently, he underwent Furlow palatoplasty instead of pharyngeal flap. Second, a 5-year-old male with 22q11.2DS presented at 4 years old for treatment of VPI. Palatal lengthening with double-opposing buccal flaps was performed to mitigate the risk for carotid artery injury, need for preoperative imaging, and risk for developing obstructive sleep apnea (OSA). Right carotid artery medialization was seen intraoperatively as marked pulsations. Both patients underwent cardiac and anesthesia evaluations prior to surgery given their histories of congenital heart defects (CHD) and prior postoperative hypocalcemia.

Ian Jackson's Sphincter Pharyngoplasty.

Velopharyngeal insufficiency (VPI) after cleft palate repair remains an intriguing problem for the cleft surgeon. While other options for the treatment of VPI, in many ways the sphincter pharyngoplasty has become a reliable and satisfying operation. When the applied to the properly selected patient, it rearranges the palatopharyngeus muscles to provide dynamic closure of the newly created central velopharngeal port. The dynamic action is particularly satisfying to the surgeon. The surgery evolved in part because of the dedication and creativity of Dr Ian Jackson who's description is closest to the design used today. In his memory we felt it fitting to review Dr Jackson's involvement with the surgery over the decades as well as include our own thoughts on the advantages of the procedure.

Successful Pharyngoplasty After Le Fort I Advancement In A Severely Neglected Cleft Lip And Palate Patient

Background: When indicated, velopharyngeal insufficiency (VPI) is treated with pharyngoplasty with consideration of patient’s age. Several studies have evaluated the relationship between age at surgery and speech outcome. The best results regarding reduction of open nasality were obtained when surgeries were performed around age of 5 to 6 years and operative complications were also less frequent in the younger age group than in older patients. Pre-operative assessment such as nasopharyngoscopy and/or videofluoroscopy gives surgeons a chance to estimate flap dimension to correct the defect causing the VPI. Moreover, velopharyngoplasty proceeded with speech therapy yields better recovery.Case History : A seriously neglected case of cleft lip and palate was reported. A 24 years old female underwent two palatorrhaphy at age 13 and 14 years old, which were far beyond the recommended age of 10 – 12 months. The resulting hypernasality was further worsened by absence of speech therapy which should have been followed from age 1 – 4 years old. On presentation, this patient requested to have immediate orthognatic surgery to repair his severe type 3 facial profile and malocclusion, a procedure which he underwent worsening the VPI. We decided to surgically correct the VPI. Nasoendoscopic assessment revealed he had an antero-posterior velopharyngeal closure problem which indicated a pharyngoplasty using a superiorlybased pharyngeal flap. Three months post-operatively his speech was re-evaluated by a speech therapist and nasoendoscopically. Despite imperfectness, significant improvement was achieved.Conclusion : Pharyngoplasty could still be reliable to a certain extent as a correction treatment of VPI in a seriously neglected case. A posterior pharyngeal flap helped this patient to recover significant speech capacity.

Treatment of velopharingeal insuffitiency with turn over mucoperiosteal palatinal flap in a patient with DiGeorge syndrome

Introduction. DiGeorge syndrome (velocardiofacial syndrome) occurs in about 1 in 4,000 people. It is characterized by incomplete gene penetration, due to which there is significant variability in the clinical picture in different patients. The paper describes the successful application of an inverted mucoperiosteal flap of the palate in a nine-year-old girl with DiGeorge syndrome who had pronounced velopharyngeal insufficiency (VPI). Case report. The girl was the first-born child from a normal pregnancy and a normal birth with a normal early psychomotor development. During breastfeeding, milk was occasionally returned to the nose, and later deviations from normal speech (incomprehensible and nasal speech) were noticed. At the age of 4, detailed genetic testing was performed and a microdeletion of 22q11 chromosome was found. Also, a submucosal cleft palate was established, and magnetic resonance angiography of the head and neck revealed an abnormal position of the left internal carotid artery (ICA) that extended submucosally to the central axis of the posterior wall of the pharynx. Then, the submucosal cleft palate was surgically resolved in other clinical center, but without speech improvement. Pharyngoplasty was not performed due to the risk of serious post-operative complications. It was explained to the parents that speech recovery will not be satisfactory without surgical treatment of VPI. At the age of 9, the girl was admitted to the Clinic for Plastic and Reconstructive Surgery and Burns of the Military Medical Academy in Belgrade for surgical treatment of VPI. Taking into account the potential risks of certain surgical methods, it was decided to perform intravelar veloplasty according to Furlow. Since it was intraoperatively found that the soft palate is too short and that this procedure cannot provide its sufficient length, the mucoperiosteal flap was lifted from the palate to the palatal aponeuroses on the posterior edges of the palatine bones leaving their oral surfaces exposed. The mucoperiosteal flap raised in this way could not also provide the required length of the soft palate only by retroposition. However, its length is 160% of the soft palate axis length, which was enough to turn over the front of the flap towards the pharynx of the soft palate to reach its posterior wall. The raised mucoperiosteal palatal flap has no muscles, so its motility was achieved by the fact that along the edges of the existing short and mobile palate, the flap was fixed to the existing palate and uvula. This provided the anatomical preconditions for speech recovery, shown during the one-year post-operative follow-up of the child. Exposed palatine bones and short palate was covered by mucosal tissue, without cystic formations. Conclusion. The mucoperiosteal palatal flap can be easily, successfully and maximally safely applied in the resolution of VPI in patients with DiGeorge syndrome where there is an aberrant submucosal position of the ICA. This flap could be a ?flap of choice? for such patients with atopic position of the ISA, too.

Palatal Re-Repair With Z-Plasty in Treatment of Velopharyngeal Insufficiency of Syndromic and Nonsyndromic Patients With Cleft Palate.

Velopharyngeal insufficiency (VPI) often results from palatal shortening or insufficient levator function after cleft palate repair. To assess the efficacy of palatal re-repair with Z-plasty in treatment of VPI for patients with isolated cleft palate (ICP). This retrospective analysis comprised 130 consecutive patients who had ICP with VPI that required Z-plasty as secondary surgery between 2008 and 2017. Pre- and post-operative evaluation of velopharyngeal function was done perceptually and instrumentally by Nasometer. Median patient age at Z-plasty was 6.8 years (range 3.0-20.1). Of the 130 patients, preoperatively VPI was severe in 73 (56%), mild-to-moderate in 55 (42%), and borderline in 2 (2%). Postoperatively, 105 (81%) of patients achieved adequate (normal or borderline) velopharyngeal competence and 16 (12%) required second operation for residual VPI. The success rate was 84% in nonsyndromic patients, 79% in nonsyndromic Pierre Robin sequence patients, and 58% in syndromic patients. In syndromic children, the speech outcome was significantly worse than in nonsyndromic children (P = 0.014). Complications included wound healing problems in 3 patients (2%), mild infection in 1 patient (1%), postoperative bleeding in 1 (1%), and postoperative fistula in 2 (2%). Palatal re-repair with Z-plasty is a safe operation for VPI correction in patients with ICP with a success rate of 81%. In syndromic patients, the procedure did not seem to work as well as in nonsyndromic patients.

Palatal Re-Repair With Double-Opposing Z-Plasty in Treatment of Velopharyngeal Insufficiency of Patients With Unilateral Cleft Lip and Palate.

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair that is often related to palatal shortening and insufficient levator reconstruction. For VPI correction in our cleft center, palatal re-repair with double-opposing Z-plasty is the standard operation. To assess the efficacy of double-opposing Z-plasty in treatment of VPI after primary surgery for unilateral cleft lip and palate (UCLP). This retrospective analysis comprised 109 consecutive UCLP patients born between 1997 and 2014 with VPI that required re-operation, and were operated on by 2 highvolume cleft surgeons, followed by perceptual and instrumental (Nasometer) evaluation of velopharyngeal competence (VPC). Preoperatively, VPI was severe in 96% (105 of 109) and mild-to-moderate in 4% (4 of 109). Median age at surgery was 5.6 years (range 2.8-21.9). Postoperatively, 84% of patients achieved adequate VPC: 65% (71 of 109) were competent and 19% (21 of 109) borderline competent. Postoperative adequate VPC was 89% (70 of 79) in nonsyndromic Finnish patients, 50% (4 of 8) in syndromic patients, and 82% (18 of 22) in adoption children. Compared to Finnish nonsyndromic patients, patients with syndrome had more residual VPI (P = 0.003), but no statistically significant difference existed for adoption patients (P = 0.251). Complications of the double-opposing Z-plasty included hemorrhage, postoperative mild airway obstruction, and wound-healing problems, each arising in 2 (1.8%) patients. Fourteen (13%) patients needed a second VPI operation. Double-opposing Z-plasty seems to be a good and safe treatment option for VPI in patients with previously repaired UCLP with a success rate of 84%.

Velopharyngeal Insufficiency Impact and Nasopharngoscopy Discomfort and Cooperation: Patient, Parent, and Provider Perspectives.

Velopharyngeal insufficiency (VPI) impacts resonance and articulation and contributes to social difficulties. Nasopharngoscopies (NPs) often inform VPI treatment planning. Using a mixed-model prospective design, this study describes the impact of VPI, NP perceptions, and ratings of pain, discomfort, and cooperation during NP from multiple perspectives. Participants (N = 33) were 7 to 16 years old (mean 8.8 years) with diagnoses primarily of cleft lip and palate (52%) or cleft palate (42%). Mostly mothers (82%) completed measures in English (58%). Patients (52%) reported some teasing related to VPI, with higher parent report of their child being teased (70%). Themes of not being understood, teasing, and negative emotions were described. Coping themes included social support, distraction, and speech therapy. Patients' Beck Youth Inventories-Second Edition scores were in the average range. Over half of patients and parents reported anxiety about NPs and about a third reported understanding NPs. The Faces Pain Scale-Revised mean of 2.5 ± 3.2 and the Face, Legs, Activity, Cry, Consolability scale mean of 2.5 ± 2.2 were low. Discomfort was most often rated as "a little" by patients (55%), parents (42%), speech-language pathologists (49%), and plastic surgeons (39%). There was concordance across pain and discomfort ratings. High cooperation (61%-72%) was seen across reporters, which was negatively correlated with pain measures. Patient anxiety was related to NP pain and discomfort, suggesting integrating coping for procedural anxiety into the NP preparation might benefit patients. Additionally, negative VPI social experiences should be screened for as part of VPI management.