Velopharyngeal Incompetence Research Articles

Aerodynamic evaluation of velopharyngeal incompetence in children with cleft palate

Aerodynamic evaluation of velopharyngeal incompetence in children with cleft palate

International Adoptees With Cleft Lip and/or Palate: Lessons Learned From a Growing Population.

International adoptees with cleft lip and palate (CLP) are a growing population in the United States. They represent a clinical challenge, presenting at various ages and stages of cleft repair. A retrospective review of patients seen at the CLP Program at the Children's Hospital of Philadelphia (CHOP) between 1998 and 2012 with a history of international adoption was performed. Demographics, surgical histories, and long-term speech outcomes were reviewed. Seventy-four female and 77 male patients were evaluated. Patients were adopted at an average age of 2.3 years (range, 0.4-8.6 years); 80.8% (n = 122) of patients were adopted from China. The rate of international cleft adoption increased by approximately 1.5 patients per year (r = 0.7739, P < 0.001); 13.2% (n = 19) of all subjects with cleft palates had oronasal fistulas (ONFs) that required repair. The ONF rates for primary palatoplasties at CHOP were significantly lower compared to both preadoption repairs (P = 0.002) and postadoption repairs at outside hospitals (P = 0.01); 14.8% (n = 21) of all patients had secondary surgeries for velopharyngeal incompetence (VPI). Rates of secondary surgery for VPI were also significantly lower for primary palatoplasties at CHOP compared to both preadoption repairs (P = 0.0018) and postadoption repairs at outside hospitals (P = 0.0033). International adoptees with CLP are a growing population and are clinically challenging with high ONF rates and high secondary surgery rates for VPI. We recommend expedited repair of unoperated cleft palates in adoptees older than 18 months. Adopted patients with CLP should be rigorously evaluated for the need for speech therapy and secondary surgeries to correct for VPI.

Conformation du lambeau antébrachial en arche sur mesure pour la reconstruction du voile du palais. Cas clinique

Reconstruction of the soft palate after oncologic resection remains a surgical challenge. Speech and swallowing problems are the consequences of velopharyngeal incompetence following soft palate resection. Free tissue transfer like radial forearm flaps can be used in larger defects for complex reconstruction. The conformation of the flap in order to be closer to the shape of the soft palate improves the functional outcome. In the same way, we describe an original "double-arched" flap design. A double arch of the exact length of the soft palate tumor resection is designed. After suturing, the flap spontaneously formed a double arch of the exact dimensions of the resected piece. The patient achieved good functional recovery without any surgical complications. The original "double-arched" forearm flap design allows a tailored reconstruction with exactly the same shape and dimensions, preserving the functional requirements of speech and deglutition.

Modeling of oropharyngeal articulatory adaptation to compensate for the acoustic effects of nasalization.

Hypernasality is one of the most detrimental speech disturbances that lead to declines of speech intelligibility. Velopharyngeal inadequacy, which is associated with anatomic defects such as cleft palate or neuromuscular disorders that affect velopharygneal function, is the primary cause of hypernasality. A simulation study by Rong and Kuehn [J. Speech Lang. Hear. Res. 55(5), 1438-1448 (2012)] demonstrated that properly adjusted oropharyngeal articulation can reduce nasality for vowels synthesized with an articulatory model [Mermelstein, J. Acoust. Soc. Am. 53(4), 1070-1082 (1973)]. In this study, a speaker-adaptive articulatory model was developed to simulate speaker-customized oropharyngeal articulatory adaptation to compensate for the acoustic effects of nasalization on /a/, /i/, and /u/. The results demonstrated that (1) the oropharyngeal articulatory adaptation effectively counteracted the effects of nasalization on the second lowest formant frequency (F2) and partially compensated for the effects of nasalization on vowel space (e.g., shifting and constriction of vowel space) and (2) the articulatory adaptation strategies generated by the speaker-adaptive model might be more efficacious for counteracting the acoustic effects of nasalization compared to the adaptation strategies generated by the standard articulatory model in Rong and Kuehn. The findings of this study indicated the potential of using oropharyngeal articulatory adaptation as a means to correct maladaptive articulatory behaviors and to reduce nasality.

Assessing palatal mobility in post-tonsillectomy patients

Objectives: To assess palatal mobility in post-tonsillectomy patients. Material and methods: This study was conducted in one year duration in Sohag University Hospital and consisted of 100 patients with ages ranging from 4 to 21years. Inclusion criteria: history with previous tonsillectomy at least since 6months or more. Exclusion criteria: any neurological deficit, muscular disorder or structural defects of the palate such as cleft palate or submucous cleft palate. All patients had undergone ear, nose and throat examination. Palatal mobility was assessed through oral examination. Further assessing palatal mobility by endoscopic examination and videofluoroscopy was done for those who have poor palatal mobility detected by intraoral examination. Result: Forty patients (23 males, 17 females) had poor palatal mobility on oral examination. Fourteen patients (8 males, 6 females) had definite poor palatal mobility on endoscopic examination. On Auditory Perceptual Assessment, 12 patients had closed nasality and 2 patients had mixed nasality. On endoscopic examination, 14 patients had a large adenoid. In 12 patients, the velopharyngeal orifice closure was veloadenoidal closure while in the other 2 patients there was slight velopharyngeal incompetence (coronal closure). Conclusion: Poor palatal mobility may be caused by malpractice of tonsillectomy or it may be a sign that was present and missed by the otolaryngologist. Pre-tonsillectomy evaluation of palatal mobility should be done by nasofiberoptic endoscope and/or videofluoroscopy. Also post-tonsillectomy evaluation of palatal mobility should be taken in consideration if adenoidectomy is needed to prevent possible postoperative open nasality.

Diagnosis and Management of Velopharyngeal Dysfunction.

Velopharyngeal dysfunction (VPD) describes any condition whereby the velopharyngeal valve does not properly close during the production of oral sounds. VPD contains multiple causes, including velopharyngeal mislearning (nasopharyngeal sound substitution for an oral sound), velopharyngeal incompetence (neurolophysiologic dysfunction causing poor pharyngeal movement), and velopharyngeal insufficiency (a structural or anatomic defect prevents velopharyngeal closure). Evaluation for VPD is best performed within the context of a multidisciplinary team and consists of history and physical examination, perceptual speech evaluation, and instrumental assessment of speech with either video nasoendoscopy or multiview speech fluoroscopy.

Oropharyngeal stenosis: A rare complication following adenotonsillectomy

Oropharyngeal stenosis (OPS) is a narrowing of the oropharynx as a result of adhesions from the base of tongue to the anterior tonsillar pillars and inferior tonsillar fossa [1]. OPS is a rare complication of oropharyngeal surgery and can cause dysphagia, sleep disordered breathing, velopharyngeal incompetence due to tethering of the soft palate, and dyspnea. Whereas OPS occurred historically following oropharyngeal infection, the advent of antibiotic treatment for common infectious agents in the early 20th century has made OPS an extremely rare condition [1,2]. OPS has been associated with multilevel, single-stage upper airway surgery involving lingual tonsillectomy and in conjunction with nasopharyngeal stenosis [2]. OPS is mentioned historically anecdotally after simple adenotonsillectomy but to our knowledge this is the first case report of a patient who developed OPS following routine adenotonsillectomywith no other risk factors. She underwent successful surgical repair which included scar division and palatal scar lengthening with local advancement flap. This

Prevalence of 22q11.2 microdeletion syndrome in Iranian patients with cleft palate.

Background:22q11.2 microdeletion syndrome is the most common multiple genetic disorder associated with learning disabilities, developmental delays, immune deficiency, hypocalcemia, and cleft palate. Finding some valid criteria for screening of 22q11.2 deletion syndromes in infants would be very helpful in early diagnosis and treatment.Materials and Methods:Since 69% of individuals with 22q11.2 deletion have a palatal abnormality, we studied the prevalence of 22q11.2 deletion syndrome in 378 Iranian patients during a 5-year period, including 291 patients affected with cleft palate only without cleft lip (CPO) and 87 patients affected with velopharyngeal incompetence (VPI) and/or submucous cleft palate (SMCP). DNA copy number was analyzed with multiplex ligation-dependent probe amplification (MLPA) technique.Results:In our study, 15/378 (3.97%) patients with palatal anomalies showed 22q11.2 deletion. Interestingly, this prevalence between syndromic patients was 15/104 (14.42%).Conclusion:It seems that SMCP or VPI, in addition to one or more another features of 22q11.2 deletions, especially developmental delay, may be good criteria for molecular investigation of 22q11.2 region.

Does cleft palate repair reduce the incidence of middle ear pathology?

Introduction: In an infant, cleft palate usually affects his/her feeding, speech, eustachian tube, and middle ear physiology. The incidence of otitis media with effusion is particularly very high in the children having cleft palate. Repair of cleft palate is believed to reduce this incidence. Objective: This study was conducted to assess the effect of cleft palate repair on middle ear physiology. Methodology: The study sample was divided into two groups: Group A consists of patients who are 6 years and older with unrepaired cleft palate and Group B of the patients whose cleft palate were repaired before the age of 2 years and completed at least 4 years after surgery. There were thirty patients in each group. All of them were evaluated clinically, by otoscopy and tympanometry. Clinical assessment included examination of the palate in terms of the presence of scarring, fistula, length of soft palate (visual assessment only), mobility of the soft palate, and speech scoring by Pittsburgh weighted speech score. Results: About 21% of operated patients had velopharyngeal incompetence. Thirty-four ears (56.6%) in Group A and 24 ears (40.6%) in Group B had normal otoscopy finding. Normal tympanogram (Type A curve) was found in exactly similar proportion of ears examined in both the groups (20% each). Conclusion: Early repair of cleft palate did not have any beneficial effect on middle ear pathology.

Clinics in Plastic Surgery: Fat Grafting: Current Concept, Clinical Application, and Regenerative Potential, Part 2

Lee L.Q. Pu, Kotaro Yoshimura, and Sydney R. Coleman, eds. Clinics in Plastic Surgery: Fat Grafting: Current Concept, Clinical Application, and Regenerative Potential, Part 2 . New York, NY: Elsevier; 2015. ISBN-10: 0323392709, ISBN-13: 978-0323392709. $99.00. ![Graphic][1] The credentials of the editors of this 2-part summary of fat grafting are impeccable and, as such, these volumes (of which part 2 is reviewed here) provide an authoritative summary of fat grafting to date. While part 1 provided a comprehensive overview of the basic science of fat grafting, including adipose stem cell biology, fat preparation, and graft take, these 12 additional chapters focus on the diverse clinical applications of the technique. Importantly, the volume focuses not only on aesthetic liposculpture (although breast augmentation and facial rejuvenation are covered here) but also includes chapters on such disparate topics as breast reconstruction, problematic wounds, scleroderma, velopharyngeal incompetence, and Dupuytren's disease. The volume concludes, as we might expect, with chapters on how to manage the complications of fat grafting and future perspectives. This volume, like its companion volume (part 1), is of general interest and assumes no prior expertise in the … Corresponding Author: Dr Graeme Glass, 6 Park St. James, Prince Albert Road, St. John's Wood, London, NW8 7LE, UK. E-mail: graeme.glass{at}ndorms.ox.ac.uk [1]: /embed/inline-graphic-1.gif

Double-Opposing Z-Palatoplasty for Secondary Surgical Management of Velopharyngeal Incompetence in the Absence of a Primary Furlow Palatoplasty.

The present study was performed to identify factors that lead to a favorable outcome of postpalatoplasty velopharyngeal incompetence using the double-opposing Z-palatoplasty. A retrospective analysis was performed on 23 consecutive nonsyndromic patients who underwent secondary surgical management of velopharyngeal incompetence using a double-opposing Z-palatoplasty technique following primary, non-Furlow palatoplasty for overt cleft palate. All subjects were evaluated preoperatively using a perceptual speech assessment scale, nasendoscopy, and videofluoroscopy. Inclusion criteria consisted of a velopharyngeal gap of 9 mm or less on phonation. Patients were followed with perceptual speech assessment for at least 1 year following secondary surgery. The perceptual speech assessment score for all patients decreased from 6.48 ± 2.26 (mean ± standard deviation; range, 3 to 11) to 1.90 ± 1.51 (range, 0 to 6) at 6 months or more postoperatively (P < .0001). Of the 21 patients with follow-up data 1 year or more post-op, 16 (76%) achieved velopharyngeal competence and five (24%) had borderline competence. Preoperative assessment factors associated with compromised outcome included a large velopharyngeal gap of 7 to 9 mm, poor lateral wall motion of 40% or less, and an elevated perceptual speech assessment score. Double-opposing Z-palatoplasty is a surgical technique that can be used successfully to correct velopharyngeal incompetence in selected secondary palatoplasty patients. This technique permits correction of velopharyngeal incompetence and restoration of the velopharyngeal mechanism irrespective of prior intravelar veloplasty and without accompanying loss in the nasal airway. Preoperative assessment can better identify those patients who are less likely to achieve velopharyngeal competence following double-opposing Z-palatoplasty alone.

A case description of speech disturbance and treatment following corrective surgery for stress velopharyngeal incompetence

The purpose of this study was to determine the effectiveness of a motor learning guided (MLG) approach to speech treatment in a unique case of speech disturbance following surgery for stress velopharyngeal incompetence (SVPI). The patient was a 20-year-old female college student. Treatment took place over 6 sessions and focused on eliciting productions through a hierarchy of clinician support, with an emphasis on self-evaluation and -correction. Acoustic measurements and ratings from the treating clinician and unfamiliar listeners revealed a speech disturbance following surgery that was corrected following speech treatment. The patient’s main difficulty appeared to be in producing the vocalic/postvocalic approximant, /r/, although vowel distortions were also noted. These difficulties may be explained by the structural alteration and formation of scar tissue as a result of surgery. The results provide initial support for an MLG approach to treating an acquired speech disturbance following SVPI surgery; however, additional research is warranted.

Developmental trajectories in 22q11.2 deletion.

Chromosome 22q11.2 deletion syndrome (22q11.2DS), a neurogenetic condition, is the most common microdeletion syndrome affecting 1 in 2,000-4,000 live births and involving haploinsufficiency of ∼50 genes resulting in a multisystem disorder. Phenotypic expression is highly variable and ranges from severe life-threatening conditions to only a few associated features. Most common medical problems include: congenital heart disease, in particular conotruncal anomalies; palatal abnormalities, most frequently velopharyngeal incompetence (VPI); immunodeficiency; hypocalcemia due to hypoparathyroidism; genitourinary anomalies; severe feeding/gastrointestinal differences; and subtle dysmorphic facial features. The neurocognitive profile is also highly variable, both between individuals and during the course of development. From infancy onward, motor delays (often with hypotonia) and speech/language deficits are commonly observed. During the preschool and primary school ages, learning difficulties are very common. The majority of patients with 22q11.2DS have an intellectual level that falls in the borderline range (IQ 70-84), and about one-third have mild to moderate intellectual disability. More severe levels of intellectual disability are uncommon in children and adolescents but are more frequent in adults. Individuals with 22q11.2DS are at an increased risk for developing several psychiatric disorders including attention deficit with hyperactivity disorder (ADHD), autism spectrum disorder (ASD), anxiety and mood disorders, and psychotic disorders and schizophrenia. In this review, we will focus on the developmental phenotypic transitions regarding cognitive development in 22q11.2DS from early preschool to adulthood, and on the changing behavioral/psychiatric phenotype across age, on a background of frequently complex medical conditions.

The use of acellular dermal matrix in the closure of oronasal fistulae after cleft palate repair.

Although the management of cleft lip and palate has improved significantly during the last years, repairing oronasal fistulae is still a challenge. Reports of the incidence of postoperative fistulae following palate repair range from 10% to 20%.1 Several techniques are reported for the treatment of oronasal fistula, such as local mucoperiosteal flap, V-Y 2-layer repair, superior lip mucosal or myomucosal flap, buccal myomucosal flap, superiorly based facial artery myomucosal flap, tongue flap, free flap, free cartilage graft, and distraction osteogenesis. The great number of different techniques is the demonstration that there is not any particular technique that provides satisfactory results. Usually, the fistula occurs at the junction of the hard and soft palate, a defect in this location is frequently associated with hypernasality of the speech, velopharyngeal incompetence, and nasal regurgitation of food and liquids with consequent impairment of the quality of life. Repair of existing fistula is also prone to failure because prior palatal surgery inevitably creates scars, altered vascularity, and tension.

The Use of Acellular Dermal Matrix in the Closure of Oronasal Fistulae after Cleft Palate Repair

Although the management of cleft lip and palate has improved significantly during the last years, repairing oronasal fistulae is still a challenge. Reports of the incidence of postoperative fistulae following palate repair range from 10% to 20%.1 Several techniques are reported for the treatment of oronasal fistula, such as local mucoperiosteal flap, V-Y 2-layer repair, superior lip mucosal or myomucosal flap, buccal myomucosal flap, superiorly based facial artery myomucosal flap, tongue flap, free flap, free cartilage graft, and distraction osteogenesis. The great number of different techniques is the demonstration that there is not any particular technique that provides satisfactory results. Usually, the fistula occurs at the junction of the hard and soft palate, a defect in this location is frequently associated with hypernasality of the speech, velopharyngeal incompetence, and nasal regurgitation of food and liquids with consequent impairment of the quality of life. Repair of existing fistula is also prone to failure because prior palatal surgery inevitably creates scars, altered vascularity, and tension. METHODS This study was conducted on 30 patients who had oronasal fistulae secondary to prior cleft palate repair. In group 1, 20 patients underwent fistula repair using local mucoperiosteal flap or local mucoperiosteal flap and free cartilage graft between January 2010 and January 2012. In group 2, 10 patients underwent fistula repair with local mucoperiosteal flap and acellular dermal matrix (Protexa, AFS Medical GmbH, Seedorf, Germany) between January 2012 and June 2013. All the patients were subjected to closure of the fistula under general anesthesia with oral endotracheal intubation. In 12 patients of group 1 and 6 patients of group 2, a lipofilling of the scar around the fistula was made to ameliorate the contracture of the scar. Two mucoperiosteal flaps based on the palatine artery and 2 mucosal flaps on the nasal plane were harvested. After rehydration, the dermal matrix was cut to size and sandwiched in the middle of the mucoperiosteal flap and the nasal flaps. RESULTS The age of the patients ranged from 1 year to 10 years; there were 18 female and 12 male patients. The mean diameter of the fistula was 12 mm. In group 1, there were 5 dehiscence of the wound with consequent recurrence of the fistula; in group 2, there was only one partial dehiscence with partial exposition of the dermal matrix but with no recurrence of the fistula. CONCLUSIONS The repair of oronasal fistulae is often made difficult by the preexisting scarring and the altered vascularity resulting from the primary palatoplasty. Although different techniques are described to repair oronasal fistulae, no single procedure has proved to be ideal. The dermal matrix is believed to act as a scaffold for migration of the host fibroblast and retains its basement membrane complex to facilitate attachment of surface epithelium. In only one case in group 2, there was a dehiscence of the oral wound with a partial exposure of the dermal matrix, but it healed completely in 4 weeks with a complete mucosalization of the graft (Figs. 1–4).Fig. 1: Preoperative view of a 5-year-old girl.Fig. 2: Postoperative view of a 5-year-old girl after 2 months.Fig. 3: Preoperative view of an 8-year-old girl.Fig. 4: Postoperative view of an 8-year-old girl after 3 months.In our study, we reported a 100% closure rate of oronasal fistula in the group treated with dermal matrix. Similar results are reported by Clark et al2 and Kirschner et al.3 Losee et al4 reported only a 3.6% recurrence rate of the fistula. Based on our results and the small literature available on this topic, we believe that the use of the dermal matrix is a promising technique to repair oronasal fistula after palatoplasty.

Postoperative evaluation of the folded pharyngeal flap operation for cleft palate patients with velopharyngeal insufficiency.

Background:Velopharyngeal function is very important for patients with cleft palate to acquire good speech. For patients with velopharyngeal insufficiency, prosthetic speech appliances and speech therapy are applied first, and then pharyngeal flap surgery to improve velopharyngeal function is performed in our hospital. The folded pharyngeal flap operation was first reported by Isshiki and Morimoto in 1975. We usually use a modification of the original method.Purpose:The purpose of this research was to introduce our method of the folded pharyngeal flap operation and report the results.Materials and Methods:The folded pharyngeal flap operation was performed for 110 patients with velopharyngeal insufficiency from 1982 to 2010. Of these, the 97 whose postoperative speech function was evaluated are reported. The cases included 61 males and 36 females, ranging in age from 7 to 50 years. The time from surgery to speech assessment ranged from 5 months to 6 years. In order to evaluate preoperative velopharyngeal function, assessment of speech by a trained speech pathologist, nasopharyngoscopy, and cephalometric radiography with contrast media were performed before surgery, and then the appropriate surgery was selected and performed. Postoperative velopharyngeal function was assessed by a trained speech pathologist.Results:Of the 97 patients who underwent the folded pharyngeal flap operation, 85 (87.6%) showed velopharyngeal competence, 8 (8.2%) showed marginal velopharyngeal incompetence, and only 2 (2.1%) showed velopharyngeal incompetence; in 2 cases (2.1%), hyponasality was present. Approximately 95% of patients showed improved velopharyngeal function.Conclusions:The folded pharyngeal flap operation based on appropriate preoperative assessment has been shown to be an effective method for the treatment of cleft palate patients with velopharyngeal insufficiency.

Use of buccal myomucosal flap for palatal lengthening in cleft palate patient: Experience of 20 cases.

Background:The purpose of this review was to assess the effectiveness of the buccal myomucosal flap in secondary repairs of cleft palate in 20 patients.Patients and Methods:Totally, 20 patients, who underwent secondary palatoplasty between 5 years and 8 years in which a buccal myomucosal flap was used, were reviewed retrospectively. All patients had undergone at least one previous attempted repair at other institutions. Indications for the secondary repair included velopharyngeal incompetence and/or oronasal fistula. Patients were evaluated preoperatively for oronasal fistula status, velopharyngeal competence, nasal resonance, speech quality, and nasal escape.Results:The buccal myomucosal flap was used in all 20 patients, and there was marked increase in the quality of speech as well as nasal regurgitation decreased. In patients with levator dysfunction due to poor primary surgery and glottal speech the results were inconclusiveConclusion:Palate re-repair combined with a buccal myomucosal flap, occasionally in conjunction with other techniques, is an effective method for correcting failed cleft palate repairs. Minimum donor site morbidity and complication makes the buccal flap a useful armamentarium of a cleft surgeon.

Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function

The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function. This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation. All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001). ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.

Fetal acetylcholine receptor inactivation syndrome: A myopathy due to maternal antibodies.

Background:Transient neonatal myasthenia gravis (TNMG) affects a proportion of infants born to mothers with myasthenia gravis (MG). Symptoms usually resolve completely within the first few months of life, but persistent myopathic features have been reported in a few isolated cases.Methods:Here we report 8 patients from 4 families born to mothers with clinically manifest MG or mothers who were asymptomatic but had elevated acetylcholine receptor (AChR) antibody levels.Results:Clinical features in affected infants ranged from a mild predominantly facial and bulbar myopathy to arthrogryposis multiplex congenita. Additional clinical findings included hearing impairment, pyloric stenosis, and mild CNS involvement. In all cases, antibodies against the AChR were markedly elevated, although not always specific for the fetal AChR γ subunit. There was a correlation between maternal symptoms; the timing, intensity, and frequency of maternal treatment; and neonatal outcome.Conclusions:These findings suggest that persistent myopathic features following TNMG may be more common than currently recognized. Fetal AChR inactivation syndrome should be considered in the differential diagnosis of infants presenting with unexplained myopathic features, in particular marked dysarthria and velopharyngeal incompetence. Correct diagnosis requires a high degree of suspicion if the mother is asymptomatic but is crucial considering the high recurrence risk for future pregnancies and the potentially treatable nature of this condition. Infants with a history of TNMG should be followed up for subtle myopathic signs and associated complications.

A survey of assessment and management of velopharyngeal incompetence (VPI) in the UK and Ireland

A questionnaire designed to survey methods of assessment and management of velopharyngeal incompetence (VPI) was circulated to all surgical members of the Craniofacial Society of Great Britain and Ireland. 45 questionnaires were distributed yielding 30 respondents (66.6% response rate). 27 respondents performed surgery for both cleft and non-cleft forms of VPI. Multi-planar videofluroscopy and nasendoscopy were the most frequently used methods of assessing and diagnosing VPI. The most frequently utilised corrective surgical procedure was palatal re-repair, followed by the Hynes pharyngoplasty and the Furlow double opposing z-plasty technique. Orticochea and Jackson pharyngoplasties were less commonly performed. Splitting the palate during pharyngoplasty procedures was an inconsistent practice. 20 palatal surgeons referred patients to an otolaryngology specialist when tonsillectomy and/or adenoidectomy was indicated prior to their corrective palatal procedure. This was most frequently performed 3 months prior to palatal surgery. This survey identified normal patient speech as the criterion of success after correctional surgery for VPI. Assessment and management of VPI in Great Britain and Ireland is a highly varied practice. When a palatal procedure is indicated, surgical approaches are tailored to address each individual's pattern of velopharyngeal closure deficiency. The surgeons surveyed reported this as being most accurately demonstrated by direct nasendoscopic visualisation and dynamic multi-planar videofluoroscopic studies.