Velopharyngeal Gap Research Articles

Correlation of Velopharyngeal Score in Nasoendoscopy with Perceptual Speech Intelligibility of Patients with Cleft Palate

Background and Objective: One of the challenges patients with cleft palate face is the production of intelligible speech. Though instrumental assessment of velopharyngeal function is required, there is a need to correlate the results obtained with speech outcome. The objective of this study is to correlate the Golding-Kushner scale scoring system for velopharyngeal defects as observed on nasoendoscopy with patients’ speech intelligibility. Method: The design is an observational cross-sectional study conducted from December 2022 to May 2023. This study was carried out at the orofacial cleft clinic of a tertiary hospital. Participants: The study included English-speaking patients with cleft palate who had palatorrhaphy done at least 6 months before recruitment. Intervention: Speech intelligibility was measured using a simple analog scale that ranged from 0 to 5 (0—worst speech intelligibility possible, 5—best speech intelligibility). The Golding-Kushner scale is used to measure gap size (defect) in nasoendoscopy. Main outcome measures: The primary outcome is to correlate the score of speech intelligibility with the Golding-Kushner score during nasoendoscopy. Results: A total of 40 people participated in the study, with a median age of 11 years (IQR: 6.25-21.75 years). There is a moderately negative correlation between velopharyngeal gap size and speech intelligibility (correlation coefficient = −0.6, P < .01). Only the size of the size of the gap is a significant predictor of speech intelligibility after cleft palate repair. Conclusion: There is a significant, moderate correlation between velopharyngeal gap size and speech intelligibility.

Velopharyngeal Gap Size During Sustained Vowel Production Correlates With Perceptual Ratings of Hypernasality in Connected Speech.

The purpose of this study was to investigate the relationship between perceptual ratings of hypernasality made during connected speech and velopharyngeal (VP) gap size measured in millimeters in the sagittal plane during sustained vowel production using magnetic resonance imaging (MRI). A retrospective cross-sectional analysis was completed. A subgroup of 110 participants from another study with an Mage of 10.1 years presenting for management of VP insufficiency was included. Perceptual ratings of hypernasality during connected speech and measurement of gap size during sustained /i/ production on MRI were performed by raters blinded to the participants' medical and surgical history. There was a moderate-to-strong, positive correlation (r = .61; p < .001) between hypernasality ratings and VP gap size measured on MRI using sustained /i/. The odds of a higher hypernasality rating increased as the gap size increased (odds ratio = 1.34; 95% CI [1.20, 1.49]; p < .001). The predicted probability for hypernasality ratings of none/minimal/mild steadily decreased as the gap size increased indicating that lower ratings of hypernasality were associated with smaller gap sizes. For the rating of "moderate" hypernasality, the predicted probability of the rating steadily increased up to 8 mm and then decreased as the gap size continued to increase. The predicted probability for a hypernasality rating of "severe" consistently increased as the gap size increased. Hypernasality ratings made at the connected speech level were significantly associated with VP gap size as measured during sustained vowel production. These findings suggest sustained vowel production elicited on MRI may adequately characterize VP gap size in the evaluation of VP insufficiency.

Effects of suspension pharyngeal flap on speech in Filipino individuals with velopharyngeal insufficiency.

This study investigated the effects of suspension pharyngeal flap surgery for velopharyngeal insufficiency (VPI) due to cleft palate. Ten Filipino individuals (mean age = 20.63 years, range = 8.4 to 34.9 years) with a cleft palate who underwent suspension pharyngeal flap surgery for VPI were included in this study. Perceptual and instrumental speech assessments were conducted at two different time points: before surgery (data point 1) and after surgery (data point 2, range = 4 to 26 weeks post-operatively). Speech intelligibility in different contexts and satisfaction with speech were assessed by the participants themselves using a self-report questionnaire. Additionally, the risk for obstructive sleep apnea was assessed using the The Berlin Questionnaire. Velopharyngeal gap size significantly decreased after the surgery. Additionally, significant improvements in speech understandability and acceptability were observed following the suspension pharyngeal flap procedure. Besides, a significant reduction in hypernasality, nasal emission, and the occurrence of passive articulation errors was seen. No difference in the occurrence of active articulation errors was observed when comparing data pre- and post-surgery. The ten individuals reported to be significantly more intelligible in different contexts after surgery. Improved speech was observed in individuals who received the suspension pharyngeal flap procedure. This procedure also positively influences an individual's intelligibility in different contexts in daily life. In individuals with persisting active articulation errors, post-surgery speech therapy will still be necessary.

Do Palatoplasty Procedures Resolve Hypernasality as Effectively as Pharyngoplasty Procedures in Patients with 22q11.2 Deletion Syndrome?

Compare the effectiveness of palatoplasty and pharyngoplasty procedures at resolving hypernasality in patients with 22q11.2 deletion syndrome (22q). Retrospective cohort study. Metropolitan children's hospital. Fourteen patients with 22q presenting for management of velopharyngeal insufficiency. Palatoplasty or pharyngoplasty procedure. Resolution of hypernasality 12 months postoperatively. Both procedure groups had a mean preoperative velopharyngeal gap of 6.2 mm during phonation. No patient who underwent palatoplasty achieved resolution of hypernasality; 1/7 patients had worse hypernasality, 4/7 had no change, and 2/7 had improved hypernasality. In contrast, hypernasality was resolved in 6/7 patients in the pharyngoplasty group, which was significantly (P = .03) higher than the palatoplasty group. In patients with 22q, palatoplasty procedures may be less effective than pharyngoplasty procedures at resolving hypernasality. This may be due to underlying anatomic or physiologic differences, such as increased pharyngeal depth and hypodynamic muscles.

Superiorly based pharyngeal flap versus myomucosal resection and direct closure of the posterior pharyngeal wall (Mahrous technique) for surgical correction of velopharyngeal insufficiency

ABSTRACT Introduction: Superiorly based pharyngeal flap is one of the most common surgical techniques described for surgical correction of velopharyngeal disorders. Being a technique-sensitive and owing to its associated complications, a simple technique has been introduced and compared with it. Aim: The aim was to compare the surgical results and the phoniatric outcome of the superiorly based pharyngeal flap versus the myomucosal resection and direct closure of the posterior pharyngeal wall. Patients and Method: One hundred patients of both sexes were classified into two groups. Group A patients included fifty patients who had velopharyngeal insufficiency (VPI) and were surgically corrected by the superiorly based pharyngeal flap. Group B patients included fifty patients who had VPI and were surgically corrected by myomucosal resection and direct closure of the posterior pharyngeal wall. Results: Postoperatively, 13% of Group A patients had open nasality Grade 4 as compared to 0% in Group B patients. Hyponasality and obstructive sleep apnea were not recorded in any case of Group B patients as compared with 10% of Group A patients. With regard to the postoperative velopharyngeal gap during speech, 18% of patients in Group A had velopharyngeal gap 3 mm, while 10% of patients in Group B had velopharyngeal gap 3 mm. Conclusion: Myomucosal resection and direct closure of the posterior pharyngeal wall is a simple reliable technique for the correction of velopharyngeal disorders.

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions.

This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction. Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea. Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Speech following Le Fort I Maxillary Advancement in Cleft Maxillary hypoplasia - an objective and subjective outcome analysis.

To objectively evaluate the effect of maxillary advancement on speech and VPI using video-fluoroscopy (VFS), direct nasoendoscopy, and speech evaluation and subjectively assess patients and their peer's perception regarding their speech outcome. 27 cleft patients who underwent Lefort 1 maxillary advancement were divided into 2 groups- Group A with 4-7mm of advancement and Group B with 8-13mm advancement. VFS in lateral view, nasoendoscopy, and speech recordings were performed pre and 6 months postoperatively. VFS assessed the relative position of velum in relation to the pharyngeal wall, speech was evaluated for changes in nasal emission, resonance, and articulation along with nasal endoscopy to assess the overall function of the velopharyngeal valve. Subjective speech evaluation was done with a Patient-Reported Outcome Measure [PROM] questionnaire. As per VFS, for every 1mm maxillary advancement, the velopharyngeal gap at rest increased by 1.75mm in group A and 1.58mm in group B. The compensatory changes in group B were more pronounced. Post-operative VFS showed velar closure remained the same as preoperative closure in 86.7%, and worsened in 13.3% in group A whereas it remained unchanged in 66.7%, improved in 25%, and worsened in 8.3% in group B. In nasoendoscopy, the closure pattern showed no change in 86.6%, improved in 6.7%, and deteriorated in 8.3% in group A while there was no change in 83.4%, improved in 8.3%, and deteriorated in 8.3% in group B. Dental and labiodental articulation statistically improved [p < 0.05] after surgery. PROM reported 85.7% of patients with improved speech, 82.1% improved sound quality along with 89.3% improvement in articulation. The primary cause for functional impairment and poor aesthetics in cleft deformity is the maxillary hypoplasia and therefore, should be the focus during correction. The pre-operative VP status or the amount of maxillary advancement could not predict the postoperative VP status. Maxillary advancement over 10mm did not seem to significantly affect the final VP status. Articulation improves due to increased tongue space and favorable dental segment positioning. Mild to moderate immediate post op changes in nasality improves or even reverts to their preoperative status in the majority of the cases in about six months.

Caracterização anatomofuncional da velofaringe hipodinâmica em indivíduos com fissura de palato

ABSTRACT Purpose: to characterize the velopharyngeal function of individuals presented with velopharyngeal dysfunction, suggestive of a hypodynamic velopharynx. Methods: the sample comprised nasoendoscopy examinations from adult subjects with repaired cleft palate, no fistula, velopharyngeal dysfunction, and a probable diagnosis of hypodynamic velopharynx. All participants used a pharyngeal bulb prosthesis and had never undergone speech therapy for velopharyngeal dysfunction. Three speech-language pathologists assessed the movement of velopharyngeal structures. The results were analyzed using descriptive statistics, the Kappa being employed to measure intra-rater agreement. Results: out of the 28 recordings, 23 (82%) exhibited minimal mobility of the soft palate and lateral pharyngeal walls, with a large residual velopharyngeal gap. Additionally, 23 (82%) showed no antagonistic movement, and the Passavant's ridge was present in 7 (25%). Regarding the type, 16 (57%) had a circular gap, 8 (28%) had a circular gap with a Passavant´s ridge, 3 (10%) had a coronal gap, and 1 (5%) had a sagittal one. There was no movement of the posterior pharyngeal wall in 14 (50%) recordings. Agreement was considered almost perfect for all aspects analyzed (Kappa = 1.00). Conclusion: subjects presented with velopharyngeal dysfunction, indicative of a hypodynamic velopharynx, exhibited a velopharyngeal gap equal to or greater than 50% of the resting size of the velopharyngeal space, with minimal movement of the soft palate and pharyngeal walls.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI.The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy.The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC.Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy

The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.

Task-Dependent Velopharyngeal Timing in Singers with Classical Training

This study examined velopharyngeal (VP) timing characteristics during singing and speaking tasks among singers with varying degrees of classical training. Pressure-flow data were collected when eight soprano singers sang and spoke the phrase, "I will say hamper," at different pitch (C4 and C5) and loudness levels (soft, medium, and loud). VP aerodynamic variables (VP gap, peak nasal airflow [NF], and peak intraoral pressure [OP]) and timing variables (NF pulse duration, OP pulse duration, and total duration of the /mp/ sequence) were of particular interest. Results of linear mixed-effects models showed no significant main effect of task type (speaking vs. singing) on VP aerodynamic variables. Task type was found to have a statistically significant main effect on OP pulse duration (F(1, 77) =27.590, P<0.05) and total duration of the /mp/ sequence (F(1, 75.034) =17.895, P<0.05), with both durational measures significantly shorter for singing (OP pulse duration: 200ms, total duration of the /mp/ sequence: 212ms) than for speaking (OP pulse duration: 228ms, total duration of the /mp/ sequence: 238ms). The pitch had a significant main effect on OP pulse duration, with C5 (207ms) significantly shorter than C4 (221ms). Loudness was found to have no significant main effects on any of the VP timing variables. VP timing patterns significantly differed between the singing and the speaking task. Specifically, the singers employed a quick OP pulse rise time, which shortened OP pulse duration as well as the total duration of the /mp/ sequence during the singing task in comparison to the speaking task. Robust VP timing patterns observed during singing may reflect the singers' skilled control of the VP mechanism to achieve functional and esthetic goals.

Magnetic Resonance Imaging of the Velopharynx: Clinical Findings in Patients with Velopharyngeal Insufficiency.

Magnetic resonance imaging (MRI) is the only imaging modality capable of directly visualizing the levator veli palatini (LVP) muscles: the primary muscles responsible for velopharyngeal closure during speech. MRI has been used to describe normal anatomy and physiology of the velopharynx in research studies, but there is limited experience with use of MRI in the clinical evaluation of patients with velopharyngeal insufficiency (VPI). MRI was used to evaluate the velopharyngeal mechanism in patients presenting for VPI management. The MRI followed a fully awake, nonsedated protocol with phonation sequences. Quantitative and qualitative measures of the velopharynx were obtained and compared with age- and sex-matched individuals with normal speech resonance. MRI was completed successfully in 113 of 118 patients (96%). Compared with controls, patients with VPI after cleft palate repair had a shorter velum (P < 0.001), higher incidence of LVP discontinuity (P < 0.001), and shorter effective velar length (P < 0.001). Among patients with persistent VPI after pharyngeal flap placement, findings included a pharyngeal flap base located inferior to the palatal plane [11 of 15 (73%)], shorter velum (P < 0.001), and higher incidence of LVP discontinuity (P = 0.014). Patients presenting with noncleft VPI had a shorter (P = 0.004) and thinner velum (P < 0.001) and higher incidence of LVP discontinuity (P = 0.014). MRI provides direct evidence of LVP muscle anomalies and quantitative evaluation of both velar length and velopharyngeal gap. This information is unavailable with traditional VPI imaging tools, suggesting that MRI may be a useful tool for selecting surgical procedures to address patient-specific anatomic differences.

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

The purpose of this study was to analyze perceptual, acoustic, and aerodynamic changes in speech and velopharyngeal function after bilateral buccal flap revision palatoplasty (BBFRP) in patients with repaired cleft palate. Ten consecutive patients ages 4 to 18 years with velopharyngeal dysfunction treated with BBFRP by a single surgeon were evaluated. Using a visual analog scale, nine blinded speech-language pathologists independently rated hypernasality, hyponasality, audible nasal emission, and speech acceptability. Measurements of the acoustic speech signal were used to quantify changes in hypernasality and nasal emission. The pressure flow technique was used to determine changes in velopharyngeal gap size. Complete records were available for eight patients. After surgery, hypernasality decreased ( P < 0.001) and speech acceptability increased ( P < 0.001) significantly. Audible nasal emission was significantly reduced ( P < 0.001). Postoperative acoustic measures showed a reduction of nasal emission and nasalization. Velopharyngeal gap size significantly decreased after BBFRP ( P < 0.001), correlating with lower visual analog scale ratings of hypernasality ( P = 0.015). Hyponasality did not change significantly after surgery ( P = 0.964). No patient developed sleep-disordered breathing. BBFRP resulted in a measurable improvement in hypernasal speech, audible nasal emission, and speech acceptability without significant changes in hyponasality or risk of obstructive sleep apnea. Therapeutic, IV.

"Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction."

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

Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome Patients: An Assessment of Nasal Endoscopy and Speech Evaluation Findings

Objective: The goal of this study was to assess the correlation between nasal endoscopy and speech evaluation findings in a population of 22q11.2DS patients undergoing operative intervention for correction of VPI at a quaternary care pediatric hospital. We hypothesized using a modified grading scale, certain nasal endoscopy findings such as larger pre-operative velopharyngeal gap size would correlate with perceptual speech assessment findings such as decreased intelligibility, increased hypernasality, and increased nasal emission. Subjects and Methods: A retrospective chart review was conducted, reviewing fifty-two pediatric patients with 22q11.2DS who presented to the VPI clinic and were candidates for surgery at an urban, quaternary care children’s hospital between 2010 and 2019. The following information was collected: demographic information, presenting symptoms of 22q11DS, speech therapy evaluation data, VPI surgical data, and complications. Thirty-two patients had complete preoperative records and thus were ultimately included in the review. Results: Twelve patients (37.5%) had a small gap size, 13 patients (40.6%) had a moderate gap size, and 5 patients (15.6%) had a large gap size. There was no statistically significant correlation between intelligibility and right lateral wall movement (rho: 0.315, p-value: 0.218), left lateral wall movement (rho: 0.175, p-value: 0.502), or AP movement (rho: 0.172, p-value: 0.525). Velum length was negatively correlated with intelligibility (rho:-0.486, p-value:0.048). Conclusion: Our data emphasizes the importance of a multidisciplinary team when evaluating complex 22q11.2DS patients. Our unique scale provides an objective measure of nasal endoscopy by consistently documenting the findings of AP movement, gap shape, gap size, as well as other details such as velar notch and presence of Passavant’s ridge.

Surgical Management of Submucous Cleft Palate by Radical Muscle Dissection Veloplasty: Speech Outcomes in Patients with 22q11.2 Deletion Syndrome.

To evaluate the benefit of anatomical muscle dissection repair for velopharyngeal insufficiency (VPI) in patients with submucous cleft palate (SMCP) with 22q11.2 deletion syndrome. Retrospective blinded randomised analysis of a surgeon's management over 10 years. The study was performed at a specialised Paediatric hospital in the United Kingdom. Children with SMCP and 22q11.2 deletion syndrome. All participants underwent radical muscle dissection veloplasty. Pre- and post- operative measurements included severity of anatomical defect, speech samples and lateral images which were digitised, randomised then externally and blindly analysed using validated techniques. Stata software was used to perform statistical analysis. 57 children with 22q11.2 deletion syndrome were included in this analysis. Intra-operatively, the majority of cases were identified as SMCP Grade I anomalies. Post-operatively, a statistically significant improvement in hypernasality, resting palate length, palate length at maximum closure, palate excursion and gap size at maximum closure was observed. Secondary surgery was performed for 59% of patients by ten years. Muscle dissection repair improves hypernasality, palate closure function and the closure gap in patients with 22q11.2 deletion syndrome. Although over 50% of patients may require further surgery, muscle dissection repair should be a first step due to its utility at a younger age, when invasive investigations are impossible, its lower morbidity, speech and language benefits or altering the plans for less obstructive secondary surgery when it lead to reduced velo-pharyngeal gap and improved palate mobility even when adequate velo-pharyngeal closure was not achieved.

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.

Posterior pharyngeal wall augmentation using autologous tiered costal cartilage for velopharyngeal insufficiency

The aim of this study was to retrospectively estimate intervention outcomes and to establish suitable indications for autogenous tiered cartilage augmentation (ATCA) of the posterior pharyngeal wall for velopharyngeal insufficiency (VPI). The sample cohort comprised 17 consecutive patients with VPI (10 boys, 7 girls), excluding syndromic cases. Pre- and postoperative findings were comprehensively evaluated using a combination of speech assessment and lateral pharyngography (LPG). Hypernasality and consonant distortion were scored (normal: 0; mild: 1; moderate: 2; severe: 3). Velopharyngeal gap size at rest (AC) and at maximum closure (BC) were measured on LPG. All patients displayed improvements in velopharyngeal function and speech score, and no patients required re-operation. Pre- and postoperative hypernasality scores were 1.9±0.5 and 0.6±0.5, respectively (P < .001). Pre- and postoperative consonant distortion scores were 1.9±0.6 and 0.6±0.5, respectively (P < .001). Pre- and postoperative AC distances were 8.2±3.4mm and 5.9±2.6mm, respectively (P < .001). Pre- and postoperative BC distances were 3.9±2.4mm and 0.3±0.8mm, respectively (P < .001). Conclusions: ATCA appears effective for surgical treatment of VPI patients with a gap less than 10mm.

Speech Outcomes of Treatment for Velopharyngeal Insufficiency: Combined Use of an Overlapping Intravelar Veloplasty and Dynamic Sphincter Pharyngoplasty.

Velopharyngeal insufficiency involving a large velopharyngeal gap and poor lateral wall movement is referred to as a "black hole" and remains a challenging problem for cleft surgeons. The effect of the pharyngeal flap on this form of velopharyngeal insufficiency is still debatable because a wide pharyngeal flap is associated with a high incidence of airway obstruction. The present study aimed to evaluate the speech outcomes of combined overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency. Between March 2016 and June 2019, 15 patients with velopharyngeal insufficiency were treated with a combination of overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty. Preoperative speech evaluation was performed on the basis of perceptual speech evaluation, nasometry, and nasoendoscopy. Postoperative speech evaluation using the same approach as that used preoperatively was performed after completion of speech therapy. All 15 patients achieved satisfactory velopharyngeal port closure and speech phonation after completion of speech therapy. No additional procedures were performed to improve velopharyngeal port closure and speech production. The preoperative and postoperative results of perceptual speech evaluation, nasometry, and nasoendoscopy evaluation were significantly different (P < 0.01). Combined treatment with overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty can correct the velopharyngeal insufficiency "black hole" with highly reliable results and minimal risk of airway obstruction.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty.

Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning. This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length. Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001). BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.