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Background: Velopharyngeal dysfunction (VPD) in head and neck cancer is frequently clinically reported, affecting both speech and swallowing function. This review sought to identify the tumor subsites and treatment modalities reported in association with VPD and summarize the current reporting methodology of VPD-related speech and swallowing outcomes in patients following head and neck cancer treatment., Methods: A literature search was conducted through December 2020 using electronic databases and a total of 15 studies were included in review., Results: Reported VPD was largely secondary to palate resections. Large variability in reporting methodology was noted with heavy reliance on speech-related perceptual measures and swallowing-related patient-reported outcomes over imaging and instrumental evaluations., Conclusions: This review revealed inconsistencies in evaluating and reporting VPD, which likely translates into inconsistencies in clinical management. Further attention to VPD secondary to other head and neck malignancies would provide a broader perspective on VPD through head and neck cancer treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Rhinophonia aperta may result from velopharyngeal insufficiency. Neuromuscular electrical stimulation (NMES) has been discussed in the context of muscle strengthening. The aim of this study was to evaluate in healthy subjects whether NMES can change the velopharyngeal closure pattern during phonation and increase muscle strength., Method: Eleven healthy adult volunteers (21-57 years) were included. Pressure profiles were measured by high resolution manometry (HRM): isolated sustained articulation of /a/ over 5 s (protocol 1), isolated NMES applied to soft palate above motor threshold (protocol 2) and combined articulation with NMES (protocol 3). Mean activation pressures (MeanAct), maximum pressures (Max), Area under curve (AUC) and type of velum reactions were compared. A statistical comparison of mean values of protocol 1 versus protocol 3 was carried out using the Wilcoxon signed rank test. Ordinally scaled parameters were analyzed by cross table., Results: MeanAct values measured: 17.15±20.69 mmHg (protocol 1), 34.59±25.75 mmHg (protocol 3) on average, Max: 37.86±49.17 mmHg (protocol 1), 87.24±59.53 mmHg (protocol 3) and AUC: 17.06±20.70 mmHg.s (protocol 1), 33.76±23.81 mmHg.s (protocol 3). Protocol 2 produced velum reactions on 32 occasions. These presented with MeanAct values of 13.58±12.40 mmHg, Max values of 56.14±53.14 mmHg and AUC values of 13.84±12.78 mmHg.s on average. Statistical analysis comparing protocol 1 and 3 showed more positive ranks for MeanAct, Max and AUC. This difference reached statistical significance (p=0.026) for maximum pressure values., Conclusions: NMES in combination with articulation results in a change of the velopharyngeal closure pattern with a pressure increase of around 200% in healthy individuals. This might be of therapeutic benefit for patients with velopharyngeal insufficiency., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2024 Miller et al.)

Background: During articulation the velopharynx needs to be opened and closed rapidly and a tight closure is needed. Based on the hypothesis that patients with cleft lip and palate (CLP) produce lower pressures in the velopharynx than healthy individuals, this study compared pressure profiles of the velopharyngeal closure during articulation of different sounds between healthy participants and patients with surgically closed unilateral CLP (UCLP) using high resolution manometry (HRM)., Materials and Methods: Ten healthy adult volunteers (group 1: 20-25.5 years) and ten patients with a non-syndromic surgically reconstructed UCLP (group 2: 19.1-26.9 years) were included in this study. Pressure profiles during the articulation of four sounds (/i:/, /s/, /ʃ/ and /n/) were measured by HRM. Maximum, minimum and average pressures, time intervals as well as detection of a previously described 3-phase-model were compared., Results: Both groups presented with similar pressure curves for each phoneme with regards to the phases described and pressure peaks, but differed in total pressures. An exception was noted for the sound /i:/, where a 3-phase-model could not be seen for most patients with UCLP. Differences in velopharynx pressures of 50% and more were found between the two groups. Maximum and average pressures in the production of the alveolar fricative reached statistical significance., Conclusions: It can be concluded that velopharyngeal pressures of patients with UCLP are not sufficient to eliminate nasal resonance or turbulence during articulation, especially for more complex sounds. These results support a general understanding of hypernasality during speech implying a (relative) velopharyngeal insufficiency., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2024 Miller et al.)

Background: Velopharyngeal structure augmentation methods are used as alternatives to pharyngeal flap operations. Recently, we investigated the sites of velopharyngeal structure augmentation in dogs and reported that the most effective injection location is the soft palate. However, there have been no reports regarding the optimal materials for implantation or injection. In this study, we aimed to investigate the injectable materials used in soft palate augmentation in dogs to ameliorate velopharyngeal insufficiency (VPI)., Methods: Endoscopic soft palate augmentation (ESPA) was performed in dogs using purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. ESPA is an original technique developed by our group, and this is the first report of its performance. Moreover, we assessed the amount of nasal air leakage during inspiration at rest and during expiration under the rebreathing system at 1, 2, 3, 4, 5, and 6 months after injection of these materials., Results: The amount of nasal air leakage during expiration under the rebreathing system was significantly decreased in all dogs injected with the ESPA materials, but neither apnea nor hypopnea was observed., Conclusions: We investigated the optimal materials for use in ESPA, such as purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. We found that all of them reduced nasal air leakage and only autogenic fat tissue showed significant histologic differences in dogs at 6 months. This technique may also be useful for the treatment of patients with VPI., Competing Interests: The authors have declared that no competing interests exist.

Despite uneventful primary surgery, patients with cleft palate may experience velopharyngeal insufficiency (VPI) and hypernasal speech. Videoradiography of velopharynx is a commonly used method to visualize velopharyngeal function and a velopharyngeal flap is often used to counteract VPI. The aim of this study was to investigate whether the frontal projection on videoradiography plays a role in the decision-making about velopharyngeal flap surgery, or possibly the width and orientation of the flap. A secondary aim was to evaluate the effect of the flap in improving velopharyngeal function. Between 2007 and 2016, 75 patients had received a flap at our department. During the same period of time, 41 patients who had undergone videoradiography did not receive a flap. Medical records, particularly regarding speech assessments, videoradiography statements and operating records, were scrutinised to seek information about the factors leading up to the decision about whether or not to perform a flap. In only one instance, reduced lateral pharyngeal wall movement found on the frontal projection was clearly taken into account when deciding to refrain from performing a velopharyngeal flap. Only a slight agreement was found between pre-operative speech assessment and findings in videoradiography. Hypernasality was reduced by flap surgery in 97% of the patients. We conclude the frontal projection of the videoradiographic examination seems to have no crucial role in the decision-making on performing a velopharyngeal flap or not in patients with cleft palate. Even with reduced lateral pharyngeal wall movement, a velopharyngeal flap effectively reduces hypernasality and VPI.

Objective: To identify and describe the dynamic features of velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome relative to patients with non-syndromic cleft palates., Study Design: Retrospective case-control study., Setting: Pediatric tertiary care center., Subjects and Methods: A total of 30 children (aged 9-16 years) with VPD were included in this study. Fifteen children with a definitive diagnosis of 22q11.2 deletion syndrome requiring surgical VPD repair were included in the 22q11.2 deletion syndrome group. Fifteen age- and sex-matched children with non-syndromic cleft palate requiring surgical VPD repair were included in the non-syndromic cleft palate group for comparison. Velar displacement, lateral pharyngeal wall displacement, and lateral pharyngeal wall motion pattern data were extracted from preoperative Multiview Videofluoroscopy imaging studies of all children and compared across groups., Results: Lateral pharyngeal wall displacement was found to be reduced in the 22q11.2 deletion syndrome group (U = 29.50, p = .001, r = .63). However, measures of velar displacement were not observed to differ between groups. Similarly, lateral pharyngeal wall motion pattern distributions were not found to differ across these two groups., Conclusions: Velopharyngeal dysfunction in patients with 22q11.2 deletion syndrome showed differences in dynamic velopharyngeal function when compared to non-syndromic cleft palate patients. The current findings provide initial insights into the unique aspects of velopharyngeal dysfunction for patients with 22q11.2 deletion syndrome. These findings may guide further efforts directed toward understanding the dynamic velopharyngeal characteristics of this population and potentially optimize surgical management and functional outcomes.

Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.

Purpose: To investigate the reliability in auditory-perceptual assessment of hypernasality of the Borg centiMax scale and the influence of the speech material on the reliability of two scales., Methods: Four experienced speech-language pathologists rated hypernasality of 80 audio recordings of patients with repaired cleft palate (40 single-word string and 40 sentences) using the 5-point ordinal scale and the Borg centiMax scale. Intra and inter-rater reliability were calculated for both scales and for both types of speech samples. The comparison between the agreement coefficients of the two speech samples was calculated using the Z test and between the scales was calculated by Spearman correlation coefficient, considering as significant p<0.05., Results: A very high and statistically significant correlation was found between the Borg centiMax scale and the ordinal scale for both speech samples. Intra- and inter-rater reliability was higher for Borg scale as compared to ordinal scale. Good to excellent intra-rater reliability was found for Borg scale for both speech samples. Poor to excellent intra-rater reliability was found for ordinal scale for both stimuli. Higher inter-rater reliability was demonstrated for Borg scale than ordinal scale for both speech samples. There was a significant difference between the single words string and sentences for intra- and inter-rater reliability using Borg scale, and for inter-rater reliability using ordinal scale., Conclusion: The Borg centiMax scale showed better intra and inter-rater reliability. Additionally, the speech material comprising of single words string showed better reliability in most of the comparisons for both scales.

The presence of hypernasality in repaired cleft palate (CP) speech is a consequence of velopharyngeal insufficiency. The coupling of the nasal tract with the oral tract adds nasal formant and antiformant pairs in the hypernasal speech spectrum. This addition deviates the spectral and linear prediction (LP) residual characteristics of hypernasal speech compared to normal speech. In this work, the vocal tract constriction feature, peak to side-lobe ratio feature, and spectral moment features augmented by low-order cepstral coefficients are used to capture the spectral and residual deviations for hypernasality detection. The first feature captures the lower-frequencies prominence in speech due to the presence of nasal formants, the second feature captures the undesirable signal components in the residual signal due to the nasal antiformants, and the third feature captures the information about formants and antiformants in the spectrum along with the spectral envelope. The combination of three features gives normal versus hypernasal speech detection accuracies of 87.76%, 91.13%, and 93.70% for /a/, /i/, and /u/ vowels, respectively, and hypernasality severity detection accuracies of 80.13% and 81.25% for /i/ and /u/ vowels, respectively. The speech data are collected from 30 control normal and 30 repaired CP children between the ages of 7 and 12.

Audible nasal emission is a speech disorder that involves undesired sound generated by airflow into the nasal cavity during production of oral sounds. This disorder is associated with small-to-medium sized velopharyngeal openings. These openings induce turbulence in the nasal cavity, which in turn produces sound. The purpose of this study is to examine the aeroacoustic mechanisms that generate turbulent sound during production of a sibilant /s/ with and without a small opening of the velopharyngeal valve. The models are based on two pediatric subjects who were diagnosed with severe audible nasal emission. The geometries were delineated from computed tomography scans taken while the subjects were sustaining a sibilant sound. Large eddy simulation with the Ffowcs Williams and Hawkings analogy was used to predict the flow behavior and its acoustic characterization. It shows that the majority of the acoustic energy is produced by surface loading, which is related to dipole sources that resonate in the nasal cavity. The quadrupole source term that is associated with the unsteady shear layers is seen to be less significant. It also shows that closure of the velopharyngeal valve changes the far-field spectrum significantly because aeroacoustic mechanisms in the nasal cavity are eliminated.

Introduction: Cleft palate is among the most common birth abnormalities. The success of primary surgery in the early months of life is crucial for successful feeding, speech, hearing, dental development and facial growth. Over recent decades, age at palatal surgery in infancy has reduced. This has led to palatal closure in one-stage procedures being carried out around the age of 12 months, but in some cases as early as 6 months. The primary objective of the Timing Of Primary Surgery for Cleft Palate (TOPS)trial is to determine whether surgery for cleft palate performed at 6 or 12 months of age is most beneficial for speech outcomes., Methods and Analysis: Infants with a diagnosis of non-syndromic isolated cleft palate will be randomised to receive standardised primary surgery (Sommerlad technique) for closure of the cleft at either 6 months or 12 months, corrected for gestational age. The primary outcome will be perceived insufficient velopharyngeal function at 5 years of age. Secondary outcomes measured across 12 months, 3 years and 5 years will include growth, safety of the procedure, dentofacial development, speech, hearing level and middle ear function. Video and audio recordings of speech will be collected in a standardised age-appropriate manner and analysed independently by multiple speech and language therapists. The trial aims to recruit and follow-up 300 participants per arm. Data will be analysed according to the intention-to-treat principle using a 5% significance level. All analyses will be prespecified within a full and detailed statistical analysis plan., Ethics and Dissemination: Ethical approval has been sought in each participating country according to country-specific procedures. Trial results will be presented at conferences, published in peer-reviewed journals and disseminated through relevant patient support groups., Trial Registration Number: NCT00993551; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Retropharyngeal lipostructure is a recent procedure in velopharyngeal insufficiency (VPI), offering an effective alternative to heavier surgery., Objectives: To update and assess retropharyngeal lipostructure as a treatment for VPI in the University Hospital Center of Rouen (France)., Type of Study: Single-center prospective study, from May 2012 to May 2014., Patients and Methods: Six patients (4 girls, 2 boys) presenting with VPI were treated by retropharyngeal lipostructure. Age at surgery ranged between 6 and 12 years. Four of the patients bore a 22q11 microdeletion. Treatment was indicated in case of Borel-Maisonny type 2b (n=2) or 2m (n=4) despite well-conducted speech therapy and of≥50% velopharyngeal sphincter closure on nasal endoscopy. Patients were assessed preoperatively and at 3 months, by a multidisciplinary team. Borel-Maisonny type was assessed by a speech therapist. Nasality was measured on assisted vocal evaluation (EVA ® ). Sphincter closure was assessed on dynamic MRI., Results: Between 6 and 8cm 3 autologous fat was injected. At 3months, 4 children showed 1-grade improvement in Borel-Maisonny type. Nasality decreased systematically, from a mean 14.5% preoperatively to 10.5% postoperatively. MRI showed improvement in all cases, with complete closure in occlusive vowels in 3 children., Conclusion: EVA ® and MRI provide precise objective assessment of VPI. Retropharyngeal lipostructure is a simple, relatively non-invasive, reproducible technique, providing good results in VPI., (Copyright © 2019. Published by Elsevier Masson SAS.)

Dysfunction of the velopharyngeal valve in the human airway causes speech disorders because there is no separation between the oral and nasal cavities during normal oral speech. The speech literature hypothesizes that undesired sound is formed by turbulent flow in the nasal cavity in cases of small velopharyngeal openings. The aim is to determine the flow behavior and the sound-generating mechanism in the vocal tract using computational fluid dynamics in two patient-specific models with small and large velopharyngeal openings and contrast it with cases of complete velopharyngeal closure. The geometry for the models was reconstructed from computed tomography scans that were taken while the patients were sustaining a sibilant sound. The results for the turbulence are correlated with the broadband acoustic models of Proudman and Curle. The models show that turbulence in the vocal tract increases downstream of a constriction and that sound may be generated from it. Furthermore, most of the sound due to turbulence in the nasal cavity is governed by a dipole source where turbulence interacts with the nasal cavity walls. The generated sound power by turbulence itself in the nasal cavity (the quadrupole source) is two orders of magnitude less than the dipole source.

Background: Velopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI)., Methods: Velopharyngeal structure augmentation was performed on 10 beagles (age range: 20-24 months; weight range: 9-12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage., Results: Pre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls., Conclusions: During VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients., Competing Interests: The authors have declared that no competing interests exist.

Objective: To investigate the therapeutic effects of mechanical inspiration and expiration exercise using mechanical cough assist on velopharyngeal incompetence in patients with subacute stroke., Design: Pilot, randomized controlled study., Setting: University-based rehabilitation centre., Subjects: Thirty-six patients with subacute stroke diagnosed with velopharyngeal incompetence by videofluoroscopic swallowing study., Methods: Subjects were randomly assigned to 2 groups. The study group received conventional dysphagia therapy and additional mechanical inspiration and expiration exercise. The control group received conventional dysphagia therapy only. Swallowing function was evaluated according to the American Speech-Language-Hearing association scale, functional dysphagia score, and the penetration aspiration scale, based on the videofluoroscopic swallowing study. Coughing function was measured using peak cough flow., Results: Eighteen patients in each group completed the protocol and were analysed. After treatment, the study group showed significant improvement in functional dysphagia score with regard to nasal penetration degree. Comparing the treatment effect between the 2 groups, nasal penetration degree and peak cough flow showed greater improvement in the study group., Conclusion: Mechanical inspiration and expiration exercise had a therapeutic effect on velopharyngeal incompetence in subacute stroke patients with dysphagia. This therapy is easy to provide clinically and could be a useful therapeutic strategy for velo-pharyngeal incompetence with dysphagia in patients with stroke.

Aim: To report our initial experience and preliminary results of autologous free fat transfer to improve speech and hypernasality in patients with velopharyngeal insufficiency (VPI) as a sequela of cleft lip and palate repair., Material and Methods: To date 2 patients with a mean age of 25 years were treated with this method. Both had initially received multiple procedures elsewhere for cleft lip and palate repair. We recorded the number of free fat transfer sessions, anatomical places of placement and volumes injected in-patient stay, occurrence or absence of complications and effectiveness of this operation in terms of clinical speech evaluation, functional velopharyngeal closure measurements and speech improvement percentage by an Ear, Nose and Throat (ENT) specialist., Results: Two autologous free fat transfer sessions per patient were performed. Mean hospitalization time was 1 day per operation. Following liposuction, autologous free fat was transferred to the following anatomical areas: a) Passavant's ridge, b) uvula, c) palatopharyngeal and palatoglossal folds. The volume of fat injected varied from 6.5 cc to 8 cc per session. Postoperative periods were uneventful for both cases in each session. On clinical examination, improvement in speech was noted as well as a reduction in hypernasality with an improvement in articulation and audibility of consonant words, which were also reported by the patients' relatives. This was confirmed by objective nasendoscopy velopharyngeal closure measurements, both during speech and deglutition., Conclusion: Augmentation pharyngoveloplasty with autologous free fat transfer in patients with velopharyngeal insufficiency is a safe and innovative alternative, particularly for small to medium degrees of structural velophayngeal dysfunction.

Background: There is a lack of high-level evidence on the surgical management of cleft palate. An appreciation of the differences in the complication rates between different surgical techniques and timing of repair is essential in optimizing cleft palate management., Method: A comprehensive electronic database search will be conducted on the complication rates associated with cleft palate repair using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Two independent reviewers with expertise in cleft pathology will screen all appropriate titles, abstracts, and full-text publications prior to deciding whether each meet the predetermined inclusion criteria. The study findings will be tabulated and summarized. The primary outcomes will be the rate of palatal fistula, the incidence and severity of velopharyngeal insufficiency, and the rate of maxillary hypoplasia with different techniques and also the timing of the repair. A meta-analysis will be conducted using a random effects model., Discussion: The evidence behind the optimal surgical approach to cleft palate repair is minimal, with no gold standard technique identified to date for a certain type of cleft palate. It is essential to appreciate how the complication rates differ between each surgical technique and each time point of repair, in order to optimize the management of these patients. A more critical evaluation of the outcomes of different cleft palate repair methods may also provide insight into more effective surgical approaches for different types of cleft palates.

Hypernasality is seen in cleft lip and palate patients who had undergone repair surgery as a consequence of velopharyngeal insufficiency. Hypernasality has been studied by evaluation of perturbation, noise measures, and cepstral analysis of speech. In this study, feature extraction and analysis were performed during running speech using six different sentences. Jitter, shimmer, Mel frequency cepstral coefficients, bionic wavelet transform entropy, and bionic wavelet transform energy were calculated. Support vector machines were employed for classification of data to normal or hypernasal. Finally, results of the automatic classification were compared with true labels to find accuracy, sensitivity, and specificity. Accuracy was higher when Mel frequency cepstral coefficients were combined with bionic wavelet transform energy feature. In the best case, accuracy of 85% with sensitivity of 82% and specificity of 85% was obtained. Results prove that acoustic analysis is a reliable method to find hypernasality in cleft lip and palate patients.

Introduction: Oro-facial clefts involving the palate is the commonest structural defect causing velopharyngeal insufficiency (VPI) and poor intelli gibility of speech. Proper repair of the soft palateis a surgical challenge. Posterior-based buccinator myomucosal flap (BMF) is used to lengthen the soft palate of patients who undergo primary palatoplasty at Teaching Hospital, Karapitiya (THK). BMF is a good choice for the repair of medium sized mucosal defects in the oral cavity since it has appropriate thickness, contains mucous membrane with mucous glands and has a rich blood supply. Objectives To assess improvement in quality of speech after soft palate repair using BMF in patients with previously corrected cleft pate., Methods: Thirty four patients (M:F-1:1) who had undergone palatal lengthening using BMF procedure for correction of VPI for speech improvement at Teaching Hospital, Karapitiya from 2010 to 2012, were assessed before and one year after surgery for quality of speech., Results: All patients below 8 years showed significant reduction of hypernasality (p<0.05), whereas only 60% of patients above 8 years showed reduction after the surgery. All patients showed reduction in nasal air emission and in consonant production error at least by one consonant. The group below 8 years showed more improvement in speech quality after surgery., Conclusions: Palatal lengthening using BMF procedure is a good treatment option for correction of VPI.

Introduction A high agreement in the perceptual assessment of hypernasality among different listeners is difficult to achieve. Prior listener training and the standardization of analysis criteria may be effective strategies to decrease the effect of perceptual assessment subjectivity and increase the agreement among listeners. Objective To investigate the influence of prior training on agreement among different listeners in the perceptual assessment of hypernasality. Methods Three experienced speech-language pathologists analyzed 77 audio-recorded speech samples of individuals with repaired cleft palate. During the first phase, the listeners classified hypernasality according to their own criteria, using a 4-point scale. Seventy days later, they were required to complete the training to define the stimuli to be used as anchors for the assessment in the following phase. During the second phase, the listeners analyzed the same samples and rated hypernasality in a 4-point scale, using the anchors defined during training as the criteria. Intra- and interrater agreement in both the phases were calculated by the kappa coefficient. These values were statistically compared using the Z-test. Results The intrarater agreement obtained between the two phases of the study ranged from 0.38 to 0.92, with a statistically significant difference for one of the listeners (p=0.004). The agreement for the hypernasality degree obtained among the three listeners after training (0.54) was significantly higher than that obtained before training (0.37; p=0.044). Conclusion Listener training and the definition of criteria to rate hypernasality lead to the increase of intra- and interrater agreement.

Objective: To verify the influence of pharyngeal flap surgery on the management of velopharyngeal insufficiency on nasality and speech nasalance on nasal sound production in individuals with cleft lip and palate., Methods: Prospective study in 159 individuals with repaired cleft palate ± lip, of both genders, aged 6 to 57 years old. All the participants presented residual velopharyngeal insufficiency and were submitted to pharyngeal flap surgery. Perceptual speech evaluation and nasometric assessment were performed before and after (14 months on average) the pharyngeal flap surgery. Hyponasality was rated as absent or present, and nasalance scores were determined by means of nasometer using nasal stimuli, with a cutoff score of 43% used as the lowest limit of normality. Nasality and nasalance were compared before and after surgery (p < 0.05)., Results: On the basis of correlation between both the methods used, perceptual hyponasality was observed in 14% of the individuals, whereas nasalance scores indicating hyponasality (< 43%) were obtained in 25% of the patients after surgery., Conclusion: Pharyngeal flap surgery influenced the production of nasal sounds, causing hyponasality in a significant proportion of individuals. The presence of this speech symptom can also be an indicator of upper airway obstruction caused by pharyngeal flap, which should be investigated objectively and prudently postoperatively.

Purpose: To analyze the velopharyngeal (VP) activity of subjects with velopharyngeal dysfunction (VPD) by acoustic rhinometry, as compared to rhinomanometry., Methods: This was a prospective clinical study conducted in 41 adults, both genders, with repaired cleft palate, with or without a previously repaired cleft lip, and residual VPD on clinical assessment, without compensatory articulations for [p], [t], and [k]. The outcome measures were as follows: (1) on acoustic rhinometry, nasopharyngeal volumetric change (ΔV) during [p], [t], and [k], relatively to rest condition (decreases by <3 cm3 considered as absence of VP activity); (2) on modified anterior rhinomanometry, VP orifice area (areas ≥0.05 cm2 considered as inadequate closure). The plosive [p] was used when comparing the techniques (n=24)., Results: (1) A mean ΔV decrease of 18% was observed during [k], which was significantly lower (p<0.05) than the decrease reported for individuals without VPD (30%). ΔV values suggesting VPD were observed in 59% subjects. Similar results were obtained for [p] and [t], which shall be used as stimulus, given that they do not involve the use of the tongue to lift the velum during VP closure, differently from the velar plosive [k]. (2) Inadequate closure was seen in 85% subjects. No correlation was observed between ∆V and VP orifice area. Agreement between techniques was observed in 51% cases., Conclusion: Acoustic rhinometry had low accuracy as a diagnostic method of VPD when compared to the gold standard method. Nevertheless, the technique shows potential as a method for monitoring the outcomes of clinical and surgical treatment of VPD aimed at increasing velar and pharyngeal activity.

Purpose: To investigate the correlation among velopharyngeal closure, hypernasality, audible nasal air emission (NAE) and nasal rustle (NR), in individuals with repaired cleft palate., Methods: One hundred patients with repaired cleft palate and lip, submitted to pressure-flow study for measurement of velopharyngeal orifice area (velopharyngeal area) and speech sample recordings. Velopharyngeal area was estimated during the production of the sound /p/ inserted in a sentence, and the velopharyngeal closure was classified as adequate, borderline or inadequate. Hypernasality was rated using a 4-point scale, NAE and NR were rated as absent or present, by three speech language pathologists, using recorded speech samples. Inter and intra-judge agreements were established. Statistical analysis was performed using the Spearman correlation coefficient considering p<0.05. An ordinal logistic regression model was developed to investigate whether the characteristics of speech can predict velopharyngeal closure. For this, the speech samples included in this analysis were those that obtained 100% agreement among raters as to the degree of hypernasality (43 out of 100)., Results: Significant correlation was found between hypernasality and velopharyngeal area; audible NAE and velopharyngeal area. A negative correlation was observed between the NR and velopharyngeal area. The regression analysis showed that the perceptual speech characteristics contributed significantly to predict the velopharyngeal closure., Conclusion: There is significant correlation between velopharyngeal closure and hypernasality, NAE and NR. It suggests that the perceptual speech characteristics can predict velopharyngeal closure, favoring the diagnosis and the definition of treatment conduct of velopharyngeal dysfunction.

Purpose: This study obtained nasalance scores during use of compensatory articulation (CA) and compared nasalance between groups with and without hypernasality and with and without CA., Methods: Speech samples were obtained from 43 individuals with and without velopharyngeal dysfunction during repetition of 20 phrases originating 860 audio recordings and their respective nasometric values. After excluding 143 recordings due to low quality, the remaining 717 samples were rated by three speech language pathologists (SLPs), independently, for presence or absence of hypernasality and CA. Nasalance scores for the 553 samples rated with 100% agreement among the SLPs were grouped according to the auditory-perceptual ratings: Group 1 (G1) - included samples without hypernasality and without CA (n=191); Group2 (G2) - included samples with hypernasality and without CA (n=288); Group 3 (G3) - included samples with hypernasality and with pharyngeal fricative (n=33); Group 4 (G4) - included samples with hypernasality and with glottal stop (n=41)., Results: Analysis of variance (ANOVA) revealed significant difference nasalance scores which were significantly higher for G2, G3, and G4 (p<0.0001) when compared to G1. The use of pharyngeal fricative (G3), particularly during /f/ (p=0.0018) and /s/ (p=0.0017) productions resulted in nasalance scores significantly higher than scores found for G2., Conclusion: Significantly higher nasalance values where identified during use of pharyngeal fricative.

Unlabelled: Acoustic rhinometry is routinely used for the evaluation of nasal patency., Objective: To investigate whether the technique is able to identify the impairment of velopharyngeal (VP) activity in individuals with clinical diagnosis of velopharyngeal insufficiency (VPI)., Methods: Twenty subjects with repaired cleft palate and inadequate velopharyngeal function (IVF) and 18 non-cleft controls with adequate velopharyngeal function (AVF), adults, of both genders, were evaluated. Area-distance curves were obtained during VP rest and speech activity, using an Eccovision Acoustic Rhinometry system. Volume was determined by integrating the area under the curve at the segment corresponding to the nasopharynx. VP activity (ΔV) was estimated by the absolute and relative differences between nasopharyngeal volume at rest (Vr) and during an unreleased/k/ production (Vk). The efficiency of the technique to discriminate IVF and AVF was assessed by a ROC curve., Results: Mean Vk and Vr values (± SD) obtained were: 23.2 ± 3.6 cm3 and 15.9 ± 3.8 cm3 (AVF group), and 22.7 ± 7.9 cm3 and 20.7 ± 7.4 cm3 (IVF group), corresponding to a mean ΔV decay of 7.3 cm3 (31%) for the AVF group and a significantly smaller ΔV decay of 2.0 cm3 (9%) for the IVF group (p < 0.05). Seventy percent of the IVF individuals showed a ΔV suggesting impaired VP function (below the cutoff score of 3.0 cm3 which maximized both sensitivity and specificity of the test), confirming clinical diagnosis., Conclusion: Acoustic rhinometry was able to identify, with a good discriminatory power, the impairment of VP activity which characterizes VPI.

Velopharyngeal dysfunction is the inability of the soft palate to affect complete seal with the posterior or lateral pharyngeal walls. Rehabilitation of these patients with palatal defects is challenging for both surgical and prosthetic fields of dentistry. The development of sophisticated surgical techniques and procedures has greatly enhanced the rehabilitation of congenital or acquired palatal defects. However, some of these patients may present oral or systemic factors contraindicating surgical intervention. In addition, since total elimination of these defects surgically has not yet become a reality, there exists a patient population for whom non-surgical rehabilitation must be approached with the help of prosthesis and such prosthesis must restore the basic functions of mastication, deglutition and speech production. Here a non-surgical approach of rehabilitation of such defect is presented in the form of a case report of pharyngeal bulb prosthesis given for a patient with a soft palate defect.

Purpose: To investigate the postoperative outcomes of pharyngeal flap surgery (PF) and secondary palatoplasty with intravelar veloplasty (IV) in the velopharyngeal insufficiency management regarding nasalance scores and velopharyngeal area., Methods: Seventy-eight patients with cleft palate±lips submitted to surgical treatment for velopharyngeal insufficiency, for 14 months on an average, were evaluated: 40 with PF and 38 with IV, of both genders, aged between 6 and 52 years old. Hypernasality was estimated by means of nasalance scores obtained by nasometry with a cutoff score of 27%. The measurement of velopharyngeal orifice area was provided by the pressure-flow technique and velopharyngeal closure was classified as: adequate (0.000-0.049 cm²), adequate/borderline (0.050-0.099 cm²), borderline/inadequate (0.100-0.199 cm²), and inadequate (≥0.200 cm²)., Results: Absence of hypernasality was observed in 70% of the cases and adequate velopharyngeal closure was observed in 80% of the cases, in the PF group. In the IV group, absence of hypernasality was observed in 34% and adequate velopharyngeal closure was observed in 50% of the patients. Statistically significant differences were obtained between the two techniques for both evaluations., Conclusion: PF was more efficient than the secondary palatoplasty with IV to reduce hypernasality and get adequate velopharyngeal closure.

Unlabelled: The use of prosthetic devices for correction of velopharyngeal insufficiency (VPI) is an alternative treatment for patients with conditions that preclude surgery and for those individuals with a hypofunctional velopharynx (HV) with a poor prognosis for the surgical repair of VPI. Understanding the role and measuring the outcome of prosthetic treatment of velopharyngeal dysfunction requires the use of tools that allow for documenting pre- and post-treatment outcomes. Experimental openings in speech bulbs have been used for simulating VPI in studies documenting changes in aerodynamic, acoustic and kinematics aspects of speech associated with the use of palatal prosthetic devices. The use of nasometry to document changes in speech associated with experimental openings in speech bulbs, however, has not been described in the literature., Objective: This single-subject study investigated nasalance and nasality at the presence of experimental openings drilled through the speech bulb of a patient with HV., Material and Methods: Nasometric recordings of the word "pato" were obtained under 4 velopharyngeal conditions: no-opening (control condition), no speech bulb, speech bulb with a 20 mm² opening, and speech bulb with 30 mm² opening. Five speech-language pathologists performed auditory-perceptual ratings while the subject read an oral passage under all conditions., Results: Kruskal-Wallis test showed significant difference among conditions (p=0.0002), with Scheffé post hoc test indicating difference from the no-opening condition., Conclusion: The changes in nasalance observed after drilling holes of known sizes in a speech bulb suggest that nasometry reflect changes in transfer of sound energy related to different sizes of velopharyngeal opening.

Unlabelled: Patients with palatine fissure have inadequate velopharyngeal closure (VPC), with consequent vocal hypernasality which can be reduced by a basal tone., Aim: To compare VPC during a basal tone with the emission of a modal recording, in patients with repaired post-foramen palatine fissure., Materials and Methods: Case study with four adult men, all with repaired post-foramen palatine fissure. VPC images through nasal-pharyngoscopy during the emission o f the [a] vowel in a modal and basal recording. The images were studied by four ENTs., Results: In three subjects there was no change in the type of VPC considering the recordings analyzed; the changes which happened to most of the subjects are associated only to the degree of movement of the structures involved, since in the basal recording the movement of the laryngeal lateral walls was kept, the movement of the posterior pharyngeal wall stabilized, the movement of the palatine veil was mildly reduced, and the Passavant fold was evident., Conclusions: The type of VPC was kept in the four subjects analyzed, when we compared the modal and basal recordings, there was a modification in the degree of movements in the structures involved, making it clear the Passavant Fold.

Nasoendoscopy is an important tool for assessing velopharyngeal function. The purpose of this study was to analyze velar and pharyngeal wall movement and velopharyngeal gap during nasoendoscopic evaluation of the velopharynx before and during diagnostic therapy. Nasoendoscopic recordings of 10 children with operated cleft lip and palate were analyzed according to the International Working Group Guidelines. Ratings of movement of velum and pharyngeal walls, and size, location and shape of gaps were analyzed by 3 speech-language pathologists (SLPs). Imaging was obtained during repetitions of the syllable /pa/ during a single nasoendoscopic evaluation: (a) before diagnostic therapy, and (b) after the children were instructed to impound and increase intraoral air pressure (diagnostic therapy). Once the patients impounded and directed air pressure orally, the displacement of the velum, right, left and posterior pharyngeal walls increased 40, 70, 80, and 10%, respectively. Statistical significance for displacement was found only for right and left lateral pharyngeal walls. Reduction in gap size was observed for 30% of the patients and other 40% of the gaps disappeared. Changes in gap size were found to be statistically significant between the two conditions. In nasoendoscopic assessment, the full potential of velopharyngeal displacement may not be completely elicited when the patient is asked only to repeat a speech stimulus. Optimization of information can be done with the use of diagnostic therapy's strategies to manipulate VP function. Assuring the participation of the SLP to conduct diagnostic therapy is essential for management of velopharyngeal dysfunction.

We recently showed respiratory-related coactivation of both extrinsic and intrinsic tongue muscles in the rat. Here, we test the hypothesis that intrinsic tongue muscles contribute importantly to changes in velopharyngeal airway volume. Spontaneously breathing anesthetized rats were placed in a MRI scanner. A catheter was placed in the hypopharynx and connected to a pressure source. Axial and sagittal images of the velopharyngeal airway were obtained, and the volume of each image was computed at airway pressures ranging from +5.0 to -5.0 cm H2O. We obtained images in the hypoglossal intact animal (i.e., coactivation of intrinsic and extrinsic tongue muscles) and after selective denervation of the intrinsic tongue muscles, with and without electrical stimulation. Denervation of the intrinsic tongue muscles reduced velopharyngeal airway volume at atmospheric and positive airway pressures. Electrical stimulation of the intact hypoglossal nerve increased velopharyngeal airway volume; however, when stimulation was repeated after selective denervation of the intrinsic tongue muscles, the increase in velopharyngeal airway volume was significantly attenuated. These findings support our working hypothesis that intrinsic tongue muscles play a critical role in modulating upper airway patency.

Background: From 1989 to 1993, 113 previously untreated patients were admitted to the Multi-disciplinary Cleft Lip and Palate Team of the University Hospitals Leuven. Palate repair was performed in our centre by one surgeon (FO) in 88 patients. Our current surgical technique consists of a single-stage supraperiosteal retropositioning (modified Veau-Wardill-Kilner) for patients with a soft cleft palate only (SCP) or a soft cleft palate with up to 1 cm of the hard palate (HSCPpa). Patients with a larger or complete cleft of the secondary hard palate (HSCP) and patients with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate undergo two surgical stages for palate closure: a supra-periosteal retropositioning is performed around 12 months of age, and a modified Langenbeck closure of the hard palate around 60 months of age., Aim: To assess velopharyngeal function with speech as outcome measure., Patients and Methods: Velopharyngeal function was assessed in two ways. In one assessment, a "hard" outcome measure was the number of patients undergoing pharyngoplasty following palate repair in our centre (n = 88). In the other assessment, velopharyngeal function was evaluated in a homogeneous sub-population of 44 non-syndromic cleft patients with normal to slight impairment of the following functions: mental development, language development, and hearing. In this group, prospectively collected data about hypernasality and nasal emission were analysed retrospectively using a semi-objective nasality index (NI). Articulation was evaluated using a subjective articulation index (AI) representing articulation errors (retro-articulation, glottal stops and facial grimacing) associated with velopharyngeal insufficiency (VPI). Mean follow-up was 114 months., Results: Despite rigid assessment by a phoniatrician and speech pathologist, only 1 patient out of 88 patients with soft palate surgery in our institution was thought to need pharyngoplasty. In the sub-cohort of 44 non-syndromic patients, nobody needed a pharyngoplasty. In the latter cohort, at the age of about eight years, 27 patients (61.5%) had undetectable nasality, 13 patients (29.5%) had an NI of 1 or "mild" nasality, and 4 patients (9%) had moderate nasality. At this point in time, articulation errors associated with VPI were noted in 14% of patients., Conclusion: In this subgroup of cleft palate patients treated following the Leuven protocol, there was no need for secondary pharyngoplasty. Ninety-one per cent of patients had no, or only mild, rhinolalia aperta by the age of eight years, and 84% did not display VPI-related articulation disorders. This suggests that velopharyngeal function in patients treated by this protocol is excellent compared to results in the literature.

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications. Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed. We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery. Outcome of surgery was determined by a 'Cleft Audit Protocol for Speech' (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality. Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.

In a curved tube, the amount of airflow appears to be influenced by the amount of curvature. The purpose of this study was to investigate changes in obstructive sleep apnoea (OSA) severity and awake velopharyngeal curvature in response to an anteriorly titrated mandibular position in 20 male OSA patients. Baseline supine cephalometry was obtained before the initial insertion of a titratable oral appliance and follow-up supine cephalometry was undertaken after titration of the mandibular position with the appliance in place. The mean apnoea/hypopnea index (AHI) before treatment (31.6 +/- 13.0 events x h(-1)) was significantly reduced (9.8 +/- 7.4 events x h(-1)) after titration of the mandibular position in all 20 patients. There was a significant increase in the anteroposterior calibre and the radius of the curvature of the anterior wall of the velopharynx in 14 good responders who exhibited an AHI reduction to < or = 15. Similar observations were not found in six poor responders. To conclude, an anteriorly titrated mandibular position reduced obstructive sleep apnoea severity, enlarged the velopharynx and diminished the curvature of the anterior velopharyngeal wall in good responders. It is proposed that this change in the upper airway curvature associated with mandibular advancement may effect obstructive sleep apnoea severity through its effect on airflow dynamics.

In this review, normal speech and its development is described and compared with the patterns typical of cleft palate speech. Attention is drawn to the importance of measuring and analysing these factors adequately for research and audit purposes, and the need for agreed parameters for reporting outcomes.

We have undertaken the design and testing of a system for making measurements of velopharyngeal function from lateral videofluoroscopic images based upon standard equipment found in any cleft clinic. The uncertainties in the measurements have been found to be acceptably low and, in conjunction with other measurement techniques, the system has made a valuable contribution to the assessment of velopharyngeal function. Additional measurements using this system are presently being developed.

There is some evidence that speech aerodynamics follows the rules of a regulating system. The purpose of the present study was to assess how the speech system manages perturbations that produce "errors" within the system. Three experimental approaches were used to evaluate the physiological responses to an imposed change in airway resistance. The first involved subjects with varying degrees of velopharyngeal inadequacy. The second and third approaches involved noncleft subjects whose airway was perturbed by bleed valves and bite blocks during consonant productions. The pressure-flow technique was used to measure aerodynamic variables associated with the production of test consonants. The results of this study provide additional evidence that the speech system actively responds to perturbations in ways that tend to minimize a change in consonant speech pressures. The degree of success in stabilizing pressures appears to reflect the capability of the system to use whatever articulatory and respiratory responses are available.

A multidisciplinary International Working Group of scientists was assembled to address the question of standardizing reporting techniques for multiview videofluoroscopy and nasopharyngoscopy, the generally accepted standards for direct observation of the velopharyngeal valve. This report is a first attempt to propose standards while seeking feedback from the readership in order to further develop a common methodology.

Passavant's ridge was studied by means of videofluoroscopy and nasopharyngoscopy in 80 patients with hypernasal speech. In patients with Passavant's ridge an improvement of the sphincter function was found to be associated with an enlargement of the ridge. It was also observed that the ridge could disappear if complete velopharyngeal closure was achieved without surgical intervention of the ridge area. The results indicate that Passavant's ridge is of compensatory origin.

Children with dysarthria are often seriously handicapped by their inability to communicate. Velopharyngeal incompetence may contribute to their speech difficulties but the indications for pharyngoplasty are poorly defined. The speech of 41 children, thought to have a defect of neurological origin and referred for possible pharyngoplasty, was assessed by a speech therapist, by nasopharyngoscopy and by multiview videofluoroscopy. These investigations revealed that 16 had velopharyngeal incompetence, with a neurological aetiology, and might be expected to benefit from pharyngoplasty. Independent assessment of the intelligibility of these 16 children before and after pharyngoplasty has been related to their preoperative oropharyngeal function. The majority benefited from surgery, some substantially. In particular, good lip and tongue function are shown to be necessary to achieve improved intelligibility. The roles of age, intelligence and aetiology in the success of pharyngoplasty are discussed.

Most, but not all, individuals with velopharyngeal inadequacy maintain consonant pressures greater than 3 cm H2O even with decreased velar resistance. The purpose of this study was to identify variables that might differentiate those who achieve adequate pressures from those who do not. Forty-four cleft lip and/or palate subjects were assessed during production of /p/ in the word "hamper." Twenty-three subjects achieved pressures greater than 3 cm H2O and 21 did not. The pressure-flow technique was used to assess velopharyngeal orifice size, nasal resistance, velar resistance, and nasal airflow during speech. Nasal cross-sectional area was measured during breathing. The data were analyzed by age and gender. Results indicate that the inability to achieve adequate consonant pressures in the presence of velopharyngeal inadequacy is more likely to occur in adults than in children. Although children are known to produce consonants at higher pressures than adults, the age disparity between groups did not account for the pressure differences. The most significant factor differentiating adequate and low pressure speakers was the magnitude of nasal plus velar resistance. This difference was consistent across age and gender.

Speech performance of three groups of speakers with cleft palate was analyzed at two-year intervals from age 4 years through age 16 years. The three groups consisted of: Group A--individuals who score below 20 percent correct on the Iowa Pressure Articulation Test (IPAT) at 4 years of age and who received secondary surgery by 8 years of age; Group B--individuals who scored below 20 percent correct on the Iowa Pressure Articulation Test at 4 years of age, but did not receive secondary management by 8 years of age; and Group C--individuals who scored above 20 percent correct on the Iowa Pressure Articulation Test and who did not receive secondary surgery by 8 years of age. The results demonstrated that Group A performed better on several measures of speech performance at 16 years of age than either of the other groups. Also, speech performance appeared to become slightly worse around 12 years of age for Group B. This may be interpreted as evidence that this group may have been negatively affected by the physiologic changes associated with puberty. The other two groups did not appear to show this effect. The results of this study emphasize the need for careful research regarding patients who, in spite of early poor speech performance, are not considered candidates for early secondary management.

Three groups of parents and three groups of children listened to 14 pairs of audio-tape-recorded words twice. One word of each pair was produced with compensatory articulation, and the other was produced with audible nasal emission. Each subject indicated which word in each pair sounded better. All three groups of parents and all three groups of children chose the words produced with compensatory articulation as sounding better more frequently than they chose the words produced with nasal emission. Individual parents and respective children did not always have the same preferences. In all instances where there was agreement, both parent and child chose words with compensatory articulation more frequently than words with nasal emission.

Patterns of velopharyngeal (VP) valving and the location of velopharyngeal gaps were investigated in 246 consecutive nasopharyngoscopy studies. The predominant pattern of closure was coronal (68 percent), followed by the circular (23 percent), circular with a Passavant's ridge (5 percent), and sagittal (4 percent) patterns. Gaps were found in 181 patients; in 121 they were considered typical (centrally located), in 28 they were in one of the lateral aspects of the valve, and in 32 they were attributed to the shape of the adenoid tissue or to abnormalities in the anatomy or function of the posterior border of the soft palate. Atypical findings occurred primarily in patients with a coronal pattern of valving. These findings raise further questions about treatment for patients with atypical valving problems.

The articulation errors associated with velopharyngeal incompetence are of particular interest to clinicians and researchers because the problems they pose usually remain after surgical repair and the reasons they appear may have important implications for speech-motor control. The intriguing question of why individuals develop and maintain such detrimental behaviors has been the focus of our laboratory's attention over the past 25 years. The purpose of this paper is to present a hypothesis dealing with compensatory speech behaviors in cleft palate, provide some data in support of this hypothesis, and project future directions for research. The hypothesis, that speech aerodynamics conform to patterns characteristic of a regulating system, proposes that compensatory behaviors in cleft palate are manifestations of regulation and control strategies.

Seven speech pathologists with expertise in the evaluation of the speech of individuals with cleft palate agreed that the following parameters should be assessed: case history, oral-peripheral mechanism, articulation, and voice quality. From such information and observations the clinician should be in a position to make inferences about velopharyngeal function. If velopharyngeal function is not normal, it is mandatory that additional information about the mechanism be obtained.