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Objective By measuring velopharyngeal structure and evaluating speech intelligibility, to explore and observe the association between velopharyngeal anatomy and speech outcomes in these patients. Methods Thirty-one adult patients with velopharyngeal insufficiency after the primary palatoplasty aged 18 to 35 years (mean 22.03 years) were enrolled as the study group. The patients had significant hypernasality and audible nasal emission. The degree of velopharyngeal closure assessed by electronic nasopharyngeal fiberoptic endoscopy was grade III. Cephalometric analysis was performed on lateral cephalograms to measure velopharyngeal structure, including hard palate length (ANS-PNS), velar length (PNS-U), pharyngeal depth (PNS-PPW), and oropharyngeal airway space (U-MPW). Their speech intelligibility was evaluated through the Mandarin Chinese speech intelligibility test, and each speech sample was examined by 2 speech and language pathologists. The results were assessed with the SPSS 23.0 software package, and regression analysis was used to examine the relationship between velopharyngeal structure and speech outcomes. Results A significant negative correlation was confirmed between speech intelligibility and pharyngeal depth. Pharyngeal depth also showed a linear relationship with speech intelligibility, and there was no significant correlation between speech intelligibility and other measures (hard palate length, velar length, oropharyngeal airway space). Conclusions In the velopharyngeal anatomy, only pharyngeal depth was associated with speech intelligibility in adult patients with severe velopharyngeal insufficiency, this is consistent with our clinical observation. It suggests that appropriate reduction of pharyngeal depth during palatopharyngoplasty may have a good effect on the speech recovery in patients with cleft palate and patients with velopharyngeal insufficiency after palatorrhaphy.

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

Objective To evaluate maxillofacial growth and velopharyngeal function in patients with isolated cleft palate who had undergone palatoplasty using a mucosal flap. Methods Measurements from lateral cephalograms taken at age 6 years of 44 patients (mucosal flap group) were obtained and compared with data reported in the literature for approximately age-matched children without cleft palate. We also compared maxillofacial growth in a subgroup analysis based on the anteroposterior length of the palatal bone defect. In addition, we examined velopharyngeal function at age 5–6 years. Results Compared with the non-cleft group, the mucosal flap group had a shorter anteroposterior length of the anterior base of the skull, shorter maxillary alveolar base, shorter mandibular body, shorter posterior maxillary height, and posteroinferior rotation of the mandible. In the mucosal flap group, the anteroposterior length of the maxillary alveolar base was shorter when the palatal bone defect extended anteriorly than when it was limited to the posterior region. In the mucosal flap group, 88.6 % had favorable velopharyngeal function. In patients who developed anterior fistula after palatoplasty, expiratory nasal emission could be reduced using a speech plate. Conclusions Use of a mucosal flap during palatoplasty is useful from the perspective of maxillofacial growth and velopharyngeal function in patients with isolated cleft palate.

BACKGROUND The most common surgical intervention to treat velopharyngeal dysfunction in the US is the posterior pharyngeal flap (PPF). In this retrospective study, the authors compare surgical and speech outcomes across 2 PPF surgical approaches: the palatal split (PS) and fish mouth (FM) techniques. METHODS An Institutional Review Board approved retrospective chart review was performed for PPF cases performed by a single surgeon between 2008 and 2016. Overall, 40 patients received the PS technique and 47 received the FM technique. Age at surgery, operative length, length of stay (LOS), revisional surgery, and pain medication administration were measured. Speech outcomes were measured based on the Universal Parameters for Reporting Speech Outcomes and included Speech Language Pathologist ratings of hypo- and hypernasality, speech acceptability, and audible nasal emission. Two sample t-tests and multivariable-mixed effects logistic regression were used to analyze the data. RESULTS Comparing the 2 groups (PS versus FM), there were statistically significant differences among the operative approaches across multiple measures: LOS (32.86 hours versus 26.20 hours, P = 0.01), acetaminophen use (1523.54 mg versus 805.74 mg, P = 0.01), revisional surgery rate (17.5% versus 2.10%, P = 0.02), and degree of postoperative hypernasality (0.61 versus 0.29, P = 0.03). Syndromic patients were more likely to receive the FM technique (PS: 15% versus FM: 29.8%; P = 0.05). The odds ratio for revision surgery with the FM technique was -2.32 (CI: -4.32 to -0.35, P = .04). CONCLUSIONS In this study, the FM technique offered a shorter LOS, lower revision rate, less acetaminophen administration, and more favorable speech outcomes when compared to the PS technique.

Submucous cleft palate (SMCP) is a congenital condition related to abnormal muscle attachments within the soft palate. Even though hypernasality and nasal emission, the primary symptom of SMCP, have been well-documented, research on articulation errors is currently lacking. The object of this study was to examine the consonant articulation in patients with unoperated SMCP and its possible correlation with the velopharyngeal function. This study analyzed the perceptual speech assessment and nasopharyngoscopy data of 338 patients with unoperated SMCP between years 2008 and 2016 retrospectively. The mean age of the patients was 13.27 years. About 125 patients showed velopharyngeal competence (VPC), 174 velopharyngeal incompetence (VPI), and 39 marginal VPI (MVPI). Among the 338 patients, 137 presented normal articulation, 124 consonant omission, 25 compensatory articulation, 36 consonant weakening, 51 consonant substitution, and 36 posterior placement. About 70.40% VPC patients, 17.24% VPI patients, and 48.72% MVPI patients demonstrated normal articulation. About 59.20% VPI patients showed consonant omission. The results demonstrated that consonant articulation varied among patients with unoperated SMCP and was correlated with their velopharyngeal functions, while consonant omission was the most common articulation error. Velopharyngeal closure pattern was not associated with either velopharyngeal function or consonant articulation.

Prader-Willi syndrome (PWS) is characterized by infantile hypotonia, hypogonadism, hyperphagia, developmental delay and mild mental retardation and characteristic facial features caused by the lack of genes on chromosome 15q11-q13. Frequency of PWS is estimated to be 1/10,000–1/15,000 and cleft lip and/or palate case is rare. Most PWS babies suffer from hypotonia with feeding problems and speech articulation defects, even though they have normal anatomical structure in oral region. We report a case of PWS with cleft palate (CP). Case We report on a three-month-old male who was referred to our department from pediatrician of our hospital to treat a cleft in the soft palate. He had hypotonia, feeding problems, almond-shaped eyes and bilateral cryptorchidism at birth. The chromosome test was performed and he was diagnosed as PWS. The volume of milk feeding was improved by feeding training with age. However, when he started feeding with solid foods at 12 months old, a nasal emission was observed, so he disliked eating. After palatoplasty performed at 18 months old, a nasal emission was disappeared and food intake was increased markedly. One year after palatoplasty, his swallowing function was progressed and the velopharyngeal function improved to slight insufficiency. Conclusion In this case, it is possible that palatoplasty had an effect on not only velopharyngeal functions but also his swallowing functions.

BACKGROUND The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author. MATERIALS AND METHODS Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined. RESULTS Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P

Objective: To investigate the impact of cleft width and cleft type on the need for secondary surgery and velopharyngeal competence from a longitudinal perspective. Design: Retrospective, longitudinal study. Setting: A single multidisciplinary craniofacial team at a university hospital. Patients: Consecutive patients with unilateral or bilateral cleft lip and palate and cleft palate only (n = 313) born from 1984 to 2002, treated with 2-stage palatal surgery, were reviewed. A total of 213 patients were included. Main Outcome Measures: The impact of initial cleft width and cleft type on secondary surgery. Assessment of hypernasality, audible nasal emission, and glottal articulation from routine follow-ups from 3 to 16 years of age. The assessments were compared with reassessments of 10% of the recordings. Results: Cleft width, but not cleft type, predicted the need for secondary surgery, either due to palatal dehiscence or velopharyngeal insufficiency. The distribution of cleft width between the scale steps on a 4-point scale for hypernasality and audible nasal emission differed significantly at 5 years of age but not at any other age. Presence of glottal articulation differed significantly at 3 and 5 years of age. No differences between cleft types were seen at any age for any speech variable. Conclusions: Cleft width emerged as a predictor of the need for secondary surgery as well as more deviance in speech variables related to velopharyngeal competence during the preschool years. Cleft type was not related to the need for secondary surgery nor speech outcome at any age.

Objective: The loud and severely distorting form of audible nasal emission (commonly known as nasal turbulence or nasal rustle) typically occurs with a small velopharyngeal opening during production of pressure-sensitive consonants. The purpose of this study was to determine whether bubbling of the secretions, which commonly occurs on the superior aspect of the velopharyngeal port when there is a small opening, is a periodic process that can generate sound in the nasal cavity. Participants: Ten pediatric patients were included in the study. All participants had normal articulation and resonance but exhibited audible nasal emission characterized as nasal rustle. Measures: For each participant, high-speed video (HSV) nasopharyngoscopy and acoustic signals were recorded simultaneously. The acoustic recordings were captured in a manner similar to nasometry using nasal and oral microphones connected to a separation plate. Spectral analysis of the audio recordings and the HSV images was used to determine correlation between the acoustic and visual measurements. Results: This study showed that secretion bubbling is a periodic process and its frequency, measured from the HSV data, was also captured by the acoustic measurements. The nasal acoustic signal correlated more strongly with the video of bubbling than the oral acoustic signal in the majority of the cases where bubbling occurred. Conclusion: These findings are strong evidence that secretion bubbling plays a significant role in the mechanism that generates undesired sound in the nasal cavity. Further work is needed to determine whether this sound is perceived as nasal rustle.

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.

There are several different types of nasal emission that can occur during speech due to either velopharyngeal dysfunction or abnormal articulation in the pharynx. Nasal emission can be inaudible or very loud and distracting, depending on the size of the velopharyngeal opening and the physics of the flow. Nasal emission can be obligatory and/or compensatory (due to abnormal structure) or it can be caused by a misarticulation that results in a substitution of a pharyngeal sound for an oral sound, despite normal velopharyngeal structure. Nasal emission can occur on all pressure-sensitive phonemes or it can be phoneme-specific. Although it is generally recognized that the loud and distracting form of nasal emission (called nasal turbulence or nasal rustle) is due to a small velopharyngeal opening, the causality of the distracted sound is debated. This article provides a brief review of the types of nasal emission, the terms used to describe it, and the potential causes. This article also stresses the need for further research to clarify the causality of the sound generated by a small velopharyngeal opening.

Background Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter (VPS) is unable to completely seal anatomical closure between the nasal and oral cavities during speech. Palatal repair can restore VPS function but the prevalence of VPI after repair has been reported ranging from 20% to 40%. The combination of flexible videonasopharyngoscopy (FVNP) and multiplanar videofluoroscopy (MPVF) has been reported as the best approach for assessing the VPS mechanism and planning effective surgical procedures aimed to correct VPI. Objective To study the outcome of three different techniques for performing pharyngeal flaps with the common denominator of individually designing the flap according to findings of VFNP and MPVF. Material and methods A total of 140 cases of pharyngeal flap surgery were reviewed. Three surgeons performed 3 different surgical techniques. All cases underwent nasometry, VNP and MPVF preoperatively. All surgical procedures were carefully planned and designed according to findings of VNP and MPVF. Results Nasal emission was completely eliminated in all cases. One-hundred-thirty-four patients (95%) demonstrated mean nasalance within normal limits after the surgical procedure whereas 6 patients persisted with mean nasalance scores above reference values postoperatively. There were no intraoperative or postoperative complications in any of the cases. No clinical data of sleep disordered breathing was detected in any of the cases after 2 months of postoperative follow-up. However, one case presented with clinical data of sleep disordered breathing 8 months postoperatively. Conclusions The results of this study suggest that as long as pharyngeal flaps are being designed according to the findings of imaging procedures, different surgical techniques can provide similar successful outcomes with minimal complications.

Our knowledge of nasal cavity anatomy has grown considerably with the advent of micro-computed tomography (CT). More recently, a technique called diffusible iodine-based contrast-enhanced CT (diceCT) has rendered it possible to study nasal soft tissues. Using diceCT and histology, we aim to (a) explore the utility of these techniques for inferring the presence of venous sinuses that typify respiratory mucosa and (b) inquire whether distribution of vascular mucosa may relate to specialization for derived functions of the nasal cavity (i.e., nasal-emission of echolocation sounds) in bats. Matching histology and diceCT data indicate that diceCT can detect venous sinuses as either darkened, "empty" spaces, or radio-opaque islands when blood cells are present. Thus, we show that diceCT provides reliable information on vascular distribution in the mucosa of the nasal airways. Among the bats studied, a nonecholocating pteropodid (Cynopterus sphinx) and an oral-emitter of echolocation sounds (Eptesicus fuscus) possess venous sinus networks that drain into the sphenopalatine vein rostral to the nasopharynx. In contrast, nasopharyngeal passageways of nasal-emitting hipposiderids are notably packed with venous sinuses. The mucosae of the nasopharyngeal passageways are far less vascular in nasal-emitting phyllostomids, in which vascular mucosae are more widely distributed in the nasal cavity, and in some nectar-feeding species, a particularly large venous sinus is adjacent to the vomeronasal organ. Therefore, we do not find a common pattern of venous sinus distribution associated with nasal emission of sounds in phyllostomids and hipposiderids. Instead, vascular mucosa is more likely critical for air-conditioning and sometimes vomeronasal function in all bats.

While phyllostomid bats show an impressive range of feeding habits, most of them emit highly similar echolocation calls. Due to the presence of an often prominent noseleaf, it has long been assumed that all phyllostomids emit echolocation calls exclusively through the nostrils rather than through the mouth. However, photo evidence documents also phyllostomid bats flying with an opened mouth. We hypothesized that all phyllostomid species emit echolocation calls only through the nostrils and therefore fly consistently with a closed mouth, and that observations of an open mouth should be a rare and random behavior among individuals and species. Using a high-speed camera and standardized conditions in a flight cage, we screened 40 phyllostomid species. Behavior varied distinctly among the species and mouth posture shows a significant phylogenetic signal. Bats of the frugivorous subfamilies Rhinophyllinae and Carolliinae, the nectarivorous subfamilies Glossophaginae and Lonchophyllinae, and the sanguivorous subfamily Desmodontinae all flew consistently with open mouths. So did the animalivorous subfamilies Glyphonycterinae, Micronycterinae and Phyllostominae, with the notable exception of species in the omnivorous genus Phyllostomus, which consistently flew with mouths closed. Bats from the frugivorous subfamily Stenodermatinae also flew exclusively with closed mouths with the single exception of the genus Sturnira, which is the sister clade to all other stenodermatine species. Further, head position angles differed significantly between bats echolocating with their mouth closed and those echolocating with their mouths opened, with closed-mouth phyllostomids pointing only the nostrils in the direction of flight and open-mouth phyllostomids pointing both the nostrils and mouth gape in the direction of flight. Ancestral trait reconstruction showed that the open mouth mode is the ancestral state within the Phyllostomidae. Based on the observed behavioral differences, we suggest that phyllostomid bats are not all nasal emitters as previously thought and discuss possible reasons. Further experiments, such as selectively obstructing sound emission through nostrils or mouth, respectively, will be necessary to clarify the actual source, plasticity and ecological relevance of sound emission of phyllostomid bats flying with their mouths open., publishedVersion

Velopharyngeal insufficiency (VPI) and hypernasality have a high prevalence in patients following cleft palate repair. The presence of hypernasality is even higher in syndromic cleft palate patients. This is a retrospective cohort study of patients who underwent primary palatoplasty at a Carle Foundation Hospital. The purpose is to evaluate the postoperative prevalence of hypernasality and VPI following primary palatoplasties looking at syndromic versus nonsyndromic patients as well as the type of repair performed. The authors expected to see an increased prevalence of VPI in syndromic patients and no difference in hypernasality among different palatoplasty techniques. The authors evaluated patients who underwent primary palatoplasties from 2008-2018. Data were collected by data engineers using CPT codes and diagnosis codes to formulate a total list of patients. Inclusion criteria included primary palatoplasty from 2008-2018, an adequate follow-up to assess for speech development, hypernasality rating by a speech-language pathologist (SLP), and evaluation for VPI. Patients who did not meet these criteria had a primary palatoplasty at another institution or are under the age of 3 were excluded from this study. Medical records of the included patients were reviewed and the following were noted: type of cleft, age at primary repair, type of repair, syndromic diagnosis, postoperative hypernasality, postoperative VPI, postoperative fistula, postoperative pharyngeal flap. VPI for this study was defined as velar incompetence diagnosed by videofluoroscopy and/or nasoendoscopy. Frequency tables show the numbers of categorical and numerical values within each finding. The authors evaluated for a statistical correlation of (VPI) in syndromic versus nonsyndromic patients. Additionally, the authors evaluated hypernasality following primary palatoplasties, looking to see if there was an association between the surgical technique and postoperative hypernasality. A total of 108 patients had primary palatoplasty during 2008-2018. After chart review, 44 patients met inclusion criteria. Four of the 44 patients are nonverbal. Five patients had postoperative VPI requiring a superior-based pharyngeal flap, 4 male and 1 female. Three patients with VPI were syndromic (2 Pierre Robin Syndrome and 1 HOXA2 mutation). Three of the patients with VPI underwent Bardach as the primary palatoplasty and 1 underwent Furlow double opposing Z plasty. Two syndromic patients, 1 with holoprosencephaly and 1 of unknown diagnosis, were unable to be assessed by SLP due to their nonverbal state. Hypernasality was assessed by a licensed SLP who is a member of the authors' interdisciplinary cleft lip and palate team. Hypernasal resonance was scaled with 1 as normal nasal emission, 2-4 as mild, 5-6 as moderate, and 7 as severe hypernasal resonance. In the 5 patients diagnosed with VPI, the average hypernasal resonance score was 4.5. In the 39 patients who did not have postoperative VPI, hypernasality was present in 13 (33%) of patients with an average score of 3. Two syndromic (Pierre Robin Syndrome: Fragile X) patients were noted to have hypernasality (2/7; 3/7) without VPI. One nonsyndromic patient with persistent hypernasality had a superior-based pharyngeal flap and hypernasality resolved. The authors recognize that there is a trend in previous literature showing that syndromic patients with cleft palate have an increased risk of VPI following cleft palate repair. VPI has been reported in the literature to occur in syndromic patients with cleft palate repairs up to 33% of the time. The retrospective cohort revealed that 5 (11%) of the 44 accepted patients were noted to have postoperative VPI. Of the 5 patients with VPI, 3 were noted to be syndromic, which does align with the literature.

Speech has a very significant impact on the life quality of people with cleft and lip palate. Restore tissue anatomy and functionality is the main aim of primary palatal surgery. Multiple factors are associated with successful handling, including the need for a velopharyngeal insufficiency (VPI) secondary surgery. The study's aim is to determine speech and velopharyngeal function outcomes in children with cleft palate operated in our institution and to determine VPI secondary surgery outcomes, if appropriate. Clinical records of nonsyndromic patients with cleft palate born between January 2009 and December 2012, who performed their multidisciplinary care on our institution, were analyzed retrospectively. One hundred forty-two patients received primary palatal surgery. Eighty (56%) were male and 62 (44%) female. Twenty-two had soft cleft palate, 9 hard and soft cleft palate, 84 unilateral, and 27 bilateral cleft lip and palate. Twelve percent of patients presented palatal fistula, with a significantly higher presentation in Soft Cleft Palate and Hard and Soft Cleft Palate. Twenty-seven patients (19%) had surgical indication for VPI correction, and 20 of them received VPI surgery, before school age. Cleft type and gender were significantly associated with VPI surgery indication rate. Postsurgery, 80% presented normal resonance. Nasal emission improved in 85% of patients. Nasometry decreased from 45% to 31%. Hyponasality increased by 10%. One case presented total flap dehiscence. Preoperative planning must be done carefully and individualized to succeed. Future prospective research that considers all the variables for a correct analysis is advisable, to improve our results.

Dental malocclusion can affect speech sound production, and cleft palate can cause velopharyngeal insufficiency

Midface advancement by distraction osteogenesis (DO) is commonly performed in patients with craniosynostosis for indications including midface hypoplasia, exorbitism, obstructive sleep apnea, class III malocclusion, and overall aesthetic facial deficiency. There is evidence to suggest that maxillary LeFort I advancement increases the risk of velopharyngeal dysfunction in the cleft palate population, yet few studies have investigated changes in speech following LeFort III or monobloc midface advancement in patients with syndromic craniosynostosis. The purpose of this study was to examine the effect of midface DO on speech as indicated by the Pittsburgh Weighted Speech Score in patients with Apert, Crouzon, and Pfeiffer Syndrome. Among 73 midface advancement cases performed during the study period, 19 cases met inclusion criteria. Overall, the highest post-advancement Pittsburgh Weighted Speech Score (PWSS) was significantly higher than the pre-advancement PWSS (0.52 versus 2.42, P = 0.01), indicating an acute worsening of VPI post-advancement. Specifically, the PWSS components nasal emission and nasality were significantly higher post-advancement than pre-advancement (nasal emission: 1.16 versus 0.21, P = 0.02) (nasality: 0.68 versus 0.05, P = 0.04). However, there was no significant difference between pre-advancement PWSS and the latest post-advancement PWSS (P = 0.31). Midface distraction is associated with an acute worsening of VPI post-operatively that is followed by improvement, and often resolution over time. Future work with additional patient accrual is needed to determine the effect of different advancement procedures and syndromes on VPI rates and profundity.

This study aimed to explore the preoperative factors that are potentially associated with the outcome of Furlow palatoplasty in treating nonsyndromic submucous cleft palate (SMCP). In this study, we reviewed patients with nonsyndromic SMCP who received Furlow palatoplasty between 2008 and 2017 at our department. A comprehensive panel of preoperative variables was included for analyses including gender, age at operation, concurrence of cleft lip, preoperative hypernasality, nasal emission, velopharyngeal closure ratio (VCR), velopharyngeal closure pattern, velum and pharyngeal wall movement, presence of Passavant Ridge and articulation error. The improvement of velopharyngeal function was considered a good outcome. Both univariate and multivariate analyses were performed to screen the potential predictors of the postoperative velopharyngeal function. Multivariate regression analyses indicated preoperative VCR as the only factor that was significantly associated with surgical outcome (p = 0.025). The receiver operating characteristic curve and Youden index indicated that VCR>52.5% was the cutoff value for predicting preferable postoperative velopharyngeal function (OR, 0.240; 95% IC, 0.059–0.979; p = 0.047). In conclusion, Furlow palatoplasty was recommended for non-syndromic SMCP patient with preoperative VCR>52.5% as the primary surgical treatment.

Introduction To meet the scarcity of training and/or educational initiatives in Uganda regarding state-of-the-art speech diagnosis and treatment in patients with cleft palate, a workshop was organized for all interested speech-language pathologists and health care workers. Objective To evaluate and compare the inter- and intra-rater reliability of the perceptual evaluation of hypernasality, hyponasality, nasal emission, nasal turbulence and speech acceptability before and after a two-day workshop in Ugandan speech-language pathologists. Methods On the first day, perceptual speech evaluation was discussed and practiced. Perceptual exercises included individual ratings of a specific speech variable followed by a group discussion and consensus listening exercises in listener pairs. The second day focused on speech treatment. Ten Ugandan speech-language pathologists rated speech samples of Ugandan patients with a CP ± L before and immediately following the two-day workshop. Inter- and intra-rater reliability of the perceptual ratings of hypernasality, hyponasality, nasal emission, nasal turbulence and speech acceptability were determined by means of the absolute percentage of agreement. The Wilcoxon signed-rank test was used to compare results at both time points. Results Overall inter- and intra-rater reliability improved when observing the absolute percentage agreement. However, median agreement results only showed enhanced reliability for hypernasality, hyponasality and nasal turbulence whereas (limited) deteriorated reliability was observed for nasal emission and speech acceptability. Regarding inter-rater reliability only the median percentage agreement for hyponasality exceeded 50% (median: 56.3%). Overall, better results were found for intra-rater reliability, with only weak results for speech acceptability. Discussion and conclusion Training positively affected reliability results. Nonetheless, this improvement was not achieved for each speech variable and reliability improvements were modest. Findings indicate the need for continued training and the search for the most effective training paradigm and feedback techniques, whilst taking into account clinical relevance and practical considerations.

Introduction One of the main goals of the team approach in management of oro-facial clefts is to help the children with cleft palate have adequate speech development. Objective The present study aimed to investigate the prevalence of articulation and resonance disorders following palate closure in children who were visited for routine examination by the Isfahan Cleft Care Team between 2011 and 2015, and to study the impact of cleft type and age at the time of palatoplasty on speech outcomes. Methods Clinical records of 180 preschool children with repaired cleft palate were reviewed. The percentage of children demonstrating hypernasality, nasal emission, nasal turbulence, and compensatory misarticulations was calculated. The relationship between cleft type and age at the time of palatal surgery, as independent variables, and speech outcomes were examined. Results 67.7 and 64.5 percent of the children demonstrated respectively moderate/severe hypernasality and nasal emission, and 71.1 percent produced compensatory misarticulations. Age at the time of palatal repair was significantly associated with compensatory misarticulations and also with moderate/severe hypernasality. The prevalence of compensatory misarticulations, significant hypernasality, nasal emission and also nasal turbulence was not significantly different in various types of cleft. Conclusions We observed a high prevalence of different speech disorders in preschool children with repaired cleft palate compared to other studies. This can be partly due to late palatal repair in the studied population. Despite many advances in cleft palate management programs in Iran, there are still many children who do not access the interdisciplinary team cares in their early childhood. We should, therefore, try to increase accessibility of appropriate and timely management services to all Iranian children with cleft lip/palate.

Velopharyngeal evaluation is aided by direct and indirect assessment techniques, including nasometry. Na- someters are designed to measure the nasalance resonance, but are unable to distinguish the relevant acoustic energy from the irrelevant aerodynamic energy associated with nasal emission. This can lead to elevation of the nasalance score, lowering the efficacy of nasometry in the presence of nasal emissions. The present study seeks to investigate the extent of this skewing. In order to quantify the influence of nasal emissions on the nasalance score, airflow with no voiced component was passed through [s]-postured airway models based on a subject-specific geometry but with varying velopharyngeal sizes: small, medium, and large. Nasometer microphones measured pressure fluctuations exterior to the nose and mouth, from which the nasalance score was calculated. Flow velocity, size of the velopharyngeal opening, and microphone position (medial or lateral) were varied in a factorial experiment. It was found that in the presence of nasal emissions, placing the nasometer microphones laterally decreases the nasalance score. Furthermore, the nasalance score generally increases with increased velopharyngeal opening size. These results indicate that aerodynamic pressure from nasal emissions can increase the nasalance score and that this influence could be mitigated via microphone placement.

Introduction: Materials used for posterior pharyngeal wall augmentation have been associated with important complications (exogenous materials) or variable and unpredictable durability (exogenous and endogenous materials); therefore, introducing a different material for augmenting the posterior pharyngeal wall seems necessary for reviving this relatively forgotten technique.The purpose of this study was to emphasize on the use of a material associated with minimal complications and maximum recovery and durability in correcting VPI and the use of evaluative adjuncts such as nasoendoscopy and videofluoroscopy to assess surgical outcomes. Methods: In a pilot study, 24 patients underwent posterior pharyngeal wall augmentation with dermal fat graft harvested from the low crease abdominal region. Early and late complications, autologous graft durability in posterior pharynx, and speech improvement were assessed. Results: There was a significant improvement in hypernasality, nasal emission, and nasal grimace after posterior pharyngeal wall augmentation with dermal fat graft (p

BACKGROUND Palatal re-repair aims to improve velar function by retropositioning the levator muscles. Although it has become a popular procedure, very few studies document its efficacy. To date, this is the largest series reported to clarify its indications and efficacy. METHODS One hundred eighty-three consecutive cleft patients presenting with velopharyngeal incompetence and evidence of abnormally oriented levator muscles underwent palate re-repair (regardless of the gap size) performed by a single surgeon from 2000 to 2015. Perceptual speech assessment was performed using the Pittsburgh Weighted Speech Score. Other patients' demographic data were collected. RESULTS Complete records of 111 patients were available. Eighteen cases were syndromic (18.9 percent). Postoperatively, there was highly significant improvement (p < 0.001) in nasal emission (from 2.24 to 0.64), nasality (from 3.44 to 1.27), articulation (from 5.32 to 2.01), and total score (from 11.29 to 4.11). Speech became normal/borderline normal, improved or did not improve in 66.7, 24.3, and 9 percent of patients, respectively. An initial diagnosis of isolated cleft palate, Caucasians, intravelar veloplasty in the primary repair, older patients, and nonsyndromic cases were associated with better outcome. There were no reported cases of postoperative fistula or new obstructive sleep apnea. CONCLUSIONS This large series study provides confirmatory evidence of the effectiveness and safety of the re-repair procedure. It is recommended as a first-line procedure in all velopharyngeal incompetence cases with abnormally oriented levator muscles regardless of gap size, even if the primary operation included prior muscle dissection. The pharyngoplasty rate could be significantly reduced with the current protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

ObjectiveTo evaluate speech in adults treated for unilateral cleft lip and palate with one-stage or two-stage palate closure and compare the speech of the patients with that of a noncleft control group.DesignCross-sectional study with long-term follow-up.Participants/SettingAll unilateral cleft lip and palate patients born from 1960 to 1987 and treated at Uppsala University Hospital, Sweden, were invited (n = 109). Participation rate was 67% (n = 73) at a mean of 35 years after primary surgery. Forty-seven had been treated according to one-stage palate closure and 26 according to two-stage palate closure. Pharyngeal flap surgery had been performed in 11 of the 73 patients (15%). The noncleft control group consisted of 63 age-matched volunteers.Main Outcome Measure(s)Speech-language pathologists rated perceptual speech characteristics from blinded audio recordings.ResultsAmong patients, seven (10%) presented with hypernasality, 12 (16%) had audible nasal emission and/or nasal turbulence, five (7%) had consonant production errors, one (2%) had glottal reinforcements/substitutions, and one (2%) had reduced intelligibility. Controls had no audible signs of velopharyngeal insufficiency and no quantifiable problems with the other speech production variables. No significant differences were identified between patients treated with one-stage and two-stage palate closure for any of the variables.ConclusionsThe prevalence of speech outcome indicative of velopharyngeal insufficiency among adult patients treated for unilateral cleft lip and palate was low but higher compared with individuals without cleft. Whether palatal closure is performed in one or two stages does not seem to affect the speech outcome at a mean age of 35 years.

Cleft palate patients experience various problems, especially those affecting their speech intelligibility, such as speech articulation disorder. The aim of this research was to prove the effect of cleft palate reconstruction with modified pushback z–plasty technique at the nasal mucosa on velopharyngeal function and articulation function in speaking. A research has been conducted on post-reconstruction cleft palate patients by using modified pushback z-plasty technique at the nasal mucosa. The methods were examining velopharyngeal components with cephalometric radiograph, assessing airflow released from the nose when the patients pronounce vowel ‘a’ using nasal emission device and assessing speech articulation results through Sehati Program at Harapan Kita Children and Maternity Hospital, Jakarta. The research results showed that there was a statistically significant effect of cleft palate reconstruction with pushback z-plasty technique at the nasal mucosa on velopharyngeal function, and there was a statistically significant effect of cleft palate reconstruction with pushback z-plasty technique at the nasal mucosa on articulation function in speaking. In addition, there was also a statistically significant correlation between velopharyngeal function and speech articulation function of post-reconstruction cleft palate patients with pushback z-plasty technique at the nasal mucosa based on the cephalometric radiograph, but the result was not significant statistically based on nasal emission assessment.

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

BACKGROUND This study aimed to evaluate the outcomes of posterior pharyngeal fat grafting for the management of velopharyngeal insufficiency using a simplified therapeutic algorithm and a tailored surgical technique. METHODS This was a prospective study of consecutive nonsyndromic patients with repaired cleft palate and velopharyngeal insufficiency who were stratified according to a simplified algorithm (minimally scarred palate, transverse orientation of levator veli palatini, and pinhole-to-small velopharyngeal gaps) and who underwent tailored posterior pharyngeal fat grafting. The patients were screened for obstructive sleep apnea before and after surgery. Three blinded evaluators randomly rated perceptual speech (hypernasality, audible nasal emission, and intraoral pressure) and nasoendoscopic (velopharyngeal active gap size) characteristics using audio and video recordings. Successful speech outcome was defined as normal or borderline sufficient velopharyngeal function at 15 months after surgery. RESULTS All included patients (n = 96) presented with a preoperative and postoperative low risk of obstructive sleep apnea. At 15 months after surgery, hypernasality (0.26 ± 0.53), audible nasal emissions (0.29 ± 0.48), intraoral pressure (0.1 ± 0.31), and velopharyngeal closure size (1.86 ± 0.34) were significantly decreased (all, P < 0.05) compared with the corresponding preoperative measurements (hypernasality, 2.17 ± 0.75; audible nasal emissions, 1.89 ± 0.82; intraoral pressure, 0.85 ± 0.35; and velopharyngeal closure size, 0.2 ± 0.49). In total, 84 (87.5%) patients showed successful speech outcomes. CONCLUSIONS Tailored posterior pharyngeal fat grafting is an effective and safe surgical strategy for the management of velopharyngeal insufficiency in a selected cohort of patients with repaired cleft palate.

Nasal emission is a speech disorder where undesired airflow enters the nasal cavity during speech due to inadequate closure of the velopharyngeal valve. Nasal emission is typically inaudible with large velopharyngeal openings and very distorting with small openings. This study aims to understand how flow characteristics in the nasal cavity change as a function of velopharyngeal opening using computational fluid dynamics. The model is based on a subject who was diagnosed with distorting nasal emission and a small velopharyngeal opening. The baseline geometry was delineated from CT scans that were taken, while the subject was sustaining a sibilant sound. Modifications to the model were done by systematically widening or narrowing the velopharyngeal opening while keeping the geometry constant elsewhere. Results show that if the flow resistance across the velopharyngeal valve is smaller than resistance across the oral constriction, flow characteristics such as velocity and turbulence are inversely proportional to the size of the opening. If flow resistance is higher across the velopharyngeal valve than the oral constriction, turbulence in the nasal cavity will be reduced at a higher rate. These findings can be used to generalize that the area ratio of the velopharyngeal opening to the oral constriction is a factor that determines airflow characteristics and subsequently its sound during production of sibilant sound. It implies that the highest level of turbulence in the nasal cavity, and subsequently the sound that will likely be perceived as the most severe nasal emission is produced when the size of openings is equal.

Background There is no consensus in the UK regarding the types of speech samples or parameters of speech that should be assessed at 3 years of age in children with cleft palate ± cleft lip (CP±L), despite cleft units routinely assessing speech at this age. The standardization of assessment practices would facilitate comparisons of outcomes across UK cleft units; earlier identification of speech impairments-which could support more timely treatments; and more reliable recording of therapy impacts and surgical interventions. Aims To explore assessment practices used to assess speech in 3-year-old children with CP±L, including speech parameters, methods of assessment and the nature of the speech sample used. Methods & procedures A broad examination of the literature was undertaken through the use of a scoping review conducted in accordance with Joanna Briggs Institute guidelines. Search terms were generated from a preliminary search and then used in the main search (Medline, CINAHL, Embase, AMED and PsycINFO). Main contribution A combination of approaches (medical, linguistic, developmental and functional) is required to assess CP±L speech at age 3. A developmental approach is recommended at this age, considering the complexity of speech profiles at age 3, in which typically developing speech processes may occur alongside cleft speech characteristics. A combined measure for both nasal emission and turbulence, and an overall measure for velopharyngeal function for speech, show potential for assessment at this age. Categorical ordinal scales are frequently used; the use of continuous scales has yet to be fully explored at age 3. Although single-word assessments, including a subset of words developed for cross-linguistic comparisons, are frequently used, more than one type of speech sample may be needed to assess speech at this age validly. The lack of consensus regarding speech samples highlights a need for further research into the types of speech samples 3-year-olds can complete; the impact of incomplete speech samples on outcome measures (particularly relevant at this age when children may be less able to complete a full sample); the impact of different speech samples on the validity of assessments; and the reliability of listener judgements. Conclusions & implications Whilst a medical model and linguistic approaches are often central in assessments of age-3 cleft speech, this review highlights the importance of developmental and functional approaches to assessment. Cross-linguistic single-word assessments show potential, and would facilitate the comparison of UK speech outcomes with other countries. Further research should explore the impact of different speech samples and rating scales on assessment validity and listener reliability.

"Nasal rustle" is a type of nasal emission associated with a small velopharyngeal (VP) gap and distracting loud noise. Currently, the mechanisms behind noise generation are unclear. In this study, we use a combination of retrospective and prospective data to test the hypotheses that bubbling of secretions could be a source of audible noise.Retrospective: Nasopharyngoscopy records of 151 patients with nasal rustle were reviewed to determine if bubbling occurred during their nasopharyngoscopy examination. Prospective: Nine children with nasal rustle and bubbling of secretions were suctioned with the scope in place to assure removal of secretions. The Nasometer II was used to record the children's production of oral sentences prior to and post suctioning. All sentences were analyzed for the presence or absence of noise, nasalance scores, and Cepstral Peak Prominence (CPP). Intra-and inter-judge reliability of coding was high.Retrospective: 70% of the patients with nasal rustle had bubbling of secretions during nasopharyngoscopy. Prospective: Percentages of audible noise were reduced significantly post suctioning (Friedman's Test, Chi-square = 24.5, p = 0.001) with the greatest decrease in syllables with fricatives and bilabial stops (p 0.05). The average CPP and nasalance scores pre-vs post-suctioning showed no significant differences (p = 0.91, 0.29).Retrospective: The high percentage of patients with nasal rustle had bubbling of secretions when producing speech in nasopharyngoscopy evaluations. Prospective: The incidence of audible noise was reduced as a result of suctioning. This suggests that the presence of secretions contributes to the production of nasal rustle.

BACKGROUND Persistent velopharyngeal insufficiency occurrence after double-opposing Z-plasty has been treated with either posterior pharyngeal flap or sphincteroplasty. Both these methods can be accompanied by mild discomfort, such as mouth breathing and hyponasal resonance, and can lead to severe complications, such as sleep apnea and upper airway compromise. The purpose of this study was to review the efficacy of repeat double-opposing Z-plasty for the management of persistent velopharyngeal insufficiency in patients who received a prior surgical intervention by double-opposing Z-plasty. METHODS All patients who were treated by repeat double-opposing Z-plasty between January 2000 and December 2014 were reviewed. Patient demographics, cleft type, surgical technique, and complications, such as wound dehiscence, infection, fistula, and upper airway obstruction, were evaluated. Preoperative and postoperative speech evaluations were reviewed for comparison. RESULTS Fourteen patients underwent repeat double-opposing Z-plasty, with an average follow-up of 34 months. There was no complication including wound dehiscence, flap necrosis, fistula, or upper airway compromise. Velopharyngeal competence (resonance, nasal emission, intraoral pressure, social/personal problems) was significantly improved postoperatively (P < 0.05). Only 1 patient required posterior pharyngeal flap for persistent velopharyngeal insufficiency. CONCLUSIONS Repeat double-opposing Z-plasty is an effective and safe surgical strategy for the management of persistent velopharyngeal insufficiency, in patients who received a prior surgical intervention by double-opposing Z-plasty. This strategy allows speech improvement and reduces the risk of postoperative upper airway compromise.

Background The state of the art for correcting velopharyngeal insufficiency (VPI) is a surgical procedure which is customized according to findings on imaging procedures: multiplanar videofluoroscopy (MPVF) and flexible videonasopharyngoscopy (FVNP). Recently, the use of MPVF has been challenged because of the potential risk of using ionizing radiation, especially in children. Objective To study whether using a protocol for performing MPVF can effectively decrease radiation dose in patients with VPI while providing useful information for planning surgical correction of VPI in combination with FVNP. The methodology used for performing the imaging procedures is described as well as the effectiveness of the surgical procedure. Material and methods Eighty - nine patients (Age range = 3–17 years; median = 5.5 years) with VPI resulting from multiple etiologies were studied. All patients underwent MPVF and FVNP for planning surgical correction of VPI. Radiation dosage data in each case was recorded. Forty of the 89 patients also completed a postoperative evaluation. Eleven out of the remaining 49 patients have not completed a postoperative evaluation and 38 patients are still pending surgical correction. Results Radiation dosage ranged from 1.00 to 8.75 miliSieverts (mSv); Mean = 2.88 mSv; SD = 1.575 mSv. Preoperative nasometry demonstrated mean nasalance ranging from 41%–95%; Mean = 72.30; SD = 4.54. Postoperatively mean nasalance was within normal limits in 36 (90%) out of 40 cases, ranging from 21% to 35%; Mean = 28.10; SD = 5.40. Nasal emission was eliminated postoperatively in all cases. Conclusion MPVF provides useful information for planning the surgical procedure aimed at correcting VPI. The combination of MPVF and FVNP is a reliable procedure for assessing velopharyngeal closure and to surgically correcting VPI with a highly successful outcome.

Objective Although the goal of cleft palate (CP) repair is to achieve normal speech, no standard procedure ensures that patients' speech will be at the same level as speech in children without CP. In this study, postoperative speech outcomes following primary CP repair combined with or without a mucosal graft was analyzed in comparison with that of control subjects without CP. Participants Eighty-two patients who underwent modified V-Y palatoplasty with a mucosal graft on the nasal side for symmetrical muscular reconstruction during 2006-2012 (MG group) and 109 patients who previously underwent modified V-Y palatoplasty without a mucosal graft (non-MG group) were enrolled in this study. Speech data on 37 Japanese subjects without CP were used as a control. Main outcome Measures Perceptual rating of resonance and nasal emission and nasometry were carried out for all participants. Furthermore, cephalometric analyses were performed to assess postoperative velopharyngeal morphology and velar movement. Results Normal resonance was achieved at a significantly higher rate (90.3% of patients) in the MG group than in the non-MG group (68.8%) ( P ≤ .01). The mean nasalance scores in the MG group were significantly lower (P ≤ .01) and were almost at the same level as in controls. Cephalometric analyses revealed a greater velar length and velar elevation angle during phonation in the MG group ( P ≤ .01 and P ≤ .05, respectively). Conclusions Modified V-Y palatoplasty combined with a mucosal graft on the nasal side of the velum for symmetrical muscular reconstruction facilitates speech outcomes for children with cleft palate that are comparable with those for peers without CP.

UNLABELLED This study was designed to compare intravelar veloplasty with and without V-Y pushback palatoplasty regarding postoperative functional and speech outcomes. THE AIM is to find out the importance and influence of palatal lengthening on the functional and speech outcomes after SMCP repair. STUDY DESIGN This is a prospective randomized comparative study of 20 patients divided into 2 equal groups. The study was conducted between February 2008 and January 2015. METHODS Radical Intravelar Veloplasty (RIVVP group): included 10 patients with a mean age of 5.539±1.335 years and V-Y Pushback Pharyngoplasty and Radical Intravelar Veloplasty (VYP+RIVVP group): included 10 patients with a mean age of 5.688±1.341 years for non-syndromic SMCP. SETTING Academic tertiary care medical centres. RESULTS In both groups there was a significant change in Eustachian tube function, nasal emission and nasal tone of voice postoperatively than preoperatively, while there was no significant difference between both groups in the postoperative outcomes as regards the same parameters (ET function, nasal emission and resonance) (p=0.558, 0.563 and 0.164 respectively). However, there was a significant difference between both groups as regards palatal lengthening, no statistically significant difference was present between both groups as regards the postoperative mean pharyngeal gap, using videoendoscopic analysis. In conclusion, RIVVP and VYP+RIVVP are both effective methods to repair non-syndromic SMCP. Moreover, the lengthening of the palate in non-syndromic SMCP is an unnecessary process.

OBJECTIVE To describe and assess the results of central inset L-shaped posterior pharyngeal flap (PF) for treatment of velopharyngeal incompetence. METHODS This study included 12 patients who were diagnosed as persistent velopharyngeal insufficiency. L-shaped central inset superiorly based PF was harvested from oropharynx and inserted into the soft palate through a transverse full-thickness palatal incision 1 cm behind the posterior margin of the hard palate, then the flap was spread 1 cm horizontally and 1 cm in the anteroposterior direction in soft palate. Before and after surgery, patients were assessed by examination, video: nasoendoscopy, and speech assessment. RESULTS Postoperative speech assessment showed significant improvement in the nasal emission, resonance, intraoral pressure, and articulation defects. Grade 4 velopharyngeal valve closure (complete closure) could be achieved in all patients. No patients showed dehiscence (partial or total) of the flap and no obstructive sleep apnea reported. CONCLUSIONS The new used L-shaped PF could properly correct velopharyngeal functions (closure and speech) in patients with persistent velopharyngeal insufficiency with no reported complication.