Search

Background: Orthognathic surgery (OGS) is a common intervention used to correct midfacial hypoplasia in patients with cleft. Previous studies have reported that Le Fort I maxillary advancement may affect velopharyngeal function, but similar investigations focusing on 2-jaw OGS have not been conducted., Methods: A total of 162 consecutive patients with cleft lip and palate who underwent 2-jaw OGS between 2015 and 2020 were enrolled. Clinical data were collected, and preoperative and postoperative skeletal measurements were obtained from cephalometric images. Velopharyngeal function was evaluated using perceptual analysis and nasopharyngoscopy. A logistic regression model was used for risk factors associated with changes in velopharyngeal function., Results: After 2-jaw OGS, 82.1% of patients showed no change in velopharyngeal function, 3.7% experienced improvement, and 14.2% exhibited worsening of function. Changes in velopharyngeal function were statistically significant compared with velopharyngeal status before OGS. Multivariable logistic regression revealed that the amount of maxillary advancement independently predicted the deterioration of velopharyngeal function after OGS (odds ratio, 1.74; 95% CI, 1.20 - 2.52; P = 0.004). The receiver operating characteristic curve based on maxillary advancement demonstrated good discrimination, with an area under the curve of 0.727 (95% CI, 0.62 - 0.83; P = 0.001). The Youden index was 4.27 mm., Conclusions: Despite the risk of velopharyngeal function deterioration in patients with cleft palate undergoing OGS, some individuals experienced improved function after 2-jaw OGS. The extent of maxillary advancement has a negative effect on velopharyngeal function., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

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

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.

Objective: To evaluate a method of measuring the change in palatal length and shape following maxillary advancement using synchronous lateral videofluoroscopy and voice recording in order to understand how movement of the maxilla may affect VPI risk in patients with cleft lip and/or palate (CL/P)., Design: Retrospective cohort study of children with cleft lip and/or palate., Setting: Single center, tertiary children's hospital., Participants: Patients with cleft lip and/or palate who underwent maxillary advancement between 2016-21 inclusive., Interventions: Maxillary advancement surgery, including those who underwent concurrent mandibular procedures., Main Outcome Measures: The length of the soft palate and the genu angle were measured throughout palatal dynamic range. Pre- and post-operative measurements were compared using a one sided T-test, with subgroup analysis for patients with clinical VPI., Results: Ten patients were examined. The mean distance of maxillary advancement was 10.5 mm. The average increase in pre-genu soft palate length was 2.8 mm in the resting position and 2.9 mm in the closed position. The genu angle decreased in the closed position by 16.3 degrees., Conclusions: The soft palate showed limited ability to lengthen following maxillary advancement and this may explain the risk of VPI. There was partial compensation by the muscle sling of the palate as demonstrated by a more acute post-operative genu angle and this suggests one reason for the variability of VPI reported. Future research is required to investigate how length and shape changes measured using this method can predict VPI risk., 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.

This study aimed to document the prevalence, severity, and risk factors of velopharyngeal dysfunction (VPD) in craniofacial microsomia (CFM) and to analyse differences in VPD-related speech characteristics between CFM patients without cleft lip and/or palate (CL/P), CFM patients with CL/P, and CL/P patients without CFM (control). A total of 223 patients with CFM were included, of whom 59 had a CL/P. Thirty-four CFM patients had VPD, including 20 with a CL/P. VPD was significantly more prevalent in CFM with CL/P than in CFM without CL/P (odds ratio (OR) 4.1, 95% confidence interval (CI) 1.9-8.7; P < 0.001). Multivariate logistic regression showed a significant association between CL/P and VPD in CFM patients (OR 7.4, 95% CI 2.1-26.3; P = 0.002). The presence of VPD was not associated with sex, the laterality or severity of CFM. Speech problems related to VPD appeared to be similar among the different groups (CFM without CL/P, CFM with CL/P, CL/P without CFM). As 15.2% of all CFM patients and 8.5% of CFM patients without CL/P had VPD, it is proposed that all patients with CFM, with or without CL/P, should be assessed by a speech and language therapist for the potential risk of VPD., Competing Interests: Competing interests None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This clinical report describes the implementation of magnetic resonance imaging (MRI) to evaluate a patient with long-standing velopharyngeal dysfunction. She was referred to the craniofacial clinic at age 10 with no prior surgical history and subsequently completed a Furlow palatoplasty due to a suspected submucous cleft palate. However, results were unfavorable with minimal improvement in speech or resonance. The clinical presentation, treatment, outcomes, and contributions from MRI for secondary surgical planning are described. Addition of MRI into the clinical workflow provided insights into the anatomy and physiology of the velopharyngeal mechanism that were unable to be obtained from nasendoscopy and speech evaluation alone., Competing Interests: Declaration of Conflicting InterestsThe author(s) of this manuscript have no conflicts of interest to disclose with respect to the research, authorship, and/or publication of this article. This study was approved by the University of Virginia Institutional Review Board (IRB-HSR#200333).

Background: Submucous cleft palate (SMCP) is a congenital anomaly characterized by the presence of Calnan's triad. However, in clinical practice, it is common for individuals to exhibit one or two anatomical abnormalities within the triad. Furthermore, the definition of SMCP has been diverse and ambiguous in literature. Therefore, this study aimed to analyze the correlation between anatomical abnormalities and development of velopharyngeal insufficiency (VPI)., Methods: We conducted a retrospective analysis of 99 patients referred to our clinic for speech issues or anatomical abnormalities identified during routine oral examinations from January 2012 to June 2023. A single surgeon performed all physical examinations. We evaluated the presence of bony notch, zona pellucida, and bifid uvula, assigned a score to each abnormality, and analyzed their correlation with VPI. The correlation of each of the abnormalities with VPI development was examined, along with the relationship between the number of abnormalities and VPI., Results: Among the 99 patients, 27 were diagnosed with VPI. Only the bony notch had a significant correlation with VPI development. The incidence of VPI tended to increase with the presence of more anatomical abnormalities. VPI occurred in approximately 40% of patients exhibiting all three anatomical abnormalities., Conclusion: The study findings highlight the importance of meticulous intraoral examinations in patients with SMCP and careful monitoring of patients with a bony notch or two or more anatomical abnormalities., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Learning Objectives: After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations., Summary: To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed., (Copyright © 2024 by the American Society of Plastic Surgeons.)

To determine the sensitivity and specificity of velar notching seen on nasopharyngoscopy for levator veli palatini (LVP) muscle discontinuity and anterior positioning., Nasopharyngoscopy and MRI of the velopharynx were performed on patients with VPI as part of their routine clinical care. Two speech-language pathologists independently evaluated nasopharyngoscopy studies for the presence or absence of velar notching. MRI was used to evaluate LVP muscle cohesiveness and position relative to the posterior hard palate. To determine the accuracy of velar notching for detecting LVP muscle discontinuity, sensitivity, specificity, and positive predictive value (PPV) were calculated., A craniofacial clinic at a large metropolitan hospital., Participants: Thirty-seven patients who presented with hypernasality and/or audible nasal emission on speech evaluation and completed nasopharyngoscopy and velopharyngeal MRI study as part of their preoperative clinical evaluation., Among patients with partial or total LVP dehiscence on MRI, presence of a notch accurately identified discontinuity in the LVP 43% (95% CI 22-66%) of the time. In contrast, the absence of a notch accurately indicated LVP continuity 81% (95% CI 54-96%) of the time. The PPV for the presence of notching to identify a discontinuous LVP was 78% (95% CI 49-91%). The distance from the posterior edge of the hard palate to the LVP, known as effective velar length, was similar in patients with and without notching (median 9.8 mm vs 10.5 mm, P  = 1.00)., The observation of a velar notch on nasopharyngoscopy is not an accurate predictor of LVP muscle dehiscence or anterior positioning., 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.

Objectives: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions., Methods: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort., Results: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision., Conclusion: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions., Competing Interests: Declarations of competing interest None., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To develop tools for predicting velopharyngeal competence (VPC) based on auditory-perceptual assessment and its correlation with objective measures of velopharyngeal orifice area., Design: Methodological study., Participants and Methods: Sixty-two patients with repaired cleft palate, aged 6 to 45 years, underwent aerodynamic evaluation by means of the pressure-flow technique and audiovisual recording of speech samples. Three experienced speech-language pathologists analysed the speech samples by rating the following resonance, visual, and speech variables: hypernasality, audible nasal air emission, nasal turbulence, weak pressure consonants, facial grimacing, active nonoral errors, and overall velopharyngeal competence. The correlation between the perceptual speech variables and velopharyngeal orifice area estimates was analysed with Spearman's correlation coefficient. Two statistical models (discriminant and exploratory) were used to predict VPC based on the orifice area estimates. Sensitivity and specificity analyses were performed to verify the clinical applicability of the models., Results: There was a strong correlation between VPC (based on the orifice area estimates) and each speech variable. Both models showed 88.7% accuracy in predicting VPC. The sensitivity and specificity for the discriminant model were 92.3% and 97.2%, respectively, and 96.2% and 94.4% for the exploratory model., Conclusion: Two predictor models based on ratings of resonance, visual, and speech variables and a simple calculation of a composite variable, SOMA (Eng. "sum"), were developed and found to be efficient in predicting VPC defined by orifice estimates categories based on aerodynamic measurements. Both tools may contribute to the diagnosis of velopharyngeal dysfunction in clinical practice., 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.)

Objective: To develop a universal system for assessing the speech function in patients with congenital palatal cleft in the postoperative period., Materials and Methods: A universal system for assessing the speech function for patients with a palatal cleft can be applied both after the primary operation of uranoplasty and for patients diagnosed with velopharyngeal insufficiency (VPI). The patient's speech is assessed according to the following criteria: defects in the pronunciation of consonants by place of articulation: labial, labiodental, lingual-dental, lingual-palatal, lingual-alveolar; speech breathing; tongue position; directed air stream; voicing disorders; The patient's is also evaluated for the following findings: hypernasality (reflected speech); hypernasality (spontaneous speech); hyponasality; pharyngeal reflex; audible nasal emission/turbulence; facial grimaces; speech intelligibility. The speech therapy and dental assessments are added to obtain a value characterizing the patient's condition: from 0 to 10 scoring indicates than only speech therapy correction is needed; from 11 to 18 - the decision on the necessity of surgical treatment is made by the surgeon together with the speech therapist, from 18 to 25 - surgical treatment is necessary with subsequent sessions with a speech therapist., Results: With the help of this questionnaire, the operating surgeon can more accurately and objectively assess in dynamics the result of the surgical treatment, regardless of the results of speech therapy treatment in the postoperative period. The creation of this scoring system for speech assessment is aimed at objectivizing the results of uranoplasty and speech-improving operations. It allows the surgeon to compare the effectiveness of different surgical methods., Conclusion: The universal scoring system for assessing the state of speech function can be applied in the diagnosis of a patient with a palatal cleft both after the primary operation on the palate and after corrective surgical interventions. It allows monitoring progress and identifying dynamics in surgical and speech therapy treatment.

Aim: Videofluroscopy studies of speech are a recognized assessment of velopharyngeal insufficiency (VPI). Yet, this method is subjective and has low inter-rater reliability. Quantitative measures of timing, distance, and area in videofluoroscopic studies of swallowing have been shown to be valid and reliable, but quantitative measures are not routinely used in videofluroscopy studies for VPI. This study explored the use of quantitative measures in patients with VPI in terms of feasibility and reliability., Methods: Forty patients of mixed etiology diagnosed with VPI through perceptual speech assessment underwent videofluroscopy. Anatomical landmarks and timing, distance, and area measurements were taken of the velopharyngeal port at rest and during speech tasks using specialized Swallowtail software. 50% of measures were double-blind rated to test inter-rater reliability. Raters reported on the time they took to complete each assessment and the challenges they had. Associations between measures were explored., Results: Ten timing, line, and area measures were developed based on 3 landmarks. Measures had moderate-substantial inter-rater reliability (intraclass coefficient: 0.69-0.91) except for time to lift (secs), which only achieved fair agreement (intraclass coefficient: 0.56). Measures demonstrated internal consistency ( R >0.60). Raters took, on average, 15 mins per patient and reported some challenges with image resolution, especially in timing measures where structures were blurred by movement., Conclusion: Quantitative measures are reliable and have the potential to add novel information regarding VPI to support multidisciplinary decision-making. Further research with larger patient cohorts is needed to clarify how quantitative measures can support tailored decisions about surgical and therapeutic interventions in order to maximize outcomes for individuals., Competing Interests: A.M. is an expert advisor for BellDev Medical, who owns the Swallowtail Software but has no financial relationship with the product. The remaining authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Stickler syndrome is a genetic disorder of connective tissue. One of the major symptoms associated with this disorder is an oro-facial malformation, which may cause a submucous cleft or a complete cleft of the hard palate. A 32-year-old man diagnosed with Stickler syndrome and a submucosal cleft palate (SMCP) visited our hospital with a chief complaint of excessive daytime sleepiness. The patient was diagnosed with severe obstructive sleep apnea (OSA), and administration of a polysomnography test revealed an apnea-hypopnea index (AHI) of 30.9 events/hour (h). Auto-titrating continuous positive airway pressure was initiated to control the OSA symptoms and subsequently the patient showed some improvement. However, due to continuous velopharyngeal insufficiency symptoms, intravelar veloplasty was performed. Three months after surgery, the AHI had decreased to 12.4 events/h. Recent studies have described a greater risk for OSA in individuals with cleft palate, than in the general population. The present case demonstrates surgical success in a patient with OSA and SMCP, suggesting that palatal surgery may be considered an optional surgical treatment for OSA patients with SMCP., (Copyright © 2020. Published by Elsevier B.V.)

Background: Although multiple studies have been reported on the palatopharyngeus and levator veli palatini, their subtle anatomy and functions remain unclear. The authors elucidated the relationship between these muscles and their functional implications based on three-dimensional digital techniques., Methods: Cadaveric specimens were stained with iodine-potassium iodide and scanned using micro-computed tomography. The muscle fibers were drawn on the exported Imaging and Communications in Medicine images to reconstruct a three-dimensional model and further simplified., Results: In the soft palate, the palatopharyngeus was divided into three bundles. The largest inferior head was found to attach to the palatine aponeurosis, soft palate, and the hard palate on the oral side, which occupied approximately the anterior 28.4 to 36.2 percent of the soft palate in the midline. The superior head was thin and attached to the palatine aponeurosis and the surrounding mucosa on the nasal side. The posterior head was located posterior to the levator veli palatini with fibers attaching to the levator veli palatini and the median portion of the uvula. The levator veli palatini was clasped by the three heads of the palatopharyngeus. The fasciculi of the palatopharyngeus converged into a bundle of muscles at the pharynx and inserted into the lateral and posterior pharyngeal wall., Conclusions: The palatopharyngeus is the largest muscle that connects the soft palate and pharyngeal wall; it closely coordinates with the levator veli palatini to control levator veli palatini overlifting, narrow the velopharyngeal port with the help of the superior constrictor, and elevate the pharynx. The palatopharyngeus and levator veli palatini help each other in velopharyngeal closure through coordination from other muscles., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown., Methods: Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate-only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible., Results: Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate-only patients.Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only., Conclusion: Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5., Clinical Question/level of Evidence: Risk, II., Competing Interests: Disclosure:None of the authors has any financial disclosures or commercial associations that might suggest a conflict of interest in relation to this work., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Objectives: To describe a case of coincident Castleman's disease and myasthenia gravis that initially presented as rapidly progressive dysphagia and dysphonia and to review the unique pathophysiology of these two uncommon diagnoses., Methods: Case report and literature review., Results: Castleman's disease, angiofollicular or giant lymph node hyperplasia, is a rare benign lymphoid proliferation. Traditionally, the disease is classified based on histologic and clinical characteristics. Fewer than 10 cases with concurrent myasthenia gravis have been reported. Myasthenia gravis and thymic epithelial tumors are both associated with acetylcholine receptor antibody. While patients with isolated Castleman's disease are usually asymptomatic, those who have concurrent myasthenia gravis and undergo surgical treatment are at increased risk of postoperative myasthenic crisis. Both pre- and postoperative plasmapheresis are suggested to improve muscle strength and prevent severe postoperative complications., Conclusions: In the setting of multiple cranial neuropathies including velopalatal insufficiency and bilateral ptosis it is important to consider myasthenia gravis. Castleman's disease occurs rarely in conjunction with myasthenia gravis but may increase the risk of myasthenic crisis.

Objective: To study whether providing Speech and Language Pathology (SLP) interventions by telepractice (TP) could effectively improve speech performance in children with cleft palate (CCP)., Methods: Forty-three CCP were treated with TP intervention in 45 min sessions, 2 times per week for a period of one month. Children ages ranged 4-12 years (X = 7.04; SD = 2.59). All children presented with velopharyngeal insufficiency (VPI) and compensatory articulation (CA) after palatal repair. TP was provided in small groups (5-6 children) following the principles of the Whole Language Model (WLM). Severity of CA was evaluated by a standardized scale at the onset and at the end of the TP period., Results: At the onset of the TP intervention period, 84% of the patients demonstrated severe CA. At the end of the TP period there was a significant improvement in severity of CA (p < 0.001)., Conclusion: The results of this study suggests that TP can be a safe and reliable tool for improving CA. Considering that the COVID-19 pandemic will radically modify the delivery of Health Care services in the long term, alternate modes of service delivery should be studied and implemented., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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.

Background: No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate-associated velopharyngeal insufficiency., Methods: Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate-associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome., Results: Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome., Conclusion: The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome., Clinical Question/level of Evidence: Risk, III.

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.

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.

Objective: There are various methods to treat velopharyngeal dysfunction including　surgery and rehabilitation therapy. Even if a rehabilitation program is effective, the evaluation of its efficacy remains subjective. In this paper, we propose a new method of rehabilitation training for velopharyngeal dysfunction focusing on the objective peak inspiratory flow (PIF) rate., Methods: Four patients, who were diagnosed with velopharyngeal dysfunction without cleft palate at ENT clinic of the National Hospital Organization, Tokyo Medical Center, participated in this study. All patients underwent our original rehabilitation program for velopharyngeal dysfunction, a method using the In-Check Dial, Turbohaler model. As a self-training rehabilitation program, we asked them to inhale forcefully 10 times daily at home using the In-Check Dial to increase the value of PIF rate for 3 months. We measured the patients' PIF rates with the In-Check Dial at the ENT clinic at the initial visit and after the 3-month training., Results: The PIF rates of the four patients without nasal clips were higher than the rates with nasal clips at the initial visit. After the training, PIF rate without a nasal clip of all patients increased than the rate at the initial visit, which represented significant difference (P < 0.05). Also, after 3 months, PIF rate without a nasal clip was higher or equal than the rates with a nasal clip at the initial visit except one case. Naso-pharyngo-laryngeal fiberscopy did not detect salivary pooling around larynx and mirror fogging test did not show nasal escape in the three of four patients after 3 months of training. All reported improvement in dysphagia and dysarthria., Conclusion: This new method can be used not only to evaluate velopharyngeal function but also as an effective self-training treatment., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To explore an alternative approach to evaluate velopharyngeal function on those speakers with compensatory misarticulation., Method: Nasopharyngeal endoscopy was used to observe the velopharyngeal movement on 26 adult Mandarin speakers during articulation and different nonverbal state, including SCPS, DCPS, and ABS., Results: There were significant differences for the rate of velopharyngeal incompetence (RVPI) among the 4 different states. The RVPI was least for the Articulation State, followed by the Air Blowing and DCPS. The RVPI was largest for the SCPS., Conclusion: The result indicated that the ABS may be used as an alternative approach to evaluate the velopharyngeal function instead of the articulation samples while patients cannot make clear articulation due to compensatory misarticulation habits. It merits further study on nonverbal activities, which could lay a foundation for exploring more effective approach for evaluation of the velopharyngeal function.

Background: Velopharyngeal insufficiency is the inability to close the velopharyngeal port during speech and swallowing, leading to hypernasal speech and food regurgitation., Objective: This study aimed to explore the aetiological factors contributing to the development of velopharyngeal insufficiency in a non-cleft paediatric population, especially following adenoidectomy., Methods: A retrospective case review was conducted of all children without a known cleft palate, born between 2000 and 2013, who were referred to a tertiary cleft centre with possible velopharyngeal insufficiency., Results: The data for 139 children diagnosed with velopharyngeal insufficiency following referral to the cleft centre were analysed. Thirteen patients developed the condition following adenoidectomy; only 3 of these 13 had a contributing aetiological factor., Conclusion: Velopharyngeal insufficiency is a rare but significant complication of adenoidectomy. The majority of patients who developed velopharyngeal insufficiency following adenoidectomy did not have an identifiable predisposing factor. This has important implications for the consent process and when planning adenoidectomy.

Objective: Velopharyngeal (VP) closure has high impact on the quality of life, especially in patients with cleft palate. For better understanding the VP closure, it is important to understand the airflow dynamics of different closure patterns, including circular, coronal, sagittal, and circular with a Passavant's ridge. The purpose of this study was to demonstrate the airflow characteristics of different velopharyngeal closure patterns., Methods: Sixteen adults with no notable upper airway abnormality who needed multislice spiral computed tomography scans as part of their clinical care. Airways were reconstructed. A cylinder and a cuboid were used to replace the VP port in three models of VP port patterns. Flow simulations were carried using computational fluid dynamics. Airflow pressures in the VP orifice, oral cavity and nasal cavity, as well as airflow velocity through the velopharyngeal orifice, were calculated., Results: The airflow dynamics at the velopharynx were different among different velopharyngeal patterns as the area of the velopharyngeal port increased from 0 to 25 mm 2 . The orifice areas of different closure conditions in four velopharyngeal closure patterns were significantly different. The maximal orifice area for adequate velopharyngeal closure was 7.57 mm 2 in the coronal pattern and 6.21 mm 2 in the sagittal pattern., Conclusions: Airflow dynamics of the velopharynx were correlated to the velopharyngeal closure patterns. Different closure patterns had different largest permitted orifice areas for getting the appropriate oral pressures for normal speech.

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.

Objective: To examine the effect of age on voice onset time (VOT) and VOT variability in children with repaired cleft palate., Methods: Twenty-two children with repaired cleft palate were allocated into two age groups: younger children (YC: n = 13) and older children (OC: n = 9). VOT measurements from monosyllabic words (/pɑ/, /tɑ/, and /kɑ/) and intraspeaker VOT variability estimated by coefficients of variation (CoV) of two age groups were compared., Results: Age was found to have a statistically significant effect on VOT and VOT variability. Specifically, OC had significantly longer VOT (F(1,66) = 4.196, p < 0.05) and less VOT variability (F(1,66) = 6.007, p < 0.05) for English voiceless stops than YC. No statistically significant main effect for speech sample or age by speech sample interaction was observed., Conclusions: Our data supplement the existing literature by adding VOT and VOT variability information for older children/adolescents with repaired cleft palate. Findings from the study suggest VOT patterns acquired at younger age appear to be further exaggerated and stabilized during the adolescent period among children with repaired cleft palate. A future study is necessary to determine different sources of VOT variability in children with a history of cleft palate, which may have clinical therapeutic implications., (© 2019 S. Karger AG, Basel.)

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.

Background: Maxillary advancement may affect speech in cleft patients., Aims: To evaluate whether the amount of maxillary advancement in Le Fort I osteotomy affects velopharyngeal function (VPF) in cleft patients., Methods: Ninety-three non-syndromic cleft patients (51 females, 42 males) were evaluated retrospectively. All patients had undergone a Le Fort I or bimaxillary (n = 24) osteotomy at Helsinki Cleft Palate and Craniofacial Center. Preoperative and postoperative lateral cephalometric radiographs were digitized to measure the amount of maxillary advancement. Pre- and postoperative speech was assessed perceptually and instrumentally by experienced speech therapists. Student's t-test and Mann-Whitney's U-test were used in the statistical analyses. Kappa statistics were calculated to assess reliability., Results: The mean advancement of A point was 4.0 mm horizontally (range: -2.8-11.3) and 3.9 mm vertically (range -14.2-3.9). Although there was a negative change in VPF, the amount of maxillary horizontal or vertical movement did not significantly influence the VPF. There was no difference between the patients with maxillary and bimaxillary osteotomy., Conclusions: The amount of maxillary advancement does not affect the velopharyngeal function in cleft patients., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The objective of this study was to investigate the occurrence of Passavant's ridge in patients with history of cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatal surgery. Twenty-five adult patients (mean age of 32 years), who wore a pharyngeal bulb prosthesis to correct VPI after primary palatoplasty participated in the study. Presence of Passavant's ridge was investigated in four conditions: prior to pharyngeal bulb for treatment of VPI (C1); during the molding of the pharyngeal bulb (C2); six months after the use of the pharyngeal bulb, but with the prosthesis removed (C3), and six months after the use of the pharyngeal bulb, but with the prosthesis in place (C4). Images of nasoendoscopic assessment of velopharyngeal function were obtained under all conditions were analyzed by speech-pathologists to identify the occurrence of Passavant's ridge during speech production. The results revealed a significant difference between molding condition (C2: 40%) and six months of bulb use (C4: 68%) (p = 0.028). The pharyngeal bulb may elicit the Passavant`s ridge in patients with history of cleft palate presenting with VPI., (Copyright © 2019. Published by Elsevier Inc.)

Purpose of Review: This article highlights important trends in speech outcomes following orthognathic surgery in the cleft lip and palate populations. The geometric changes in the velopharyngeal port caused by maxillary advancement by standard means and distraction are only one consideration in predicting speech outcomes. Myriad and variable preoperative risk factors, both anatomic and functional, have been identified in the literature because of weaknesses in experimental design and small patient populations. Therefore, elucidating risk factors for postoperative velopharyngeal dysfunction remains a challenge in our field., Recent Findings: Recent pharyngeal morphologic studies using computed tomography demonstrate volumetric discrepancies in the unilateral and bilateral cleft lip and palate populations before and after orthognathic surgery, suggesting differing requirements of velar adaptation among these two populations. Perceptual and instrumental speech evaluation studies and cephalometric correlates revisit 'borderline' velopharyngeal insufficiency and isolate preoperative velar length as a risk factor for velopharyngeal dysfunction following orthognathic surgery., Summary: Research design heterogeneity, small patient populations, and inherent risk of bias of retrospective reviews obscure velopharyngeal dysfunction risk factor identification prior to orthognathic surgery. However, recent reports on the volumetric changes in the pharyngeal airway and preoperative 'borderline' velopharyngeal insufficiency and velar length offer improved predictive value in anticipating postoperative velopharyngeal dysfunction.

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.

Purpose This study predicts and simulates the function and relative contributions of the intravelar and extravelar portions of the levator veli palatini (LVP) and palatoglossus (PG) muscles in velic constrictions. Method A finite element-based model of the 3-dimensional upper airway structures (palate, pharynx, tongue, jaw, maxilla) was implemented, with LVP and PG divided into intravelar and extravelar portions. Simulations were run to investigate the contributions of these muscles in velopharyngeal port (VPP) closure and constriction of the oropharyngeal isthmus (OPI). Results Simulations reveal that the extravelar portion of LVP, though crucial for lifting the palate, is not sufficient to effect VPP closure. Specifically, the characteristic "bulge" appearing in the posterior soft palate during VPP closure ( Pigott, 1969 ; Serrurier & Badin, 2008 ) is found to result from activation of the intravelar portion of LVP. Likewise, the intravelar portion of posterior PG is crucial in bending the "veil" or "traverse" ( Gick, Francis, Klenin, Mizrahi, & Tom, 2013 ) of the velum anteriorly to produce uvular constrictions of the OPI ( Gick et al., 2014 ). Conclusions Simulations support the view that intravelar LVP and PG play significant roles in VPP and OPI constrictions.

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.

An automated cleft speech evaluator, available globally, has the potential to dramatically improve quality of life for children born with a cleft palate, as well as eliminating bias for outcome collaboration between cleft centers in the developed world. Our automated cleft speech evaluator interprets resonance and articulatory cleft speech errors to distinguish between normal speech, velopharyngeal dysfunction and articulatory speech errors. This article describes a significant update in the efficiency of our evaluator. Speech samples from our Craniofacial Team clinic were recorded and rated independently by two experienced speech pathologists: 60 patients were used to train the evaluator, and the evaluator was tested on the 13 subsequent patients. All sounds from 6 of the CAPS-A-AM sentences were used to train the system. The inter-speech pathologist agreement rate was 79%. Our cleft speech evaluator achieved 85% agreement with the combined speech pathologist rating, compared with 65% agreement using the previous training model. This automated cleft speech evaluator demonstrates good accuracy despite low training numbers. We anticipate that as the training samples increase, the accuracy will match human listeners., (Copyright © 2018. Published by Elsevier Ltd.)

Purpose of Review: The purpose of this manuscript is to highlight the latest advances in diagnosis and management of velopharyngeal incompetence (VPI) as it pertains to swallowing deficits in children. This is timely and relevant as otolaryngologists are often amongst the first to diagnose and treat VPI. Although nasal regurgitation of a bolus is frequently transient, persistent problems can be associated with other swallowing problems and other significant medical problems. Furthermore, velopharyngeal incompetence has implications for speech production., Recent Findings: Persistent VPI associated with a swallowing deficit can be an isolated anomaly with or without a cleft palate or submucous cleft palate. VPI may be secondary to a cranial neuropathy, esophageal abnormality or associated with another airway anomaly, any of which may further contribute to dysphagia. Findings of additional anomalies may be suggestive of a syndrome. Workup should explore these potential causes. When velopharyngeal incompetence is associated with dysphagia, fiberoptic endoscopic evaluation of swallow (FEES) and videofluoroscopic swallow study (VFSS) can be helpful in diagnosis and management. The advantages and disadvantages of FEES and VFSS have been well delineated over the past few years. Similarly, nasopharyngoscopy and fluoroscopy are increasingly used in diagnosis and management of VPI that is associated with hypernasal resonance disorders., Summary: Concurrent medical diagnoses or syndrome manifestations are often associated with or contribute significantly to the cause of dysphagia in children with VPI. As VPI can be a sign of brainstem vagal neuropathy, the clinician should investigate by imaging the CNS if other correlative symptoms of dysphagia and examination findings are present. Endoscopy is advocated for evaluation of vocal fold function. Fluoroscopy is best for further assessment of airway protection or safety of swallow. And, whenever indicated, additional workup is recommended to determine an underlying cause of the swallowing disorder.

Background: Maxillary retrognathia is a well-known consequence of abnormal facial growth in patients with cleft lip and palate. Orthognathic surgery improves facial appearance and occlusion but may induce velopharyngeal insufficiency. The aim of this study was to evaluate the effect of orthognathic surgery on velopharyngeal function by using speech analysis and lateral cephalometric radiographs., Patients and Methods: We conducted a retrospective study of 47 patients who underwent maxillary advancement ± mandibular setback between 2006 and 2016. Preoperative and 1 year postoperative audio recordings were blinded for scoring by three trained speech therapists. Preoperative and 1 year postoperative lateral cephalometric radiographs were used to obtain information about skeletal movement and its relationship with the velopharyngeal area. Correlations between speech outcomes and cephalometric radiographs were determined., Results: Hyponasality improved significantly after surgery (p < 0.05), whereas hypernasality deteriorated significantly only in patients who underwent maxillary advancement alone (p < 0.05). No difference in speech parameters was found between patients with hypernasality or patients who had a pharyngoplasty preoperatively and the rest of the group. No correlation was found between the amount of maxillary advancement and hypernasality. A significant correlation (r < -0.49, p < 0.05) was found between the preoperative velar length and hypernasality postoperatively., Conclusions: Maxillary advancement has a negative impact on velopharyngeal function, whereas bimaxillary surgery seems to protect from deterioration. No difference was found in the amount of maxillary advancement or in velopharyngeal measurements between the Le Fort I group and the bimaxillary group. A short soft palate is a predictor of hypernasality after orthognathic surgery., (Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to describe the clinical assessment recommendations for acquired velopharyngeal dysfunction (AVPD) and, through a literature review and online survey, summarize current practice patterns for evaluation and treatment pathway determination for this target population., Method: An online survey to query current assessment procedures and treatment pathway recommendations for AVPD was developed. Following survey results, a literature review was completed to determine evidence-based recommendations for assessment procedures and intervention recommendations based on assessment findings. Literature search terms included the following: acquired velopharyngeal dysfunction, hypernasality, non-cleft velopharyngeal dysfunction, velopharyngeal dysfunction, velopharyngeal dysfunction AND iatrogenic, velopharyngeal dysfunction AND neurogenic, velopharyngeal dysfunction AND assessment OR evaluation, velopharyngeal dysfunction AND treatment OR intervention, velopharyngeal dysfunction AND practice patterns OR clinical guidelines, velopharyngeal insufficiency. Inclusion criteria were limited to practice patterns/recommendations for assessment and/or treatment recommendations for AVPD, English language articles published between 2000 and 2017, and peer-reviewed journals. Studies regarding solely congenital or cleft palate velopharyngeal dysfunction and intervention outcome studies were excluded. Forty articles met inclusionary criteria., Results: The online survey results indicated lack of consensus for AVPD assessment and treatment recommendation protocols, with 93% of respondents indicating the need for a clinical guide for developing treatment recommendations. The majority of recommendations were filtered into an algorithm for clinical decision making., Conclusions: Clinical uncertainty among speech-language pathologists surveyed and the paucity of published clinical guidelines for assessing individuals with AVPD indicate the need for additional clinical research for this disorder, one that is heterogeneous and distinct from those with congenital velopharyngeal dysfunction. The proposed evidence-based clinical worksheet may assist in determining management for patients with AVPD and may serve as a starting place for validation of a clinical guideline.

Background: Up to 80% of individuals with unrepaired submucous cleft palate (SMCP) experience speech difficulties secondary to velopharyngeal insufficiency. Language delays are reported in the broader cleft lip and/or palate population, suggesting that individuals with SMCP may also be at risk. However, contemporary understanding of this population remains limited as there has been no systematic examination of the literature. This review aims to systematically review and document the speech and language characteristics of individuals with nonsyndromic SMCP and, in addition, to identify factors reported to impact speech and language outcomes., Method: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were comprehensively searched using keywords and indexed headings. Included studies had to report speech or language outcomes of individuals with nonsyndromic SMCP. Risk of bias and methodological design quality were examined using tools from the Scottish Intercollegiate Guidelines Network. Relevant data were extracted for analysis., Results: Eighteen studies met inclusion criteria, yielding 598 participants. Study results showed that individuals with unrepaired nonsyndromic SMCP may have speech difficulties secondary to velopharyngeal insufficiency including increased nasal resonance and palatalized or glottal articulation. Lower age at primary surgical repair led to better postsurgical speech outcomes. There is a paucity of literature outlining motor or phonological aspects of speech and receptive or expressive language abilities of this population., Conclusion: Individuals with nonsyndromic SMCP present with speech difficulties similar to those experienced by individuals with overt cleft palate. Health care professionals should be aware of possible presenting symptoms and consider early SMCP diagnoses where appropriate. Further research is needed to specify the broader communication profile in this population., (© 2018 John Wiley & Sons Ltd.)