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Velopharyngeal dysfunction (VPD) occurs when there is inadequate closure of the velopharyngeal sphincter during speech. An incompetent velopharyngeal sphincter may require surgical intervention to create a functional seal between the oropharynx and the nasopharynx during speech. To date, no single pharyngoplasty procedure has emerged as superior to another, and the comparison of results between studies has been limited by variation in outcomes reporting. Here, we use the newly defined Core Outcome Set for VPD (COS-VPD) to report a consecutive series of 109 patients managed with a midline pharyngeal flap and simultaneous dissection and repositioning of the velar muscles. The overall 30-day postoperative complication rate was 3.6% (4 out of 109 patients). At 12-month follow-up, 79.3% of patients experienced a statistically significant improvement in hypernasality. Seven patients (6.4%) developed obstructive sleep apnoea (OSA) postoperatively, and this was confirmed with polysomnography, with four (3.6%) patients requiring takedown of the pharyngeal flap. Seven patients in total (7.3%) required takedown of the pharyngeal flap and sphincter pharyngoplasty because of insufficient improvement of their VPD following the initial procedure. Patient-reported outcomes were investigated using the Velopharyngeal Effects on Life Outcome (VELO) instrument, and a mean total score of 74.5 out of 100 was recorded. We conclude that cleft surgeons should not be dissuaded by historical concerns about high rates of perioperative complications and OSA and should consider including the pharyngeal flap in their armamentarium when managing patients with VPD.

The constrictor pharyngis superior (CPS) initially develops along the posterior wall of the pharyngeal mucosal tube, whereas, during the early phase, the buccinators (BC) are far anterolateral to the CPS. The process and timing of their meeting during fetal growth have not been determined.The topographical relationship between the growing BC and CPS was assessed in histological sections from 22 early- and mid-term fetuses of approximate gestational age (GA) 8-16 weeks, and eight late-term fetuses of approximate GA 31-39 weeks.At 8-9 weeks, the palatopharyngeus appeared to pull the CPS up and forward. Until 11 weeks, the CPS was attached to the hamulus of the pterygoid (pterygopharyngeal part). Until 13 weeks, the CPS extended anterolaterally beyond the hamulus to meet the BC. Some BC muscle fibers originated from the oral mucosa. Notably, by 30 weeks, the CPS-BC interface had become covered by or attached to the palatopharyngeus. Muscle fibers of the palatopharyngeus, however, were thinner than those of the CPS and BC. At and near the interface, BC muscle fibers tended to run along the left-right axis, whereas those of the CPS ran anteroposteriorly. A definite fascia (i.e., a future pterygomandibular raphe) was usually absent between these muscles in fetuses.The excess anterior growth of the CPS with its subsequent degeneration might cause individual anatomical variations in composite muscle bundles of the palatopharyngeus-CPS complex or palatopharyngeal sphincter. A tensile transduction from the BC to the CPS through the raphe seemed unnecessary for cooperative suckling and swallowing after birth.

Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

The purpose of this study was to conduct a quantitative analysis of the temporal and sequential events of the pharyngeal phase of swallowing in 45 poststroke patients who presented or did not present with supraglottic penetration and/or laryngotracheal aspiration and to compare the groups with each other and to a group of 46 patients with normal swallowing. All individuals were assessed by videofluoroscopy and the temporal and sequential measures for the swallowing of 3 mL and 5 mL of thickened liquid, 3 mL of liquid, and 3 mL and 5 mL of pasty were obtained by analyzing the recorded exams on Virtual Dub software. The following events were measured: time of maximal displacement and sustaining of the hyoid and larynx, duration of velopharyngeal sphincter (VS) and supraglottic closure, total inversion time of the epiglottis, duration of pharyngeal constriction, and duration of upper esophageal sphincter (UES) opening. For the analysis of the temporal sequence, the initial time of larynx and hyoid elevation, VS closure, epiglottic inversion, supraglottic closure, pharyngeal constriction, and opening of the UES were obtained. For 5 mL of thickened liquid, the maximum hyoid elevation time was greater for patients with normal swallowing and the time the supraglottis remained closed was higher in the aspirators group. The time of pharyngeal constriction during swallowing of 3 mL of thickened liquid was lower in the aspirators group. During the swallowing of 3 mL of thin liquid, it was observed that in the aspirators group, the larynx took longer to reach its maximum elevation and the epiglottis took longer to complete its total inversion. The analysis of the temporal sequence showed that patients in the aspirators group presented greater disorganization with significant alteration of the time interval between the events.

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.

Objectives: Competent velopharyngeal (VP) function is the basis for normal speech. Understanding how VP structure influences the airflow during speech details is essential to the surgical improvement of pharyngoplasty. In this study, we aimed to illuminate the airflow features corresponding to various VP closure states using computed dynamic simulations. Methods: Three-dimensional models of the upper airways were established based on computed tomography of 8 volunteers. The velopharyngeal port was simulated by a cylinder. Computational fluid dynamics simulations were applied to illustrate the correlation between the VP port size and the airflow parameters, including the flow velocity, pressure in the velopharyngeal port, as well as the pressure in oral and nasal cavity. Results: The airflow dynamics at the velopharynx were maintained in the same velopharyngeal pattern as the area of the velopharyngeal port increased from 0 to 25 mm2. A total of 5 airflow patterns with distinct features were captured, corresponding to adequate closure, adequate/borderline closure (Class I and II), borderline/inadequate closure, and inadequate closure. The maximal orifice area that could be tolerated for adequate VP closure was determined to be 2.01 mm2. Conclusion: Different VP functions are of characteristic airflow dynamic features. Computational fluid dynamic simulation is of application potential in individualized VP surgery planning.

BACKGROUND The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States. METHODS A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision. RESULTS A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type. CONCLUSIONS In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Objectives Evaluate the rate of complications, readmissions, emergency department presentations, and surgical success rates amongst three standard surgical treatment options for obstructive sleep apnea: upper airway stimulation, transoral robotic surgery, and expansion sphincter pharyngoplasty. Study design Retrospective cohort. Setting Tertiary care center. Methods Patients were included who were aged ≥18 years old and underwent upper airway stimulation, transoral robotic surgery, or expansion sphincter pharyngoplasty between January 2011 and May 2020. Results 345 patients were identified: 58% (n = 201) underwent upper airway stimulation, 10% (n = 35) underwent transoral robotic surgery, and 32% (n = 109) patients underwent expansion sphincter pharyngoplasty. There were 22 emergency department presentations and 19 readmissions, most of which were experienced by patients receiving transoral robotic surgery (six emergencies, seven readmissions) and expansion sphincter pharyngoplasty (12 emergencies, 11 readmissions). Patients with upper airway stimulation had four emergencies and one readmission. Only 2% of the upper airway stimulation cohort had a complication, whereas this was 20% and 12% for the transoral robotic surgery and expansion sphincter pharyngoplasty cohorts, respectively. Patients experienced the highest surgical success rate with upper airway stimulation (69%), whereas patients who received transoral robotic surgery and expansion sphincter pharyngoplasty had success rates of 50% and 51%, respectively. Conclusion Treating obstructive sleep apnea with upper airway stimulation led to lower rates of complications, emergency department presentations, and readmissions in this series. In those for whom upper airway stimulation is appropriate, it may be more effective in successfully treating obstructive sleep apnea than transoral robotic surgery and expansion sphincter pharyngoplasty.

The most frequent palate diagnoses in patients with chromosome 22q11.2 deletion syndrome are a classic submucous cleft, occult, and velopharyngeal insufficiency without cleft, which generates alterations in speech that require surgery. Surgical protocols are controversial owing to syndrome characteristics that make their handling more complex. Pharyngeal flap pharyngoplasty is effective for this type of patient. The objective of this study is to examine the surgical management of velopharyngeal insufficiency in patients with chromosome 22 deletion, using a pharyngeal flap as the primary surgery. The clinical records of patients with chromosome 22 deletion and velopharyngeal insufficiency between 2015 and 2017 were analyzed retrospectively. Eight patients underwent pharyngeal flap pharyngoplasty as a primary surgery, including 1 with velopharyngeal insufficiency without a cleft, 1 with a classic submucous cleft, and 6 with occult submucous cleft. The pre- and postoperative protocol performed by speech therapists and surgeons included clinical evaluation of the oral cavity; perceptual, video recording, and nasometry speech evaluation; and videonasopharyngoscopy. All perceptual parameters and nasometry results significantly changed. Of the cases, 88% achieved a flap with the expected width and height and complete closure of the velopharyngeal sphincter. One patient required flap revision. Four of the 8 patients achieved normal resonance, and 2 of 8 showed mild hypernasality. Using the pharyngeal flap pharyngoplasty as a primary technique to correct velopharyngeal insufficiency in patients with chromosome 22 deletion provides satisfactory outcomes and decreases the number of surgeries. Preoperative planning must be conducted carefully and needs to be individualized to be successful.

Objective: To evaluate the feasibility/effectiveness of using magnetic resonance imaging (MRI) to document velopharyngeal (VP) structural changes induced by continuous positive airway pressure (CPAP) therapy. Outcome Measures: Changes in velar length and thickness, levator veli palatini (LVP) length and thickness, velar volume, and intravelar muscular proportion along the course of CPAP therapy participation (Pre-CPAP, Post-CPAP, and withdrawal). Results: Velar and LVP lengths remained nearly the same, with the median changes (Δ) less than 0.6%, across repeated conditions. Although varying in magnitudes of change, median velar volume (Δ4%), velar thickness (Δ20%), LVP thickness (Δ17%), and intravelar muscular proportion (Δ10%) illustrated a consistent pattern of increases following the 8-week CPAP therapy. These VP structural measurements slightly decreased but remained above the pretraining condition after 8-week detraining. Conclusions: This report successfully demonstrated that MRI is a viable tool to document CPAP therapy–induced VP structural changes while providing preliminary empirical data.

Summary Background Submucous cleft palate is a congenital deformity that may present as velopharyngeal insufficiency. The degree of anatomical abnormality varies widely among patients and does not predict severity of symptom. We present our 10-year experience treating submucous cleft palate patients with double opposing z-plasty and explore the effect of age at surgery and compensatory articulation on speech. Methods Preoperative assessment included intraoral examination, nasoendoscopy, and perceptual speech evaluation. Age, gap size, and severity of hypernasality were assessed to determine the timing and type of surgery. A retrospective study of 74 submucous cleft palate patients undergoing double-opposing z-plasty from 2005 to 2016 by a single surgeon (Baek RM) was conducted. Double opposing z-plasty was modified to fully release all abnormal insertions of the levator veli palatini muscle. Postoperative velopharyngeal function was measured and statistical analyses were performed. Results The ages of patients at surgery ranged from 11 months to 19 years. Postoperatively 87 percent of the patients achieved velopharyngeal competency and 13 percent had remaining mild hypernasality. Age was a significant factor in predicting speech outcome, and patients receiving surgery prior to the age of 5.5 years had a higher normalization rate. Compensatory articulation did not have an impact on postoperative hypernasality. There were no cases of postoperative hyponasality or airway problems. Conclusion Satisfactory speech outcome was achieved with the authors' protocol and modification of the double-opposing z-plasty. A comprehensive assessment of patient age, intraoral findings, severity of hypernasality, and gap size, is necessary for proper treatment of submucous cleft palate patients.

The transition muscle between the palatopharyngeus (PP) and the superior constrictor of the pharynx (SCP) encircles the pharyngeal isthmus from behind and is designated as the palatopharyngeal sphincter (PPS). The PPS is inferred to play important roles for velopharyngeal closure, but its existence remains controversial and its roles have been regarded as being played by the SCP. The present study aimed to clarify the anatomical status and functional implications of the PPS. Macroscopic and microscopic examinations were performed on 39 and 4 cadavers, respectively. In the former, the bilateral PPSs and their adjacent structures were exposed from outside and/or inside. In the latter, the velums embedded in paraffin were cut into frontal or sagittal sections and alternately processed with HE and Azan stains. The PPS originated from the nasal aspect of the lateral half of the palatine aponeurosis and the inferior margin of the medial pterygoid plate and was distinguishable from the PP descending in and along the palatopharyngeal arch and the cranialmost portion of the SCP in its origin. It passed dorsally on the lateral side of the levator veli palatini and traversed around the salpingopharyngeal fold running longitudinally. It then entered below the SCP and ran toward the pharyngeal raphe with SCP muscle fibers intermingled. The PPS is a muscle distinct from the SCP. Its contraction produces Passavant’s ridge and conceivably enhances the efficiency of velopharyngeal closure by pressing the salpingopharyngeal fold and the musculus uvulae ridge against the velum.

Purpose Mild and moderate velopharyngeal insufficiency is a relatively common structural defect of the velopharyngeal sphincter that occurs congenitally or secondarily to various medical conditions resulting in speech inadequacy. Currently, multiple surgical methods exist to treat mild and moderate velopharyngeal insufficiency; however, the revision rates are high and the outcomes are variable. This case series describes a novel technique using implantable AlloDerm to repair the posterior pharyngeal wall to treat mild and moderate velopharyngeal insufficiency. Materials and methods This paper presents four patients with mild or moderate velopharyngeal insufficiency who were treated with implantable AlloDerm in the posterior pharyngeal wall at a large, safety-net hospital in New England from 2000 to 2019. Additionally, a review of surgical repair techniques for velopharyngeal insufficiency was conducted with synthesis of a qualitative overview. Results There were sufficient follow-up data in three of these patients. All three reported subjective improvements in symptoms after the procedure. One patient had implant extrusion one month following the procedure with subsequent removal. Conclusion Ultimately, implantable AlloDerm for posterior pharyngeal wall augmentation is a useful, low risk method for treating mild to moderate velopharyngeal insufficiency.

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 2 m (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 8 cm3autologous fat was injected. At 3 months, 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.

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.

BackgroundAn ancient yoga technique called sutra neti, which is extensively used in India to keep the sinuses healthy, led to complete velopharyngeal stenosis in a 67-year-old male patient who presented with bilateral nasal obstruction, mouth breathing, anosmia and a change in voice.MethodThe patient was diagnosed by nasal endoscopy using a zero-degree Hopkins rod endoscope, and adhesions were released using coblation.ResultsThe patient had post-operative alleviation of symptoms and a patent velopharyngeal inlet on examination.ConclusionVigorous sutra neti can lead to velopharyngeal stenosis. Release of the stenosis is then required to cure the nasal blockade.

RESUMEN La voz hipernasal y la regurgitación nasal son síntomas de disfunción velofaríngea. Ésta puede tener múltiples causas: anatómicas, neurológicas o funcionales. Se describe el caso de una paciente de sexo femenino, de 13 años, que se presenta con voz hipernasal y regurgitación nasal aguda. Al examen físico se evidencia inmovilidad del velo del paladar derecho sin otros hallazgos neurológicos. El estudio con resonancia nuclear magnética de cerebro y punción lumbar fueron normales. Se diagnosticó una incompetencia velofaríngea aguda transitoria, de probable etiología viral. La paciente evolucionó de forma favorable con mejoría clínica progresiva. La incompetencia velofaríngea a causa de una paresia o parálisis del nervio vago y/o nervio glosofaríngeo es una causa poco frecuente de disfunción velofaríngea. ABSTRACT Hypernasal speech and nasal regurgitation are symptoms of velopharyngeal dysfunction. This may have multiple causes, including velopharyngeal incompetence due to paresis or paralysis of the vagus nerve and/or glossopharyngeal nerve. We describe the case of a 13 year-old female patient, with hypernasal speech and acute nasal regurgitation, with a physical examination showing immobility of the right palate with no other neurological findings. Magnetic resonance imaging of the brain and lumbar puncture was normal. Transient acute velopharyngeal incompetence was diagnosed, probably of viral etiology. The patient evolved favorably with progressive clinical improvement. Velopharyngeal incompetence due to paresis or paralysis of the vagus and/or glossopharyngeal nerves is a rare cause of velopharyngeal dysfunction.

Objective To examine feasibility of a simultaneous high-resolution pharyngeal manometry (HRM) and electromyography (EMG) experimental paradigm to detect swallowing-related patterns of palatal, laryngeal, and pharyngeal muscle activity during expiratory training. Study Design Technical report. Methods Simultaneous HRM, surface submental, and intramuscular EMG were acquired in two healthy participants during five tasks: 10-cc water swallow, maximum expiratory pressure (MEP) testing, and expiratory muscle strength training (EMST) at three pressure levels (sham, 50%, and 75% MEP). Results Experimental conditions were feasible. Velopharyngeal closing pressure, palate EMG activity, and pharyngeal EMG activity increased as expiratory load increased. In contrast, thyroarytenoid EMG activity was low during the expiratory task, consistent with glottic opening during exhalation. Submental EMG patterns were more variable during expiratory tasks. Intraluminal air pressures recorded with HRM were correlated with measured expiratory pressures and target valve-opening pressures of the EMST device. Conclusion Results suggest that a simultaneous HRM/EMG/EMST paradigm may be used to detect previously unquantified swallowing-related muscle activity during EMST, particularly in the palate and pharynx. Our approach and initial findings will be helpful to guide future hypothesis-driven studies and may enable investigators to evaluate other muscle groups active during these tasks. Defining mechanisms of action is a critical next step toward refining therapeutic algorithms using EMST and other targeted treatments for populations with dysphagia and airway disorders. Level of Evidence 4. Laryngoscope, 127:797–804, 2017

Objectives: Sphincter pharyngoplasty is a commonly performed procedure for the treatment of velopharyngeal insufficiency and is often indicated in patients with circular or coronal closure patterns of the velopharyngeal sphincter. The authors present a modified technique of sphincter pharyngoplasty (partially mucosalized palatal sphincter pharyngoplasty [PMPSP]) in which bilateral superiorly based myomucosal palatopharyngeal flaps were elevated (in a newly designed fashion) and inserted in the palate through preformed palatal tunnels. Methods: This case series included 14 patients (5 male, 9 female) with persistent hypernasality who were subjected to treatment by PMPSP between May 2015 and August 2018. The palatopharyngeal flap was designed to be full thickness at its caudal segment, while its cephalic segment was denuded of its mucosa. The cephalic mucosa (of the flap) was elevated off the bed muscles as a medially based mucosa flap to be used at the end of the procedure to drape the upper part of the bed. Results: Pain assessed using a visual analog scale had decreased significantly at day 10 after surgery, and normal oral feeding was regained within 7 to 10 days. No major complications were recorded. Postoperative nasoendoscopic and phoniatric assessments were reported. Statistically significant improvements were reported when comparing pre- versus postoperative auditory perceptual assessment following PMPSP. Conclusions: The newly reported PMPSP might be a useful technique for correction of velopharyngeal insufficiency in patients with weak palatal motion (coronal or circular pattern of velopharyngeal sphincter closure). PMPSP had good reported surgical and phoniatric outcomes.

The question whether or not a velopharyngeal opening is advantageous in singing has been discussed for a very long time among teachers of singing. The present investigation analyzes the acoustic consequences of a large, a narrow, and a nonexistent velopharyngeal opening (VPO). A divided flow mask (nasal and oral) connected to flow transducers recorded the nasal and oral DC flows in four female and four male classically trained singers while they sang vowel sequences at different pitches under these three experimental conditions. Acoustic effects were analyzed in three long-term average spectra parameters: (i) the sound level at the fundamental frequency, (ii) the level of the highest peak below 1 kHz, and (iii) the level of the highest peak in the 2-4 kHz region. For a narrow VPO, an increase in the level of the highest peak in the 2-4 kHz region was observed. As this peak is an essential voice component in the classical singing tradition, a narrow VPO seems beneficial in this type of singing.

Prior to performing secondary surgeries, lateral cephalograms have been used during phonation to evaluate the point of attempted velopharyngeal contact along the posterior pharyngeal wall relative to the palatal plane and the first cervical vertebra. The ability to quantify the height of velopharyngeal closure is an important aspect of planning corrective surgeries for velopharyngeal dysfunction. However, issues with patient compliance during the imaging process can present difficulties for obtaining adequate preoperative imaging data. The purpose of this study was to assess if the height of velopharyngeal closure can be accurately estimated and quantified from at rest images. Results demonstrate that the height of velopharyngeal closure above C1 can be accurately quantified using at rest images in children with cleft palate. No statistically significant difference was found between the measures obtained at rest or during sustained phonation images (P = 0.573). Thus, quantitative measures from at rest images can aid in the preoperative planning process by providing surgeons with a numeric distance for tissue insertion along the posterior pharyngeal wall above C1. This distance is correlated to the height of velopharyngeal closure and successfully placing tissue at this height is likely tied to improved postoperative speech outcomes.

Introdução: As fissuras labiopalatinas não sindrômicas estão incluídas entre as malformações craniofaciais severas mais frequentes na população humana. O indivíduo acometido pode apresentar alterações no mecanismo velofaríngeo, comprometendo-se assim a inteligibilidade da fala. O objetivo deste estudo foi analisar o efeito imediato do exercício de trato vocal semiocluído no mecanismo velofaríngeo de pacientes com fissura labiopalatina.Métodos: A amostra foi composta por cinco sujeitos com fissura labiopalatina reparada cirurgicamente submetidos a avaliação multidimensional, de videonasofibroscopia, análise das imagens dinâmicas por meio de software especializado e análise de fala por meio da avaliação perceptivoauditiva e parecer autorreferido.Resultados: Todos os pacientes apresentaram melhora na fala encadeada após o exercício, melhora acentuada na impressão geral da emissão e projeção vocal, maior fechamento velofaríngeo e efeito positivo na autoavaliação.Conclusão: Observou-se efeito positivo do exercício de trato vocal semiocluído quando aplicado nessa amostra.Palavras-chave: Esfíncter velofaríngeo; fissura labial; fissura palatina; reabilitação; trato vocal semiocluído, Introdução: As fissuras labiopalatinas não sindrômicas estão incluídas entre as malformações craniofaciais severas mais frequentes na população humana. O indivíduo acometido pode apresentar alterações no mecanismo velofaríngeo e assim, comprometendo a inteligibilidade da fala.Objetivo: Analisar o efeito imediato do exercício de trato vocal semiocluído no mecanismo velofaríngeo de pacientes com fissura labiopalatina.Métodos: A amostra foi composta por 05 sujeitos com fissura labiopalatina reparada cirurgicamente submetidos à avaliação multidimensional, de videonasofibroscopia, análise das imagens dinâmicas por meio de software especializado, análise de fala por meio da avaliação perceptivo- auditiva e parecer auto referido.Resultados: Todos os pacientes apresentaram fala encadeada melhor após o exercício, melhora acentuada na impressão geral da emissão e projeção vocal, maior fechamento velofaríngeo e efeito positivo na autoavaliação.Conclusão: Observou-se efeito positivo do exercício de trato vocal semiocluído quando aplicado nessa amostra.Palavras-chave: Esfíncter velofaríngeo; fissura labial; fissura palatina; reabilitação, trato vocal semiocluído

Objective To demonstrate a cost-effective, quick, and easily reproducible three-dimensional sticky note model to enhance the understanding and conceptualization of the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. Methods The method involves making specified incisions and rearrangements of readily available components, including disposable clear plastic cups, yellow and pink sticky notes, and white paper. Once assembly is complete, further incisions and remodeling are performed to simulate a pharyngeal flap or sphincter pharyngoplasty. Results The cost of the materials to make one model was $0.94. Average construction time was less than 10 min. Conclusion This three-dimensional model is an efficient, interactive, and simple visual aid to teach surgical trainees the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty.

Surgical management of velopharyngeal incompetence (VPI) aims at improving voice resonance and correcting nasal air escape by restoring a competent velopharyngeal sphincter. Assessment of VPI requires the examination of multiple variables. The dynamic study of movements of the velopharyngeal port during speech and the quantification of the closure gap, using flexible videonasoendoscopy and/or videofluoroscopy, is essential. Autologous fat injection represents a minimally invasive alternative to major surgery in the management of mild to moderate VPI that minimizes the risk of complications and sequelae, and can be performed without modifying the anatomy of the velopharyngeal port.

Objectives The purpose of this study was to measure and compare temporal patterns of nasalization in Persian children with and without cleft palate in three vowel contexts. Methods A Sample of 14 children with repaired cleft palates with or without cleft lip with moderate to severe hyper nasality and 14 children without cleft palate was chosen as subjects. The subjects were chosen from the ages of 4 to 12 years. The nasal onset interval, nasal offset interval and total nasalization duration were obtained from acoustic waveforms and spectrograms in three vowel contexts using Praat Software. For eliminating the effect of different speed of speech in the cleft palate group and control group, the ratio of nasalization duration was calculated. Results Total nasalization duration are demonstrated by acoustic signals which shows the total significant different temporal patterns in children with cleft palate and without cleft palate and across the vowel contexts ( P Conclusions Longer nasalization durations in children with cleft palate in comparison to children without cleft palate show the delayed or deviant temporal patterns in children with cleft palate. The duration of nasalization reflecting temporal patterns of the oral-nasal acoustic impedance in children with cleft palate may have an influence on the perception of hyper nasality.

As fissuras labiopalatinas não sindrômicas estão incluídas entre as malformações craniofaciais severas mais frequentes na população humana, e os impactos mais comumente encontrados nessa afecção relacionam-se à anatomofisiologia do esfíncter velofaríngeo. O comprometimento do mecanismo velofaríngeo pode comprometer a inteligibilidade de fala, a voz e outras funções. O estudo teve como objetivo analisar o efeito do ETVSO, com o tubo rígido de alta resistência, em curto prazo, no MVF na reabilitação fonoaudiológica de pacientes com fissura labiopalatina. Foram selecionados dados dos pacientes pré realização do ETVSO e pós realização de quatro semanas com uso exclusivo do ETVSO. Os pacientes realizaram exame de videonasoendoscopia e gravaram sua emissão vocal. Os dados obtidos foram submetidos a uma avaliação multidimensional composta por avaliação perceptivo-auditivo, análise acústica da voz, análise da imagem do esfíncter velofaríngeo por meio de um software especializado e autoavaliação vocal. Os resultados foram analisados comparando o mesmo paciente pré e pós realização do ETVSO. Non-syndromic cleft lip and palate are included among the most frequent severe craniofacial malformations in the human population, and the most commonly encountered impacts in this condition are related to the anatomy of the velopharyngeal sphincter. The impairment of the velopharyngeal mechanism may compromise speech intelligibility, voice, and other functions. The objective of this study was to analyze the effect of SOVTE (vocal tract semi-occluded exercise), with the high resistance rigid tube, in short term, on velopharyngeal mechanism in speech and language rehabilitation of patients with cleft lip and palate. Patient data were selected therapy. The individuals were submitted to a multidimensional evaluation, prior to the SOVTE and after four weeks, with exclusive use of SOVTE. The patients underwent videonasoendoscopy and recorded their vocal emission. The data were submitted to a multidimensional evaluation composed by perceptual-auditory evaluation, voice acoustic analysis, velopharyngeal sphincter image analysis through a specialized software and vocal self-assessment. The results were analyzed comparing the same patient before and after SOVTE.

Objective: Children with 22q11.2 deletion syndrome (22qDS) often require surgical intervention to treat velopharyngeal dysfunction (VPD). Although some studies have documented improved velopharyngeal (VP) closure under increased speaking effort, currently no studies have examined the effect of similar behavioral speech modifications on VP closure in children with 22qDS. The purpose of this pilot study was to explore the effect of loudness on VP closure during speech in children with 22qDS and persisting VPD. Patients and Methods: Four children with 22qDS, posterior pharyngeal flap, and persisting mild VPD underwent pressure-flow testing while repeating words at habitual and increased loudness levels. Using a single-subject A-B design, descriptive statistics and graphical measures were used to examine differences in VP orifice area (VPA) and timing of closure in the habitual versus loud condition. Results: Results were mixed. Median VPA decreased during some stimuli for 3 participants, but increased for 1 subject when speaking louder. Median duration of nasal airflow decreased for 3 participants in the loud condition. Conclusion: This study presents preliminary aerodynamic data regarding the plasticity of VP physiology in the 22qDS group. Further research is needed to determine how loudness impacts VP function in children with 22qDS.

Background and objective The outcome of different treatment protocols for primary management of patients with complete unilateral cleft lip palate (UCLP) may vary considerably. This study aimed to compare the results of quality of speech and velopharyngeal sphincter mechanism between two surgical protocols used in the repair of complete UCLP. Patients and methods This study was conducted in Zagazig University Hospitals from February 2009 to April 2012 on 30 patients. The patients were categorized into two groups: group A, which consisted of 15 patients who underwent cleft lip repair and cleft hard palate repair with a vomer flap in same sitting; and group B, which consisted of 15 patients who underwent only cleft lip repair at first sitting. At the age of 12 months in both groups, repair of the remaining cleft palate was performed. Results A significant difference between groups A and B at all postoperative comparisons was found in terms of grade of nasality, grade of closure of the velopharyngeal valve, and nasal emission of air. Conclusion Early repair of the hard palate with simultaneous cleft lip repair can be considered as a reliable alternative procedure to one-stage palatoplasty and appeared to have better early functional results in the treatment of complete UCLP.

The primary goal of cleft palate repair is to create an anatomically and functionally intact palate while minimally affecting maxillary growth and development. In order to produce normal speech, a child must have velopharyngeal competence, defined as the ability to completely close the velopharyngeal sphincter that separates the oropharynx and nasopharynx. The absence of this ability, termed velopharyngeal insufficiency (VPI), is seen in a wide range of patients following primary cleft palate repair. This article discusses patient assessment, treatment options, and the surgical management of VPI. Recent trends and future directions in management are also presented.