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Objectives/hypothesis: The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function., Methods: This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation., Results: All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001)., Conclusion: ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: When tonsillar hypertrophy obstructing the airway is encountered in a child with a repaired cleft palate and velopharyngeal insufficiency, the surgeon may opt for tonsillectomy to relieve the airway obstruction, with possible effects on velopharyngeal closure. The aim of this study was to assess the impact of hypertrophied tonsils on velopharyngeal function in children with repaired cleft palate and to measure the effect of tonsillectomy on velopharyngeal closure and speech resonance., Study Design: Case series., Methods: Twelve children with repaired cleft palate and tonsillar hypertrophy underwent tonsillectomy to relieve airway obstruction. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech and nasalance scores were measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy., Results: Preoperative impairment of velopharyngeal function was detected. However, significant postoperative improvement of speech parameters (hypernasality, nasal emission of air, and weak pressure consonants measured with auditory perceptual assessment) was achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Reduction of velopharyngeal gap size was detected after removal of hypertrophied tonsils. Although the improvement of velopharyngeal closure was not significant, three cases demonstrated complete postoperative closure with no gap., Conclusions: Hypertrophied tonsils may impair velopharyngeal function in children with repaired cleft palate, and tonsillectomy is beneficial for such patients as it can improve the velopharyngeal closure and speech resonance. Secondary corrective surgery may be avoided in some cases after tonsillectomy., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To describe a modification of the originally described superiorly based pharyngeal flap as a secondary operation to correct velopharyngeal insufficiency (VPI) in patients with nonsyndromic repaired cleft palate., Study Design: Prospective clinical trial at university medical center., Methods: Twenty-six patients with VPI after cleft palate repair underwent a modified posterior pharyngeal flap procedure. Patients with submucous cleft palate or associated with syndromic VPI or Pierre Robin sequence were excluded from the study. Flap was harvested high up in the nasopharynx and inserted into the soft palate through a transverse full-thickness palatal incision. Lateral pharyngeal ports were determined by 45-degree nasoendoscopy. Speech assessment was done preoperatively and 3 months postoperatively. The flap integrity and lateral pharyngeal ports were evaluated with postoperative nasoendoscopy., Results: Postoperative speech assessment showed significant improvement in the overall velopharyngeal function, nasal emission, resonance, and articulation defects. The pattern of velopharyngeal closure was circular in 15 patients, coronal in six patients, and sagittal in five patients. Eighteen patients received medium to wide flap, five patients had narrow flap, and three patients had near obstructing flap. Velopharyngeal function was normal or borderline insufficiency in 24 patients (92%). Partial flap dehiscence was seen in two patients and was considered as failure despite the significant improvement in their preoperative VPI., Conclusions: The minimal complication and ease of flap design with precise flap inset make this modified superior flap technique easily applicable with a high success rate for patients with VPI after cleft palate repair., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: To report our experience with cephalometry in evaluating velopharyngeal dysfunction (VPD) in velocardiofacial syndrome (VCFS) and its utility in assessing the role of cervical spine abnormalities in VPD, prior to surgical correction of VPD., Design: Clinical charts and cephalometric radiographs done prior to surgery for VPD were retrospectively analyzed to ascertain velopharyngeal measurements and cervical spine abnormalities., Patients: Twenty-six patients (age: 6-23 years) with molecularly confirmed VCFS., Setting: Wake Forest University Health Sciences (1997-2005)., Measurements: Cranial base angle, nasopharyngeal depth, velum length, and Need ratio at rest, velar dimple location, and velopharyngeal length during phonation; information on presence/absence of submucous cleft palate and cervical spine abnormalities were also obtained. The relationship between C1 anterior arch abnormalities and Need ratio was examined., Results: Seventy-three percent of the VCFS patients had excessive nasopharyngeal depth, 80% had an abnormal Need ratio, 50% had a short velum, 81% had a submucous or occult submucous cleft palate, 90.5% had a cervical spine abnormality (C1 anterior arch abnormalities in 38%) and 11.5% had platybasia. There was a significant difference in the Need ratio between patients with and without C1 anterior arch abnormalities., Conclusion: Cephalometry can be used to delineate factors such as C1 vertebral abnormalities, excessive pharyngeal depth, and short velum that contribute to VPD in VCFS. This would help otolaryngologists better understand the anatomy prior to surgical treatment of VPD. This is the first study to highlight the frequent occurrence of C1 anterior arch abnormalities in VCFS., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc., Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with obstructive sleep apnea (OSA) by evaluating perioperative nasalance, nasality, voice, and articulation., Study Design: Prospective, comparative study., Methods: Twenty-four OSA patients selected for RP (two women and 22 men; mean age, 35 years) were enrolled for the study of velopharyngeal function in speech. The RP procedure involved removal of supratonsillar adipose tissue, preservation of all palatal muscular structure, splinting the lateral pharyngeal wall, and anterior advancing of the soft palate. Measurements of nasalance (vowel /a/, /i/, consonant /m/, oronasal, oral, and nasal texts), nasality (mirror-fogging test, degree of nasality, Gutzmann test and Bzoch hypernasality test), voice (acoustic analysis), and articulation (velar sound) were taken before RP and 3 months after the procedure and compared., Results: Comparative analysis of clinical measures showed that no significant differences were found following RP in nasalance (except for the vowel /a/), nasality, articulation, and voice. The only difference with regard to vowel /a/ showed, instead of an increase, a significant decrease of nasalance from 17.3 + or - 10.8 to 11.3 + or - 6.7 (P = .004), which may be attributed to the advancing and lifting of the soft palate in RP, leading to relaxation of the levator veli palatine and uvular muscles, which facilitates their contraction in velopharyngeal closure during particular vowel phonation., Conclusions: RP for OSA does not cause velopharyngeal insufficiency in terms of voice, nasality, and articulation in spite of anterior advancement of the soft palate, but does induce a nondetrimental change in nasalance.

Objectives/hypothesis: The present study proposed to estimate phonation threshold pressure (PTP) noninvasively using airflow redirection into a pneumatic capacitance system., Study Design: Prospective study., Methods: Subjects phonated into the device, which interrupts airflow mechanically and redirects the flow into a pneumatic capacitor. Five interruptions were effected per trial. PTP was estimated as the difference between subglottal pressure (SGP) and transglottal pressure at phonation offset. The novel method was tested for consistency in 20 normal human subjects at low (75 dB) and high (85 dB) sound pressure levels. The device was tested for validity on a tracheotomy patient., Results: Mean SGP was 9.02 +/- 3.27 cm H(2)O, and mean PTP was 3.68 +/- 1.41 cm H(2)O. Intrasubject coefficient of variation, a measure of intrasubject consistency, was 0.33 +/- 0.23. Statistically significant differences existed between the means of SGP but not PTP at 75 dB and 85 dB. The correlation coefficient between accepted and experimental SGP in a tracheotomy patient was 0.947 (P < .001)., Conclusions: Measurements corresponded well to previously reported values, and intrasubject variability was low, indicating the device was consistent. Testing on a tracheotomy patient demonstrated validity. More research is needed to determine the sensitivity and specificity of the device in differentiating between normal and pathological voices. This device may have clinical application as a noninvasive and reliable method of estimating PTP and indicating that laryngeal health is likely abnormal.

Objectives/hypothesis: Velopharyngeal stress incompetence in professional musicians is an uncommon but potentially career-ending problem. Pharyngeal flaps, V-Y palatal pushback procedures, Teflon or collagen injection of the posterior pharyngeal wall, and speech therapy have all been used to address this problem. The ideal procedure for this subset of patients with velopharyngeal incompetence (VPI) with high-pressure, mild VPI would be one that combines low morbidity and an expedient recovery for the busy musician. We describe an approach of endoscopically assisted autologous lipoinjection of the soft palate., Study Design: A retrospective review of our experience treating high-pressure stress VPI in two professional musicians., Methods: Literature review and retrospective chart review., Results: Two musicians underwent autologous lipoinjection of the soft palate for stress VPI. Patients resumed full play within 2 weeks of the operation with no serious complications. There has been no recurrence of the VPI after 18 and 12 months of follow-up, respectively., Conclusions: Velopharyngeal stress incompetence in musicians is an uncommon disorder. Velopharyngeal incompetence in these patients may not present as in a typical manner with hypernasality but may go undiagnosed for years mistakenly rationalized as a declining performance ability rather than a curable structural problem. The performance demands of professional musicians necessitate a timely solution to their VPI. More precise and limited contouring of palatal bulk can be achieved through the lipoinjection technique than compared with traditional palatal V-Y pushback or a standard pharyngeal flap. Lipoinjection of the palate can be performed as an outpatient procedure with only minor discomfort and an expedient recovery for the career musician.

Objectives: To assess the speech outcomes and complications in children who had undergone sphincter pharyngoplasty (SP) for management of velopharyngeal insufficiency (VPI)., Study Design: Retrospective chart review., Methods: Charts from patients who had sphincter pharyngoplasty between January 1993 and June 1996 were reviewed. Syndrome diagnosis and presence of repaired cleft palate were reviewed. Preoperative speech assessment, videofluoroscopic and nasopharyngoscopic evaluations, age at time of surgery, and postoperative speech assessments were reviewed for all patients. Postoperative videofluoroscopy and nasopharyngoscopy were performed for those patients who had persistent VPI. Obstructive sleep symptoms were also assessed., Results: Thirty patients were identified; six patients had no follow-up evaluation, leaving 24 patients included in this study. Average follow-up was 11.7 months (range, 2-35 mo). Velocardiofacial syndrome (VCFS) was the most commonly identified syndrome. Postoperatively, 15 of 24 patients (62.5%) had complete resolution of their VPI; five of 24 (20.8%) had significant improvement; one of 24 (4.2%) had minimal to no change; and three of 24 (12.5%) were hyponasal. Of the six patients with some degree of persistent VPI, three underwent revision surgery. All three patients had complete resolution of their VPI after revision surgery, resulting in an overall success rate of 18 of 24 (75%)., Conclusions: Sphincter pharyngoplasty has wide application in the management of children with VPI, including those with VCFS. The procedure is readily modified to accommodate an individual patient's needs as determined by preoperative VPI evaluation. A modification of the procedure is described to minimize the risk of postoperative airway obstruction and hyponasality, both regarded as airway complications of sphincter pharyngoplasty.

Videofluoroscopy has long been viewed as the "gold standard" of swallowing examination for the comprehensive information it provides. However, it is not very efficient and accessible in some practical situations. In this study, we tried to use a modified technique of fiberoptic endoscopic examination of swallowing (FEES) in evaluating dysphagic patients. For each examination, a spoonful of pudding and dyed water were fed in sequence three times. The pharyngeal swallowing events were observed with fiberscope panoramically and videotaped. Twenty-eight chronic dysphagic patients underwent both videofluoroscopy and FEES in 2 weeks. Comparison of the results revealed that disagreements in premature oral leakage to the pharynx, pharyngeal stasis, laryngeal penetration, aspiration, effective cough reflex, and velopharyngeal incompetence were 39.3%, 10.7%, 14.3%, 14.3%, 39.3%, and 32.1%, respectively. FEES was found to be more sensitive in detecting these risky features of swallowing, except with respect to premature leakage. Possible causes of the discrepant results are discussed, and the limitation of videofluoroscopy in practical usage is discussed. FEES is conclusively a safer, more efficient, and sensitive method than videofluoroscopy in evaluating swallowing safety.

The purpose of this study was to ascertain the relation between preoperative glottal gap and postoperative vocal function in thyroplasty type I. Twenty-two of 64 patients who underwent thyroplasty type I between 1987 and 1994 were studied. In preoperative digitized laryngostroboscopic images, the glottal-gap, width (GGW), shape, and area were examined at the maximum closure of vibration and normalized by membranous vocal-fold length (MVFL). Postoperative vocal function analysis was performed with aerodynamic and acoustic measurements and compared with preoperative videostroboscopic images. In patients with preoperative posterior GGW of less than 10% of MVFL, postoperative vocal function was significantly better than in other patients. Although thyroplasty type I is an excellent medialization technique, it may need to be combined with a posterior closure procedure in patients with large posterior gaps.

Seven patients who received pharyngeal flaps for velopharyngeal incompetence (VPI) were studied to assess the effect of the procedure on nasal airway size. The findings suggest that the pharyngeal flap does not significantly decrease the upper airway in all patients. The effect of the flap did not correlate with the type of cleft, and was most pronounced in the inspiratory phase of the breathing cycle. Reasons for this variable effect, assumed to be related to an already impaired nasal airway in most cleft patients, are discussed.

A thorough assessment of the velopharyngeal (VP) closure dynamics is important for therapeutic planning in patients with nasal speech. An additional diagnostic tool to the standard endoscopic examination of the VP valve, the "Forced Sucking Test" (FST) is presented. In this study, 110 patients with a normal VP valve and 40 patients with VP insufficiency were subjected to a comprehensive endoscopic examination. When existent, Passavant's ridge clearly appears in 80% of these cases during the FST. This is advantageous, since the ridge is often unseen during routine nasendoscopy. Passavant's ridge appears indistinguishable in shape and level during speech and FST. During FST, the bulge of the uvular ridge is clearly seen on the flat or concave nasal surface of the velum. In cases of diastasis of the velar musculature, the midline V-defect of the velum is clearly seen. The test is particularly important in children with concomitant adenoid hypertrophy. The findings are discussed in terms of their implications for the anatomy and physiology of the VP valve. FST is recommended as an additional and complementary part of the endoscopic examination of the VP valve.

The use of Gax collagen is proposed for correcting velopharyngeal insufficiency with posterior pharyngeal wall augmentation. The indications for this procedure are velopharyngeal insufficiency that remains after surgery and treatment by a speech pathologist. The procedure is also valuable after velum paralysis. Collagen (2.5-5cc) is injected through a device designed for vocal-fold and laryngeal rehabilitation. Several injection points are necessary to raise a good Passavant's ridge. The muscular activity of the posterior pharyngeal wall models the collagen pad for the first 3 weeks; afterwards, the collagen shape remains unchanged due to its integration in the host tissues. At this time, five patients have been injected with Gax collagen and have improved. The oldest case dates from 28 months ago; the most recent dates from 8 months ago. There were no adverse reactions, and the results remain stable at the present time.

The mechanism of velopharyngeal valving in normal subjects and patients with velopharyngeal insufficiency (VPI) has been the subject of keen debate. The authors have studied 80 normal subjects and 500 patients at the Center for Craniofacial Disorders using direct nasopharyngoscopy and multi-view videofluoroscopy to ascertain the patterns and mechanism of velopharyngeal valving. Multiple patterns of valving were found in both populations and were characterized as "coronal," "sagittal," "circular," and "circular with Passavant's ridge." The incidence of the differing patterns of closure were surprisingly similar in frequency in both normal and pathologic populations. The importance of these diagnostic methods is discussed in relation to treatment of patients with VPI, particularly in designing the type and level of pharyngoplasty.