Search

Importance: Persistent velopharyngeal insufficiency (VPI) is a rare but well-recognized complication of adenoidectomy. VPI can have a significant impact on the communication of a child., Objective: To describe the pathophysiology of post-adenoidectomy VPI, identify its associated risk factors, and illustrate the techniques used to treat the entity., Evidence Review: A search of English or translated English articles concerning adenoidectomy, partial adenoidectomy, superior adenoidectomy; and velopharyngeal insufficiency, speech and voice from 1980 to 2021 was performed using Pubmed and Embase. Data from prospective and retrospective studies and their relevant references were pooled., Results: By objective measures, hypernasality is noted in many pediatric patients post-adenoidectomy, but this typically resolves in 3-6 months. Risk factors for the development of post-adenoidectomy VPI include low birth weight, family history of hypernasality, and history of speech problems or nasal regurgitation. The cleft palate, submucous cleft palate, poor palate mobility, and a deep pharynx may indicate susceptibility to VPI. Speech therapy is successful in up to 50% of patients, while surgical intervention may be tailored based on the diagnostic evaluation of the velopharynx with videofluoroscopy or nasoendoscopy., Conclusion: We present a comprehensive review of the literature on the pathophysiology, risk factors, and treatment of post-adenoidectomy VPI. We hope to bring awareness to the factors that can lead to a rare but potentially devastating complication in one of the most common procedures performed by Otolaryngologists., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Paediatric velopharyngeal insufficiency (VPI) is a known but rare complication following adenotonsillar surgery that can have significant adverse effects on the communication as well as psychological well-being of the patient and their family. We sought to assess risk factors, aetiology, assessment and management of these patients through a dedicated multidisciplinary clinic., Methods: Retrospective data collection was performed for patients seen in the Great Ormond Street Hospital for Children multidisciplinary VPI clinic from the 1 st of January 2015 until 30 th of April 2020. Paediatric patients with previous adenotonsillar surgery and no evidence of cleft palate or speech and language disorder were included in the study., Results: 29 patients met the inclusion criteria, with 16 having previous adenotonsillectomy and 13 isolated adenoidectomy. In our VPI clinic, patients were seen on average for 4.9 occasions over a 38.3-month period. Clinical assessment was conducted using GOS.SP.ASS '98 speech assessment tool, speech videofluoroscopy and nasoendoscopy, as per individual needs. The main cause of post-adenoidectomy VPI was identified in 72.5% of the cases. Speech videofluoroscopy was performed in 27 cases. Associated anatomic features identified included deep pharynx (37%), long palate (22.2%) and variable levator position. Severe hypernasality was noted in 3 patients, while in 20 cases moderate or mild hypernasality was found. There were no patients with normal speech. Ten patients were treated with speech therapy alone, whereas surgical intervention was required in seventeen cases. In the population who received treatment and had adequately recorded follow-up, improvement in speech was noted in 86.9%, with 30.4% having oral resonance on last review. Of the patients with severe hypernasality, all improved but had some persistent hyper nasality on last clinic review., Conclusions: We present our multidisciplinary management of post adenoidectomy VPI. Through the investigations in our dedicated specialist VPI clinic, the cause of VPI was found more frequently than in previous reports in the literature. Intense treatment is usually required with lengthy follow-up and multiple attendances in VPI clinic. Main modalities of management include SLT, surgery and speech prostheses. Most patients' speech will improve with intervention. We highlight the importance of early recognition, referral and a multi-disciplinary approach in treating this condition. We advise ENT surgeons to ensure patients are adequately aware of this complication given its potential impact., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: A significant proportion of the referrals made to a speech investigation clinic in a cleft unit include patients with non-cleft velopharyngeal dysfunction (VPD). This study aims to quantify the underlying diagnoses of these patients and describe the investigative pathway and diagnostic information subsequent to presentation in our clinic., Materials and Methods: The case notes of 136 consecutive patients with non-cleft VPD who attended our Velopharyngeal Investigation (VPI) clinic from July 2014-December 2019 were reviewed., Results: In the paediatric group (n = 118) the most common cause was 22q11 chromosomal anomalies (n = 46), while post palatal tumour resection was the commonest cause of acquired non-cleft VPD in adults (n = 8). Fifty-nine patients were referred to the clinic with a known underlying pathology such as a syndromic diagnosis. Of those presenting without a known aetiology, fifty-eight were referred onto our genetics and/or neurology colleagues. Although a genetic or neurological cause could not be identified in some of those patients, thirty-one patients received a new diagnosis, with subsequent implications for ongoing care., Conclusion: There are a wide range of diagnoses resulting in non-cleft VPD, but there are very few large-scale studies focusing on investigating these patients for an underlying aetiology. This study highlights the role of genetics and neurology in the diagnosis and management plan for this cohort of patients., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

The management of velopharyngeal insufficiency (VPI) in patients with 22q11.2 deletion syndrome (22q11DS) poses a significant clinical challenge due to presence of a large velopharyngeal gap and a relatively high rate of internal carotid artery (ICA) medialization. To our knowledge, we are the first group to have successfully managed VPI in a series of seven pediatric patients with 22q11DS with medialized ICAs via a novel surgical technique involving carotid artery mobilization followed by pharyngeal flap insertion. Thus far, we have found this technique to be reliably safe with no significant morbidity and caregivers have reported postoperative improvement in speech, swallowing and nasal regurgitation symptoms. Herein, we provide a detailed description of our novel surgical approach, including an instructional video, for correction of VPI in patients with medialized ICAs, who have previously had limited management options., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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.)

Objective: Posterior palatal defect after cleft palate (CP) repair is not a rare problem, it may cause velopharyngeal insufficiency (VPI). The aim of this study was to assess the effectiveness of a superiorly-based pharyngeal flap (PF) with modification of its end to accommodate the defect in treatment of post-palatoplasty VPI., Methods: Thirteen children with VPI due to posterior palatal defect after CP repair were included in this study. PF was used in treatment of all patients, the lower end of the flap was fashioned in a V-shape to accustom the shape of the defect with peeling of its overlying mucosa to enhance wound healing. The PF was inserted deeply into a tunnel created within the defect between the oral and nasal layers of the palate. Pre- and postoperative evaluation using auditory perceptual assessment (APA), nasometric assessment and velopharyngoscopy were performed., Results: Significant improvement of APA and nasalance score for both oral and nasal sentences was achieved. Also, velopharyngoscopy showed complete velopharyngeal closure in all patients postoperatively., Conclusion: A modified PF is an effective treatment for VPI caused by posterior palatal defect that may be encountered after CP repair., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined., Methods: A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos., Results: Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05)., Conclusion: Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: Tonsillar hypertrophy may affect velopharyngeal closure and speech resonance. The aim of this study was to assess the impact of hypertrophied tonsils on velopharyngeal function in children with normal palate and to measure the effect of tonsillectomy on velopharyngeal closure and speech resonance., Methods: Eighty seven children with hypertrophied tonsils and normal palate were subjected to tonsillectomy for indications other than speech problems. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech (APA) and nasometric assessment of nasalance was measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy., Results: Thirteen patients were excluded from the study because of associated adenoid hypertrophy. The mean baseline of APA scores showed insignificant changes postoperatively. However, significant postoperative changes of nasometric parameters were detected, and the overall postoperative nasalance score was improved for nasal and oral sentences. Also, improvement of velopharyngeal closure was observed postoperatively with accession of palatal mobility and significant increase in coronal closure pattern., Conclusion: hypertrophied tonsils may impair velopharyngeal function in children with normal palate by hindering palatal elevation. Tonsillectomy is a beneficial procedure for such patients as it can improve the velopharyngeal closure and speech resonance., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To determine demographics and practice patterns of surgeons treating velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome (22q11.2DS)., Methods: An anonymous electronic survey study was administered to the surgical membership of the American Cleft Palate-Craniofacial Association and the Society for Ear Nose and Throat Advances in Children. The survey queried surgeon demographics and differences in management practices for submucous cleft palate (SMCP), pharyngoplasty algorithms, and self-reported complications for nonsyndromic versus 22q11.2DS patients., Results: 126 surveys were returned from 9 international regions with the majority from the United States (73%), followed by Western Europe (9.5%) and Canada (7.9%). Plastic surgery was the most common specialty (61.9%), followed by otolaryngology (27.8%). 88.1% reported fellowship training, and 33% completed multiple fellowships. Prior to proceeding with pharyngoplasty in 22q11.2DS patients, surgeons required the following assessments: speech evaluation (79.4%), velopharyngeal imaging (51.6%), cardiac evaluation (50.0%), carotid artery MRI (29.4%), and cervical spine x-rays (11.1%). Nasoendoscopy was the most common modality used for imaging the velopharynx. Overall, providers managed patients with 22q11.2DS similarly to nonsyndromic patients, with several significant exceptions including that they were more likely to perform SMCP repair alone as a first approach in nonsyndromic patients (p = 0.031) and posterior pharyngeal flap without SMCP repair in those with 22q11.2DS (p = 0.017)., Conclusions: Practice patterns for the management of VPD in patients with 22q11.2DS vary across providers. Further collaborative studies are needed to develop optimal treatment paradigms for VPD in patients with 22q11.2 DS., (Copyright © 2018. Published by Elsevier B.V.)

Objective: The purpose of this study was to identify prognostic factors associated with improved speech outcomes following surgical correction for velopharyngeal insufficiency (VPI) in pediatric patients with 22q11.2 deletion syndrome (22q11DS)., Methods: Eighteen patients were identified via retrospective chart review of patients with 22q11DS between 2005 and 2014. Patient characteristics, medical histories, associated comorbidities, surgical procedures, and pre- and postoperative perceptual hypernasality (subjectively rated 1-5 with 5 being the most severe) were gathered for each patient., Results: 12 patients (67%) experienced improvement in hypernasality following corrective surgery for VPI. Higher severity of hypernasality preoperatively was found to be indicative of a lower chance of improvement with VPI surgery. Of 8 patients with a preoperative hypernasality score of 5, 3 (38%) showed improvement in hypernasality postoperatively, while 9 out of 10 (90%) of patients with a preoperative hypernasality score less than 5 showed postoperative improvement. Females were also found to have worse speech outcomes compared to males., Conclusion: 22q11DS patients presenting with severely hypernasal speech preoperatively are less likely to show improvement in hypernasality following corrective surgery for VPI. Those patients with moderate hypernasality are most likely to benefit from surgery., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: The aim of this study was to investigate the impact of an intensive 10-week course of articulation therapy on articulation errors in cleft lip and palate patients who have Velopharyngeal Insufficiency (VPI), non-oral and passive cleft speech characteristics., Methods: Five children with cleft palate (+/-cleft lip) with VPI and non-oral and passive cleft speech characteristics underwent 40 intensive articulation therapies over 10 weeks in a single case experimental design. The percentage of non-oral CSCs (NCSCs), passive CSCs (PCSCs), stimulable consonants (SC), correct consonants in word imitation (CCI), and correct consonants in picture naming (CCN) were captured at baseline, during intervention and in follow up phases. Visual analysis and two effect size indexes of Percentage of Nonoverlapping Data and Percentage of Improvement Rate Difference were analyzed., Results: Articulation therapy resulted in visible decrease in NCSCs for all 5 participants across the intervention phases. Intervention was effective in changing percentage of passive CSCs in two different ways; it reduced the PCSCs in three cases and resulted in an increase in PCSCs in the other two cases. This was interpreted as intervention having changed the non-oral CSCs to consonants produced within the oral cavity but with passive characteristics affecting manner of production including weakness, nasalized plosives and nasal realizations of plosives and fricatives. Percent SC increased throughout the intervention period in all five patients. All participants demonstrated an increase in percentage of CCI and CCN suggesting an increase in the consonant inventory. Follow-up data showed that all the subjects were able to maintain their ability to articulate learned phonemes correctly even after a 4-week break from intervention., Conclusion: This single case experimental study supports the hypothesis that speech intervention in patients with VPI can result in an improvement in oral placements and passive CSCs., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: We reviewed the outcomes of patients who underwent a velopharyngoplasty and subsequent speech therapy for velopharyngeal insufficiency (VPI) to determine possible prognostic variables., Methods: During the period 2002-2010, 91 patients with VPI underwent a velopharyngoplasty (either the Honig velopharyngoplasty, the modified Honig velopharyngoplasty or the Hynes pharyngoplasty). Of these, 62 had complete data for long-term evaluation of speech outcome and analysis of variables potentially influencing this outcome. Speech outcome was assessed using five criteria that were evaluated pre- and postoperatively: hypernasality, nasal emission, facial grimacing, retro-articulation and glottal stops. The former two variables were transformed into a semi-objective nasality index (NI), the latter three variables were assembled to form a subjective articulation index (AI). Prognostic variables for outcome that were studied included age at velopharyngoplasty, associated 22q11.2 deletion syndrome, intervention type, primary or secondary surgery and pre-intervention speech therapy., Results: Before surgery, based on the NI, 15 patients had mild VPI and 44 patients had moderate to severe VPI. Postoperatively at 12 months, 46 patients had a good speech outcome (normal or mild VPI), 13 patients had moderate VPI and no more severe VPI was observed. The overall success rate of 78% after one year increased to 90% in the long-term (median 27 months) with further speech therapy. Patients without the diagnosis of 22q11.2 deletion syndrome had better speech outcomes than patients with the syndrome. No statistically significant effect of the age at velopharyngoplasty on speech outcome was found. No cases of sleep apnea syndrome were reported., Conclusions: Our protocol of patient tailored surgical interventions and further postoperative speech therapy results in good speech outcomes, with no or only mild remaining VPI for the majority of patients. The correction of VPI is more difficult for the subgroup of patients with 22q11.2 deletion syndrome., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Grommets may be considered as the treatment of choice for otitis media with effusion (OME) in children born with a cleft. But the timing and precise indications to use them are not well established. The aim of the study is to compare the results of hearing and speech controls at three and six year-old in children born with total cleft or cleft palate in the presence or not of grommets., Methods: This retrospective study concerns non syndromic children born between 1994 and 2006 and operated for a unilateral cleft lip palate (UCLP) or a cleft palate (CP) alone, by one surgeon with the same schedule of operations (Malek procedure). We compared the results of clinical observation, tympanometry, audiometry and nasometry at three and six year-old. The Borel-Maisonny classification was used to evaluate the velar insufficiency. None of the children had preventive grommets. The Fisher Exact Test was used for statistical analysis with p<0.05 considered as significant., Results: Seventy-seven patients were analyzed in both groups. Abnormal hearing status was statistically more frequent in children with UCLP compared to children with CP, at three and six years (respectively, 80-64%, p<0.03 and 78-60%, p<0.02), with the use of grommets at six years in 43% of cases in both groups. Improvement of hearing status between three and six year-old was present in 5% of children with UCLP and 9% with CP, without the use of grommets., Conclusion: The use of grommets between three and six year-old was not associated to any improvement of hearing status or speech results children with UCLP or with CP, with a low risk of tympanosclerosis. These results favor the use of grommets before the age of three, taking into account the risk of long term tympanosclerosis., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Velopharyngeal insufficiency (VPI) is a common complication after cleft palate repair, it may be due to lack of levator sling reconstruction and/or palatal shortening. Furlow palatoplasty has the advantages of retro-positioning of levator palati muscles and palatal lengthening. The aim of this study was to assess the efficacy of Furlow palatoplasty in the treatment of VPI in patients who undergone previous palatoplasty., Methods: Twenty-three children with post-palatoplasty VPI were included in the study. Furlow technique which was not used in the primary repair, has been used as a secondary corrective surgery. Preoperative and postoperative evaluation of velopharyngeal function was performed, using auditory perceptual assessment (APA) and nasometry for speech, and flexible nasopharyngoscopy for velopharyngeal closure., Results: Significant improvement of APA and nasalance score for oral and nasal sentences was achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure in 19 patients (82%) postoperatively., Conclusion: Furlow palatoplasty is considered a useful treatment option for VPI in patients with previously repaired cleft palate, it improves the speech and velopharyngeal closure., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study is to determine the incidence of velopharyngeal insufficiency (VPI) and fistulae development in patients seen by the Isfahan Cleft Care Team and also determine the association of gender, age at repair, and cleft type with the incidence of each., Methods: This retrospective study was completed using records of patients referred to Isfahan Cleft Care Team between 2005 and 2009. One hundred thirty-one patients with a history of cleft palate (with or without cleft lip) who had undergone primary palate repair and were at least 4 years of age at the time of the speech evaluation were included in this review. The main outcome of this study was the incidence of fistulae and hypernasality following palatoplasty. A secondary outcome was the association of gender, age at the time of repair, and cleft type on the incidence of fistulae and hypernasality., Results: A post-surgical fistula was present in 23.7% of the patients studied. Fistula rates were significantly higher in patients who had undergone repair of bilateral clefts of the lip and palate (40.9%) than for those patients who had undergone repair of a unilateral cleft lip and palate (16.9%) (p=0.02). Presence of a fistula was not associated with gender (p=0.99) or age at time of primary surgical repair (p=0.71). Mild hypernasality was noted in 15.3% of patients. Moderate or severe hypernasality was present in 66.5% of the patients and the remaining cases presented with normal resonance. Severe hypernasality was significantly higher in patients with a Veau IV type cleft as compared to patients with Veau III cleft types (p=0.04). There was a significantly higher incidence of hypernasality in boys than in girls (p<0.001). The association of age at the time of palatal repair and incidence of hypernasality was not significant (r=0.13, p=0.07)., Conclusions: Overall, post-surgical complications were high in this cohort of patients who had undergone cleft palate repair by Isfahan Cleft Care Team during the study time frame. Therefore, there is a high priority need for increased training of best practices for the surgeons., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech., Objective: Was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabic-speaking children with velopharyngeal insufficiency (VPI)., Subjects and Methods: Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. Auditory perceptual assessment (APA) of children speech was conducted. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks. Mansoura Arabic Articulation test (MAAT) was performed to analyze the consonants articulation of these children., Results and Conclusion: The most frequent type of articulatory errors observed was substitution, more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /ʔ/ followed by /k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (/ʔ/,/ħ/,/ʕ/,/n/,/w/,/j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Although a history of cleft palate is the most common cause of velopharyngeal dysfunction (VPD), there are other disorders that can also cause hypernasality and/or nasal emission. These include other structural anomalies of the velopharyngeal valve (velopharyngeal insufficiency), neurophysiological disorders that result in inadequate velopharyngeal movement (velopharyngeal incompetence), and even faulty articulation placement in the pharynx (velopharyngeal mislearning). Unfortunately, individuals with non-cleft causes of hypernasality and/or nasal emission do not typically present at a cleft palate/craniofacial center where there are professionals who specialize in the evaluation and treatment of these disorders. As a result, they are often misdiagnosed and do not receive appropriate treatment. In this review, we present various conditions that can cause hypernasality and/or nasal emission during speech. We discuss appropriate treatment based on the underlying cause of the condition. It is important that pediatric otolaryngologists are able to recognize these disorders so that affected patients are referred to specialists in velopharyngeal dysfunction for treatment., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study was performed to investigate speech outcomes after three different types of palatoplasty for the same cleft type. The objective of this study was to investigate the surgical techniques that are essential for normal speech on the basis of each surgical characteristic., Methods: Thirty-eight consecutive nonsyndromic patients with unilateral complete cleft of the lip, alveolus, and palate were enrolled in this study. Speech outcomes, i.e., nasal emission, velopharyngeal insufficiency, and malarticulation after one-stage pushback (PB), one-stage modified Furlow (MF), or conventional two-stage MF palatoplasty, were evaluated at 4 (before intensive speech therapy) and 8 (after closure of oronasal fistula/unclosed hard palate) years of age., Results: Velopharyngeal insufficiency at 4 (and 8) years of age was present in 5.9% (0.0%), 0.0% (0.0%), and 10.0% (10.0%) of patients who underwent one-stage PB, one-stage MF, or two-stage MF palatoplasty, respectively. No significant differences in velopharyngeal function were found among these three groups at 4 and 8 years of age. Malarticulation at 4 years of age was found in 35.3%, 10.0%, and 63.6% of patients who underwent one-stage PB, one-stage MF, and two-stage MF palatoplasty, respectively. Malarticulation at 4 years of age was significantly related to the presence of a fistula/unclosed hard palate (P<0.01). One-stage MF palatoplasty that was not associated with postoperative oronasal fistula (ONF) showed significantly better results than two-stage MF (P<0.01). Although the incidences of malarticulation at 8 years of age were decreased in each group compared to at 4 years of age, the incidence was still high in patients treated with two-stage MF (45.5%). On the whole, there was a significant correlation between ONF/unclosed hard palate at 4 years of age and malarticulation at 8 years of age (P<0.05)., Conclusion: Appropriate muscle sling formation can compensate for a lack of retropositioning of the palate for adequate velopharyngeal closure. Early closure of the whole palate and the absence of a palatal fistula were confirmed to be essential for normal speech. To avoid fistula formation, multilayer repair of the whole palate may be critical., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Published reports and previous studies from our institution have reported worse overall speech results, including significantly higher rates of persistent articulation errors, in patients undergoing palatoplasty at age >18 months. This study further investigates the effects of late repair on long term speech outcomes., Methods: A retrospective review was performed of non-syndromic patients undergoing primary palatoplasty at age >18 months between 1980 and 2006 at our institution. Longitudinal speech results were compared based on reason for late repair and age at repair., Results: Forty-one patients were greater than 18 months of age at the time of palatoplasty, and 24 fit criteria for longitudinal data analysis. There was a statistically significant improvement in nasality scores at Time Point 1 for international adoptees compared to the non-adopted population (p=0.04). Patients with submucosal clefts were found to have significantly less severe nasal emission scores at Time Point 1 compared to those with overt clefts (p=0.04), but not at Time Point 2. There were no significant differences between scores if repair was performed between 18 and 36 months or >36 months, nor any difference in incidence of articulation errors between subgroups of patients with late repair at either Time Point., Conclusion: Our experience demonstrates that cleft palate repair after 18 months of age is associated with a significantly increased incidence of articulation errors associated with VPI, irrespective of reason for late repair, highlighting the persistence of learned compensatory behaviors in speech and the importance of proceeding with early repair., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Prader-Willi syndrome (PWS) is a rare genetic disorder with an incidence rate of 1 in 10,000-30,000. Patients with PWS typically have symptoms related to hypotonia, obesity, and hypothalamic dysfunction. A high rate of obstructive sleep apnea (OSA) is found among this population of patients. Adenotonsillectomy has been advocated as a first line approach for treatment of OSA in patients with PWS. Velopharyngeal dysfunction (VPD) is a known complication of adenotonsillectomy. VPD can also be present in patients with global hypotonia, such as those with PWS. The objective of this study is to review the occurrence of VPD in patients with PWS after adenotonsillectomy for OSA., Methods: A retrospective review was performed of all patients with PWS and OSA from a tertiary pediatric hospital between the years of 2002 and 2012. Pre- and post-operative sleep studies and sleep disordered breathing symptoms, post-operative VPD assessment by the speech-language pathologist (SLP), and VPD treatments were evaluated., Results: Eleven patients (five males and six females), fitting the inclusion criteria, were identified. The age of the patient at the initial otolaryngologic evaluation ranged from 2 to 9 years. All patients underwent adenotonsillectomy for sleep disordered breathing. Four patients were diagnosed with post-operative hypernasality after assessment by a speech-language pathologist. The hypernasality ranged from mild to moderately severe. Of the four patients with hypernasality, two were found to have structural issues requiring surgery (pharyngeal flap). Both of the surgical patients experienced significant improvement in their VPD after surgery. The remaining two patients were found to have articulation error patterns that were considered more developmental in nature and both responded to speech therapy. All patients, except one, had improvement in their polysomnogram or sleep symptoms after adenotonsillectomy. However, three patients continue to require continuous positive airway pressure at night., Conclusion: Velopharyngeal dysfunction may occur after adenotonsillectomy in patients with Prader-Willi Syndrome. Families should be counseled of this risk and the potential need for operative intervention to correct it., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Complications from a prolonged nasogastric tube intubation, though seldom reported, are well described. Herein we describe the first two reported cases of velopharyngeal insufficiency secondary to velopharyngeal scarring and immobility from repetitive nasogastric tube insertions and prolonged use. Differing only in location, the proposed pathophysiologic mechanism of injury is identical to that of the nasogastric tube syndrome, a rare and serious, well described entity consisting of bilateral vocal fold paralysis due to pressure-induced ulceration of the posterior cricoarytenoid musculature., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: Submucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI., Methods: This prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy., Results: Significant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory., Conclusions: Furlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Hypernasality is a common problem in cleft care. It should be treated before the age of six, because of the impact it can have on speech sound development in young children. An objective method of nasalance evaluation is nasometry. Cooperation of young children, by nature, differs over time and situations. First aim of this study is to indicate a minimum age for cooperation with the nasometer. Second aim is to compare the cooperation of children in the most used research setting (school) with the cooperation of children in the most used setting in daily practice (ENT outpatient clinic)., Method: Children from four to six years of age were recruited from schools. Outpatient clinic children were recruited from the Groningen ENT clinic. Both groups were tested with the nasometer. The cooperation with installation and repetition of speech stimuli were noted., Results: 118 school children and 41 outpatient clinic children were recruited. Six years old children cooperated significantly better than the five years old. The five years old cooperated better than the four years old. Moreover, school children cooperated significantly better than the outpatient children., Conclusion: Most children of 6 years of age and older, will show good cooperation with nasometry. In children aged 5, cooperation depends on the situation in which the nasometer is used. In a school setting the cooperation is better than in an outpatient clinic setting. In the 4 years old children the cooperation with the nasometer often is insufficient, probably due to normal, unpredictable cooperative behavior belonging to this age., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To investigate age of diagnosis, typical symptoms, finding of the palate, therapy options and accompanying diseases., Methods: A retrospective analysis of 439 patients with symptomatic submucous cleft palate (SMCP), who received a veloplasty operation (butterfly suture technique developed by Haase) was made., Results: SMCP was initially diagnosed at the mean age of 4.9 years. Main symptoms were hyper nasal speech (51%) and conductive hearing loss (45%), which resolved after veloplasty (often in combination with adenotomy and insertion of ventilation tubes). Typical findings of the palate were a lack of posterior nasal spine (68%) and bifid uvula (59%). Following surgery 17.1% required speech therapy and 5.5% needed velopharyngoplasty due to continuing hyper nasal speech., Conclusion: SMCP is often diagnosed very late, though symptoms of velopharyngeal insufficiency (hyper nasal speech, Eustachian tube dysfunction) and bifid uvula are present. We therefore recommend that all patients with such findings are examined by an appropriate specialist such as Phoniatrics, Otolaryngologist and Oral-Maxillofacial-Surgeon so that early diagnosis and palatoplasty can be performed. The veloplasty operation (butterfly suture technique) can be recommended as a safe therapy for velopharyngeal insufficiency for patients with symptomatic SMCP., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Adenoidectomy is indicated for the relief of paediatric nasal obstruction, sleep-disordered breathing and otitis media with effusion (OME). Velopharyngeal insufficiency (VPI) is a rare complication. The main risk factor is the presence of pre-existing velopharyngeal closure-impaired mechanisms, including submucosal or overt cleft palate. Despite possible benefits, adenoidectomy is frequently withheld in such children to avoid VPI. This study aims to demonstrate the efficacy and safety of partial adenoidectomy using suction diathermy in children who previously underwent overt cleft palate repair during infancy, to allow selective resection of tissue and symptom resolution without producing VPI., Methods: Since 1994, 18 patients with previously corrected overt cleft palate have undergone partial adenoidectomy at this centre, for the treatment of nasal obstruction or sleep-disordered breathing, with or without OME. Three had existing VPI following their cleft correction surgery. Selective resection of the adenoid was performed transorally under indirect vision, using a malleable suction coagulator. This allowed exposure of the posterior choanae, leaving the remaining adenoid bulk intact., Results: Patients were followed up at 4 weeks, and subsequently at regular intervals (total follow up 30-180 months, median 92 months), including perceptual speech assessment in all cases. All demonstrated symptomatic improvement with respect to the original indications for surgery. None developed worsening hypernasal speech or other features of VPI, and there were no cases of symptomatic adenoidal re-growth., Conclusions: Partial adenoidectomy, employing a variety of methods, has been used successfully in children with submucosal cleft palate. This study demonstrates the safe and effective use of suction diathermy to enable partial adenoidectomy in children who have previously undergone surgical correction of overt cleft palate, allowing symptom resolution without producing VPI.

Background: Velocardiofacial syndrome (VCFS) is one of the most common multiple anomaly syndromes in humans. Around 70% of the cases show velopharyngeal insufficiency (VPI), as a consequence of cleft palate. VPI is much more frequent due to special abnormal conditions inherent to VCFS including: platybasia, hypotrophy of adenoid, enlarged tonsils, hypotonia and abnormal pharyngeal muscles., Objective: To evaluate the surgical treatment of VPI in VCFS patients., Materials and Methods: In the Hospital Gea Gonzalez at Mexico City, all cases of VCFS from January 2000 to July December 2007 were studied. All patients subjected to velopharyngeal surgery for correcting VPI were selected. Twenty-nine patients underwent velopharyngeal surgery. All operations were planned according to findings of videonasopharyngoscopy (VNP) and multiview video fluoroscopy (MVF)., Results: Twenty patients underwent pharyngeal flap operations, and 9 patients were operated on with a sphincter pharyngoplasty. After a pharyngeal flap, 17 cases (85%) improved to normal nasal resonance or mild hypernasality. Three flaps showed moderate hypernasality postoperatively. From the 9 sphincter pharyngoplasties, 6 cases (66%) improved to moderate hypernasality. Four patients (33%) persisted with severe hypernasality postoperatively. There were no complications., Conclusions: Tailor-made pharyngeal flaps seem to be the best option for restoring velopharyngeal function in cases of VPI in VCFS patients. The use of VNP and MVF is useful for planning the operations for VPI, and they are also useful for indicating the removal of tonsils in cases with high risk of obstruction. Moreover, VNP is also useful for preventing damage to the internal carotids which are usually displaced in VCFS patients.

Objective: Persistent hypernasality after adenoidectomy is an infrequent problem in children with normal palate. However if it happened, it can render a child's speech unintelligible resulting in serious affection of social life. We aimed in this study to identify the causes of persistent post-adenoidectomy velopharyngeal insufficiency and to assess the efficacy of sphincter pharyngoplasty in the treatment of such problem., Methods: This study was conducted on 18 patients complained of hypernasal speech following removal of their adenoids after variable periods of failed expected spontaneous improvement. Their hypernasality was rated as being mild, moderate and severe, all cases were subjected to conservative treatment in the form of speech therapy for 3 months to correct the problem, and patients that did not respond to speech therapy were subjected to surgical intervention in the form of sphincter pharyngoplasty. Velopharyngeal closure was assessed using flexible nasopharyngoscopy, while speech was assessed using auditory perceptual assessment and nasometry., Results: Hypernasality was mild in 9 cases, moderate in 7 cases and severe in 2 cases. Flexible nasopharyngoscopy showed occult submucous cleft in 5 cases, short palate in 2 cases, and deep nasopharynx in 3 cases. Speech improvement was achieved in 8 cases after completion of speech therapy program (all had mild hypernasality with no anatomical palatal defects). Ten patients that had palatal defects were subjected to sphincter pharyngoplasty, 8 of them showed complete recovery, while 2 cases with severe hypernasality showed partial improvement of their speech., Conclusions: Persistent post-adenoidectomy velopharyngeal insufficiency may be due to anatomical abnormalities of the palate such as an occult submucous cleft, short palate or deep nasopharynx; such conditions may be overlooked during the preoperative preparation for adenoid removal. Speech therapy is an effective method in mild hypernasality especially if there is no anatomical abnormality, while surgical correction is usually needed in moderate and severe cases, and sphincter pharyngoplasty is a useful choice for those patients.

Objective: (a) Pharyngeal flap and sphincter pharyngoplasty are the procedures most frequently chosen by craniofacial surgeons for surgical management of velopharyngeal insufficiency. Both operations may be complicated by obstructive breathing and even sleep apnea. (b) The purpose of this study is to evaluate the efficacy of a palatopharyngeal sling in the treatment of velopharyngeal insufficiency in cases with weak palatal mobility and its effect on breathing., Methods: Seventeen cases of post-palatoplasty velopharyngeal insufficiency were subjected to treatment by palatopharyngeal sling. This sling, created by elevation of bilateral myomucosal flaps formed of palatopharyngeus and superior constrictor muscles, passed through palatal split, sutured together and to a raw area on the oral surface of the soft palate. Pre- and post-operative evaluation was carried out by perceptual speech analysis and flexible nasopharyngoscopy. Polysomnography was used to assess the effect of the operation on breathing., Results: Complete closure was achieved in 13 cases (76.5%) while 4 cases showed incomplete closure (2 of them showed improvement when compared with the pre-operative video). The overall improvement of speech and velopharyngeal closure was 88.2%. Polysomnography showed no obstructive breathing., Conclusions: Palatopharyngeal sling is a useful technique for correction of velopharyngeal insufficiency in cases with little palatal motion and it carries no risk of obstructive sleep apnea.

Objective: The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty., Materials and Methods: We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity., Results: Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients., Conclusions: Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.

Objective: To determine the clinical course of velopharyngeal incompetence in children with myasthenia gravis (MG)., Methods: A 30-year retrospective study was performed using the medical records of 538 children who presented with velopharyngeal inadequacy (VPI) to a tertiary care academic pediatric center. Children with velopharyngeal incompetence due to myasthenia gravis were identified and their clinical courses were reviewed., Results: Four children were identified with velopharyngeal incompetence associated with myasthenia gravis. All four children required intervention for improvement of speech intelligibility. A speech prosthesis was the uniform intervention., Conclusion: Neonatal myasthenia gravis patients should be followed long-term as symptoms may recur as speech impairment. In addition, a high index of suspicion for this entity is required for early diagnosis due to the highly variable presentation and clinical course.

Aim: To compare two modalities of speech intervention (SI) in cleft palate children with compensatory articulation disorder (CAD). The first modality was a phonologic based intervention, the second modality was a naturalistic intervention. The main purpose was to study whether a naturalistic intervention may reduce the total time of speech therapy necessary for correcting CAD in cleft palate children as compared to a phonologic intervention., Materials and Methods: A prospective, comparative, and randomized trial was carried out. Cleft palate children with velopharyngeal insufficiency and CAD were included in the study group. Only patients with an age ranging from 3 to 7 years were included. A total of 30 patients were selected and were divided randomly into two groups. Fifteen patients were included in the first group (control) and received phonologic SI. The other 15 patients were included in the second group (active) and received naturalistic SI. The speech pathologist in charge of the SI was the same in all cases. A blind procedure was utilized whereby each patient was evaluated independently by two speech pathologists every 3 months until both examiners were convinced that CAD had been completely corrected. The mean total time of SI required for the normalization of speech in the two groups of patients was compared., Results: Median age in the control group was 54.5 months, and 57.5 months in the active group. A Mann-Whitney rank sum test demonstrated a non-significant difference (P=0.803). The mean total time of SI in the control group was 14.53, and 16.27 in the active group. A student's t-test demonstrated that the total time of SI was not significantly reduced (P=0.331) when a naturalistic intervention was utilized., Conclusions: Naturalistic based SI did not reduce the time necessary for correcting CAD in cleft palate children.

Objective: First, to analyze the speech and hearing results at 3.5 years of age when early palate closure has been performed. Second to assess at 7 years of age the need for speech therapy and/or additional surgery in the form of cranial-based pharyngeal flap for obtaining normal speech., Methods: Retrospective study in a tertiary teaching hospital concerning 18 consecutive cases presenting cleft lip and palate with no associated abnormalities. Interventions included early palatine closure (velum at 3 months, hard palate and lip at 6 months). Speech therapy was initiated at 3.5 years of age when needed. Cranial-based pharyngeal flap was performed when normal nasal emission was not obtained by speech therapy at 7 years of age. Phonetic and otological assessment were performed in all cases., Results: Good to excellent speech in the majority (95%) of children, with only 3/18 undergoing pharyngoplasty to obtain type I or I/II speech by the age of 7 (range: 6.5-8.0). 6/18 children had drain insertion, and 2/18 had hearing loss of 20-40 dB in all frequencies., Conclusion: Most children (95%) start school with good or excellent speech. However, the high incidence of middle ear problems shows that more effective screening and treatment are warranted., (Copyright 2002 Elsevier Science Ireland Ltd.)

Velo-cardio-facial syndrome is the most common contiguous gene disorder in humans and constitutes 8% of patients with clefts of the secondary palate. Speech disorders, including severe hypernasality and articulation impairment have been documented as among the most common clinical manifestations of the disorder. A series of 36 consecutive patients with VCFS ranging in age from 3 to 14 years, all confirmed to have a 22q11.2 deletion, were studied to determine specific risk factors associated with VPI and articulation impairment. Factors studied included palatal clefting, hypotonia, platybasia, and adenoid size. The factor that correlated most strongly with speech disorders was adenoid hypoplasia or absence, a common manifestation in the syndrome. It is hypothesized that early identification of the absence or hypoplasia of the adenoids can result in the implementation of appropriate therapy plans to avoid severe disorders of speech intelligibility.

Many cleft palate teams currently schedule palatoplasty and veloplasty within the child's first year of life. At Hannover Medical School, palatoplasty and veloplasty are performed at approximately 18-24 months of age. It was questioned which speech and language outcome was achieved and whether it may be influenced by: (1) type and extent of the clefts; (2) velopharyngeal inadequacy; and (3) hearing disorders. A retrospective evaluation of data collected from 1985 to 1993 was performed summarizing receptive and expressive speech and language skills of 370 children aged 4.5 years. Cleft types were unilateral cleft lip and palate (UCLP, 30.0%), bilateral cleft lip and palate (BCLP, 28.7%), cleft hard and soft palate (CP, 21.6%), cleft soft palate (cleft velum, CV, 10.8%), cleft lip and alveolus (CLA, 5.8%) and submucous clefts (SUB, 3.2%). n = 86 had constant normal hearing, and n = 284 had conductive hearing loss > 20 dB (500-4000 Hz). Severe developmental phonology errors were found in 30-50% of children with repaired cleft palate and in less than 8% of patients with CLA and SUB. Posterior compensatory misarticulation was below 15% in the groups UCLP, BCLP, CP, CV and SUB. Nasal resonance and air emission was nearly normal in CLA, but was increased in 27% to 38% of the other cleft types. Children with conductive hearing loss had significantly more and severely affected phonology, morphology, syntax, vocabulary, language comprehension, and auditory perception than normal hearing children. Findings indicated that speech and language function in CLP patients were predominantly related to the hearing status.

Velopharyngeal insufficiency (VPI) refers to the mobility of the velopharyngeal sphincter to adequately separate the nasal cavity from the oral cavity during speech. The auditory result of this structural problem is hyperrhinophy, abnormal resonance and the production of distracting noises during speech created by turbulent airflow escaping from the nasal cavity.

Thirty-one cleft palate patients with velopharyngeal insufficiency and compensatory articulation in association with hypernasality after palate closure were studied. Videonasopharyngoscopy and multi-view videofluoroscopy were performed to all patients before and after speech therapy for correcting compensatory articulation. The ratios of movement of velopharyngeal structures were significantly increased after compensatory articulation had been corrected. Furthermore, the size of the gap at the velopharyngeal sphincter during closure was significantly reduced. The results in this study support the statement that articulation disorders in association with hypernasality in cleft palate patients should be corrected prior to the implementation of surgery for velopharyngeal insufficiency after palate closure.

Two children in whom idiopathic hypernasality was diagnosed were referred for investigation of velopharyngeal function. Multiview videofluoroscopic assessments showed the tonsils prolapsing posteriorly during speech, preventing the palate from fully approximating the posterior pharyngeal wall. Tonsillectomy was recommended. Postoperative evaluations found that the hypernasal resonance was eliminated in both children.

This report describes 7 patients with hypernasal speech associated with neurofibromatosis. Multi-view videofluoroscopic and nasopharyngoscopic examinations of the velopharyngeal sphincter showed a variety of velopharyngeal valving failures amongst the 7 patients. Extensive evaluation failed to find the pathogenesis of velopharyngeal insufficiency in these patients.

Twenty patients with hypernasal speech were studied with both flexible fiber optic nasopharyngoscopy and multi-view videofluoroscopy, as well as behavioral speech assessment. Characteristic diagnostic findings showed the hypernasality to be caused by hypertrophic tonsils with posterior placement of the upper poles of the tonsils into the oropharyngeal and nasopharyngeal airway. In 16 of the 20 cases, there was a complete resolution of hypernasal speech following only tonsillectomy with no other treatments. Three patients required a brief period of speech therapy and one additional patient required both speech therapy and temporary prosthetic treatment (speech bulb reduction).

At the Cleft Palate Unit of The Montreal Children's Hospital a number of patients are seen each year who developed velopharyngeal insufficiency after adenoidectomy. Each time one of these patients is seen, the question is asked: "What would have happened to the speech if adenoidectomy had not been done, and the adenoid had been allowed to undergo the normal process of atrophy at puberty?" We had not seen a patient develop velopharyngeal insufficiency at puberty without adenoidectomy until recently, when an 11.5-year-old boy presented with a history of hypernasality for 1.5 years. Physical examination revealed the soft palate to be slightly short but with good mobility. The voice was mildly hypernasal but there was no nasal escape. Radiologic investigation revealed a very deep nasopharynx with virtual absence of adenoid tissue and a slight shortness of the palate. The child had been on speech therapy and the recommendation was that the therapy be stopped. When the child was seen 2.5 months after cessation of speech therapy, the hypernasality had cleared completely. Speech Pathologists at other Cleft Palate Units were contacted and no similar cases were known. The literature also did not reveal any similar cases of velopharyngeal insufficiency developing after puberty in the absence of adenoidectomy and without a cleft palate.

The characteristics of 137 patients referred to the Speech Clinic at The Hospital for Sick Children, Toronto, Canada during the past 8 years for the investigation of persistent hypernasality after adenoidectomy are reported. Over 30% of the patients had preoperative factors that are thought to increase the risk, such as submucous cleft palate, fluid regurgitation through the nose, a family history of velopharyngeal insufficiency or clefting, or hypernasality. Fifty percent of the patients required pharyngoplasty to correct hypernasality, 37% required speech therapy alone, and 13% improved with no treatment.