|Year : 2014 | Volume
| Issue : 1 | Page : 4-10
Diagnosis and management of velopharyngeal insufficiency following cleft palate repair
Michael S Gart1, Arun K Gosain2
1 Department of Surgery, Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
2 Department of Surgery, Division of Plastic Surgery, Northwestern University Feinberg School of Medicine; Department of Surgery, Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
|Date of Web Publication||5-Feb-2014|
Arun K Gosain
Department of Surgery, Division of Plastic & Reconstructive Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Chicago, IL 60611
Source of Support: None, Conflict of Interest: None
Background: Cleft lip and palate repair seeks to restore normal form, improve feeding and achieve normal speech, which requires velopharyngeal competence. The absence of this ability, termed velopharyngeal insufficiency (VPI), is seen in a wide range of patients following primary cleft palate repair. This review article focuses on patient assessment and the surgical management of VPI. Recent trends and future directions in management are also presented. After reading, one should be able to describe the various treatment approaches for a patient with suspected VPI. Materials and Methods: A PubMed search was conducted using the following search terms: VPI, velopharygneal incompetence, VPI, velopharynx, velopharyngeal port, velopharyngeal mechanism, veloplasty, intravelar veloplasty and hypernasal speech. Relevant manuscripts were identified by abstract review and additional articles selected based on bibliography review. Articles were restricted to those in the English language. A total of 88 articles were selected for further review. Conclusions: VPI is a common complication following primary palatoplasty. The decision to operate, as well as the selection of operative procedure, depends on a multimodal patient assessment, including speech evaluation and imaging studies of the pharyngeal mechanism. A thorough understanding of velopharyngeal anatomy and physiology is crucial to understanding the deficits in patients with VPI as well as the myriad methods of surgical correction. While many techniques are available, there are no conclusive data to guide procedure choice and newer techniques of imaging and treating patients with VPI continue to evolve.
Keywords: Velopharyngeal incompetence, velopharyngeal insufficiency, velopharynx, veloplasty
|How to cite this article:|
Gart MS, Gosain AK. Diagnosis and management of velopharyngeal insufficiency following cleft palate repair. J Cleft Lip Palate Craniofac Anomal 2014;1:4-10
|How to cite this URL:|
Gart MS, Gosain AK. Diagnosis and management of velopharyngeal insufficiency following cleft palate repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2014 [cited 2019 Jan 20];1:4-10. Available from: http://www.jclpca.org/text.asp?2014/1/1/4/126536
| Introduction|| |
The primary goal of cleft palate (CP) repair is to create an anatomically and functionally intact palate to improve feeding and achieve normal speech. To produce normal speech, a person must be able to completely close the velopharyngeal sphincter that separates the oro-and nasopharynx.  The absence of this ability, termed velopharyngeal insufficiency (VPI), is a known complication following primary palatoplasty for CP and requires surgical correction in approximately 25% of affected patients. ,,, Here, we present a review of the available literature on veopharyngeal insufficiency and its surgical management, intended to help guide practitioners through patient and procedure selection. Recent trends and future directions in management are also presented. After reading, one should be able to describe an approach to the patient with suspected VPI.
A PubMed search was conducted using the following search terms: VPI, velopharygneal incompetence, VPI, velopharynx, velopharyngeal port, velopharyngeal mechanism, veloplasty, intravelar veloplasty and hypernasal speech. Relevant manuscripts were identified by abstract review and additional articles selected based on bibliography review. Articles were restricted to those in the English language. A total of 88 articles were selected for further review. Articles were chosen to address the specific aims of this review, namely diagnosis and surgical treatment. For more in-depth coverage, readers are directed to several comprehensive reviews articles available in the literature. ,,,,,,,,,
The velopharyngeal mechanism is a muscular valve extending from the posterior bony palate to the posterior pharynx. With the exception of three sounds in the English language (/m/, /n/, /ng/), all speech is produced with a closed velopharyngeal port.  Surgical manipulation of the velopharyngeal port dates back to the 19 th century and has undergone significant evolution, from local flaps to injectable synthetic or biologic materials. ,,,,,,,,,,,,,,,,,,,
| Patient Assessment|| |
As with all surgical patients, the assessment should begin with a thorough medical history and physical examination. The most common cause of VPI is a history of repaired or unrepaired CP.  In children who have undergone primary palatoplasty, the most common causes are: Inadequate lengthening of the velum at the time of primary palatoplasty, abnormal function of the levator musculature and cicatricial contracture of the velum.  In patients without a history of CP repair, submucous CP is a notable cause of VPI. ,,, The causes of VPI are many and may be structural, functional, or dynamic in nature. Examples include neurogenic VPI, due to insult to the cranial nerves innervating the velopharyngeal mechanism; and iatrogenic VPI following maxillary resection, uvulopalatopharyngoplasty, or adenoidectomy. ,,,,,,, Here, we focus on VPI following primary palatoplasty. For a more comprehensive discussion of VPI, including diagnosis and management, readers are directed to several excellent review articles. ,,,,,,,,
Assessment by a speech-language pathologist is essential to the workup of velopharyngeal dysfunction. This begins with a perceptual speech evaluation to assess articulation, resonance, nasal airway emission and voice.  The Pittsburgh weighted speech score (PWSS), originally described in 1979 by McWilliams and Phillips  is one tool that serves to grade VPI on a quantitative scale. This scale uses a standardized scoring system to evaluate a patient based on nasal air emission, facial grimace, resonance, voice quality and articulation. A sample patient assessment worksheet is shown in [Figure 1]. The individual scores are summed and the total scores are used to classify patients into one of four categories of velopharyngeal function (in increasing order of dysfunction): Competence, borderline competence, borderline incompetence and incompetence.
|Figure 1: Velopharyngeal insufficiency assessment worksheet. Adapted from: McWilliams, BJ, and Phillips BJ. Velopharyngeal Incompetence: Audio Seminars in Speech Pathology. Philadelphia: W.B. Saunders, Inc.; 1979|
Click here to view
A PWSS score of 3 or greater indicates borderline or frank velopharyngeal incompetence adjunctive studies are needed to determine the best treatment course.
There are three basic closure patterns of the velopharyngeal port, described as:
- Coronal: Posterior and superior movement of the velum is primarily responsible for velopharyngeal closure, with little contribution from the lateral pharyngeal walls.
- Sagittal: Medial displacement of the lateral pharyngeal walls is primarily responsible for closure, with little posterior movement of the velum.
- Circular: Combined movements of the velum and pharyngeal walls contribute equally to close the port in a "purse-string" fashion.
Nasoendoscopy (NE) and multiview video fluoroscopy (MVF) are the most commonly used methods for studying the closure pattern of the velopharyngeal mechanism.  NE utilizes a flexible endoscope to provide a "bird's eye" view of the velopharyngeal mechanism during speech. In addition to providing direct measurements of the size and location of the velopharyngeal opening and relative contributions of the velum, lateral pharyngeal walls and posterior pharynx during attempted velopharyngeal closure, NE is also useful to assess for palatal scarring, oronasal fistulae, submucous clefting and the status of the tonsils and adenoids. ,,
MVF uses multiple images obtained during a speech sample to determine the relative contributions of the velum and lateral pharyngeal walls to velopharyngeal closure.  Whereas MVF can be useful in identifying the point of attempted velar contact, it is limited in its ability to measure multiple variables in a single view.  Therefore, most clinicians prefer to use MVF as an adjunct to NE, or in cases where the patient will not tolerate invasive imaging. ,
Advances in magnetic resonance imaging (MRI) have led to the use of this technology in uncooperative patients and in cases where more precise anatomical information is needed. Benefits of MRI include its non-invasive nature and avoidance of ionizing radiation in a mostly pediatric population.  Further refinement of this technique may offer a more precise and better-tolerated assessment of the velopharyngeal mechanism during speech.
Nasometry is a method of objectively measuring the acoustic energy emitted from the nasal cavity as a percentage of acoustic energy.  A nasometer consists of a headset with two microphones positioned in front of the nose and mouth with an intervening metallic plate to isolate acoustic energy from each cavity. The headset is connected to a computer which interprets and graphically represents the percentage of nasal energy as a nasalance score, which is compared to available normative data.  Although this modality provides a purely objective assessment of acoustic energy distribution, it is currently best used as an adjunct to formal speech assessment. 
| Surgical Treatment|| |
Available treatment options for VPI include speech therapy, prosthetic devices and surgical management. Speech therapy is used for mild cases that are correctable with speech modification. Prostheses are usually reserved for poor surgical candidates; however, they have demonstrated considerable success in treating VPI. ,, Interested readers are directed to several available comprehensive reports. ,,,,,,,,,
The most commonly utilized techniques for the surgical management of VPI are:
- Furlow palatoplasty, or double opposing Z-palatoplasty (DOZ): Restores the velar levator musculature to a more physiologic condition and simultaneously lengthens the velum.
- Pharyngeal flap: Static structure that reduces the size of the velopharyneal port and relies on the lateral wall motion for closure.
- Dynamic sphincter pharyngoplasty (DSP): Augments the pharyngeal musculature to improve lateral wall motion.
- Posterior pharyngeal augmentation: Injectable or implantable alloplastic and autologous materials are used to augment the posterior pharyngeal wall in select cases. ,, This modality is not discussed in detail here and readers are directed to the references for additional information.
An understanding of the velopharyngeal motion patterns will usually guide the selection of the best surgical procedure, with a few important exceptions. Closure of the velopharyngeal mechanism depends primarily on the elevation and posterior motion of the velum; however, important contributions are made by movement of the lateral pharyngeal walls toward the midline as well as anterior "bulging" of the posterior pharyngeal wall.  To be successful, any surgical procedure performed to address VPI must take into consideration the existing pattern of velopharyngeal closure.
Our approach is based upon the pattern of velopharyngeal closure and the size of the "pharyngeal gap" present with attempted closure.
Saggital closure pattern
Posterior velar motion or velar length is deficient in this closure pattern.
- For patients with this pattern and a pharyngeal gap of <9 mm, palatal lengthening alone is often sufficient. For this, we prefer a DOZ.
- In patients with a sagittal closure pattern and a gap of >9 mm, a superiorly based pharyngeal flap is effective, as the post-operative airway concerns are less likely to occur in these patients because of the retained lateral pharyngeal wall motion.
Coronal closure pattern
Lateral wall motion is deficient and velum is the primary contributor to velopharyngeal closure.
- A DSP is used in patients with a gap of 9 mm or less. This flap is preferred over a pharyngeal flap, as lateral wall motion s deficient and may increase post-operative airway complications with a pharyngeal flap.
- Patients with a coronal closure pattern and a pharyngeal gap of >9 mm are difficult to correct. In this case, both the posterior velar motion and the lateral wall motion are deficient. Our previous work has indicated that the combination of DOZ and DSP can effect velopharyngeal competence.  In our previous study, 15% of patients had persistent hypernasality, which was corrected in all cases with secondary placement of a narrow pharyngeal flap. The combination of DOZ and DSP was shown to significantly improve speech and voice ratings on a standardized scale. 
Sphincteric closure pattern
Posterior velar and lateral wall motion are intact, but not effective.
- DOZ is our procedure of choice with a pharyngeal gap of <9 mm, as the length gained in the velum provides adequate closure.
- With a gap >9 mm, narrow pharyngeal flaps are utilized, as the adequate lateral wall motion will allow for closure while minimizing risk of airway obstruction.
Velocardiofacial syndrome (VCFS)
In general, we utilize pharyngeal flaps as a last resort option, except in cases of VCFS, where we employ a modification of the pharyngeal flap procedure.  Historically, multiple factors have contributed to poor outcomes and persistent VPI following secondary palatoplasty in these patients, including poor lateral wall motion due to pharyngeal hypotonia, abnormal muscular action and an obtuse basicranium, which contributes to the pharyngeal gap.  While DSP has been advocated, VCFS patients have shown twice the revision rate of patients without VCFS (22% vs. 11%).  The high wide pharyngeal flap, proposed by Shprintzen et al., ,, has become an accepted form of treatment for these patients; however, the success of this operation depends on high flap inset, which is technically very demanding due to limited visualization. The senior author has developed a technique for high pharyngeal flap inset that avoids such difficulties, described below.
First described by Leonard Furlow, the DOZ transposes the abnormally inserted levator musculature into a more anatomic, posterior and transverse orientation, thus recreating the levator sling and simultaneously lengthening the velum and constricting the velopharyngeal port. , To distinguish this technique of primary palatoplasty from secondary DOZ for VPI management, we will utilize the term "Furlow palatoplasty" to refer to primary CP repair and "DOZ" for secondary palatoplasty for VPI management.
In secondary palatoplasty, the levator musculature will be encased in scar. It is essential to remove all scar tissue to promote better post-operative function of the levator sling. We utilize a muscle stimulator to differentiate functional muscle in the oro-and nasomuscular flaps from scar tissue. The flaps are then transposed in standard fashion, re-creating the levator sling and lengthening the palate simultaneously.
Advantages and disadvantages
This technique can be performed in any patient, regardless of previous intravelar veloplasty. Moreover, the velum is lengthened by the Z-plasty at the expense of palatal width, tightening the velopharyngeal port. Lastly, this technique leaves all future options available should any revisional surgery become necessary.
The most common pitfall in this technique is inadequate gain in palatal length or levator muscle function. Levator muscle function can be optimized by complete removal of all scar tissue encasing the velar musculature. We find that the use of an intraoperative muscle stimulator works well to identify functional muscle tissue from encasing scar.
High-inset pharyngeal flap
A superiorly-based myomucosal flap containing the superior pharyngeal constrictor muscle is elevated in a plane anterior to the pharyngobasilar fascia. A fish mouth incision is created on the nasal side of the velum, superior to the uvula and a counter incision is made on the oral surface of the velum immediately posterior to the junction of the hard and soft palate. A pocket is developed and the pharyngeal flap is then passed through this pocket and inset into the oral mucosa. The donor site is closed or left to heal secondarily.
Advantages and disadvantages
The pharyngeal flap is the most widely utilized flap for VPI surgery and most surgeons are comfortable with the technique. However, a flap designed too narrow will fail to close the velopharyngeal port and result in persistent nasal airway emission and hypernasal speech, whereas a flap designed too wide will obstruct the nasopharyngeal passage, resulting in hyponasality, or airway compromise with obstructive sleep apnea.
The most feared complication with pharyngeal flap surgery is upper airway obstruction, which can occur acutely and result in death. ,,,,,, Intraoperative corticosteroid administration may reduce post-operative edema and is used routinely in some centers. Many of the surgeons prefer the use of a tongue stitch in case of airway obstruction; however, we have found that our technique for management of tongue edema obviates this need.
We perform the DSP as described by Orticochea.  Attempts should be made to inset the flaps high in the pharynx, at or near the point of velar contact, which is determined preoperatively. Note that one limitation to achieving high flap inset is the presence of the adenoid pad at or near the point of velar contact with the posterior pharyngeal wall.  In this setting, the patient may require adenoidectomy prior to VPI surgery and consultation with an otolaryngologist may be indicated. If tonsillectomy is required, it should be performed a minimum of 6 weeks prior to sphincter pharyngoplasty.
Advantages and disadvantages
The sphincter pharyngoplasty has several advantages as a corrective treatment of VPI. Firstly, it creates a dynamic structure, which alleviates the concerns for persistent hyper-or hyponasality seen with an improperly sized pharyngeal flap. Moreover, this procedure can be easily revised if hypernasality persists by re-elevation and further overlap of the two myomucosal flaps, further narrowing the velopharyngeal port. If hypernasality persists despite revision, the option exists for secondary placement of a narrow pharyngeal flap. Moreover, this technique can be combined with DOZ for patients with coronal closure patterns and large pharyngeal gaps.
Although airway compromise has not been nearly as common historically with sphincter pharyngoplasty compared to pharyngeal flaps, there have been documented cases of acute post-operative sleep apnea.  Moreover, cicatricial contracture of the vertical donor site scars can result in inferior displacement of the myomucosal flaps and diminished speech outcomes. When able, primary closure of the donor sites is recommended to limit contracture. 
Outcomes and current practice
We utilize a protocol of repeat perceptual speech assessment at 3 months postoperatively. If there is concern for residual VPI, the subsequent evaluation proceeds in a fashion identical to the pre-operative workup to determine the best available treatment course. Future efforts to standardize.
Despite several publications comparing different flap types, there is no current consensus regarding optimal management of patients with VPI. The pharyngeal flap remains the most commonly performed surgical procedure for management of VPI;  however, the number of surgical options available indicates the lack of consensus. ,,,,,,,,,,, A recent multicenter, randomized-controlled trial comparing these two operations showed no difference in any measured outcome at 1-year follow-up. 
There has recently been a revival in the use of autologous fat grafting to augment the posterior pharyngeal wall. Fat grafting techniques have improved in recent years, which may account for the reported success in several series. ,,, This technique offers the advantages of considerably less morbidity and ease of repeatability. Augmentation of the posterior pharyngeal wall with autologous fat has the potential to obviate the need to alter the pharyngeal anatomy in patients with mild VPI ,, and may serve as a powerful adjunct to palatal lengthening in those with more severe cases of VPI. 
| Summary|| |
VPI is a common complication following primary palatoplasty. The decision to operate, as well as the selection of operative procedure, depends on a multimodal patient assessment, including speech evaluation and imaging studies of the pharyngeal mechanism. A thorough understanding of velopharyngeal anatomy and physiology is crucial to understanding the deficits in patients with VPI as well as the myriad methods of surgical correction. Although many techniques are available, there are no conclusive data to guide procedure choice and newer techniques of imaging and treating patients with VPI continue to evolve.
| References|| |
|1.||Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg 2011;128:342e-60. |
|2.||Bicknell S, McFadden LR, Curran JB. Frequency of pharyngoplasty after primary repair of cleft palate. J Can Dent Assoc 2002;68:688-92. |
|3.||Morris HL. Velopharyngeal competence and primary cleft palate surgery, 1960-1971: A critical review. Cleft Palate J 1973;10:62-71. |
|4.||Pryor LS, Lehman J, Parker MG, Schmidt A, Fox L, Murthy AS. Outcomes in pharyngoplasty: A 10-year experience. Cleft Palate Craniofac J 2006;43:222-5. |
|5.||Riski JE. Articulation skills and oral-nasal resonance in children with pharyngeal flaps. Cleft Palate J 1979;16:421-8. |
|6.||Abdel-Aziz M, El-Hoshy H, Ghandour H. Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern. J Craniofac Surg 2011;22:813-7. |
|7.||Capra G, Brigger MT. Surgery for velopharyngeal insufficiency. Adv Otorhinolaryngol 2012;73:137-44. |
|8.||Conley SF, Gosain AK, Marks SM, Larson DL. Identification and assessment of velopharyngeal inadequacy. Am J Otolaryngol 1997;18:38-46. |
|9.||Dworkin JP, Johns DF. Management of velopharyngeal incompetence in dysarthria: A historical review. Clin Otolaryngol Allied Sci 1980;5:61-74. |
|10.||Gart MS, Gosain AK. The surgical management of velopharyngeal insufficiency. Clin Plast Surg (In press). |
|11.||Hirschberg J. Velopharyngeal insufficiency. Folia Phoniatr (Basel) 1986;38:221-76. |
|12.||McWilliams BJ, Phillips BJ. Velopharyngeal Incompetence: Audio Seminars in Speech Pathology. Philadelphia: W. B. Saunders, Inc.; 1979. |
|13.||Perry JL. Anatomy and physiology of the velopharyngeal mechanism. Semin Speech Lang 2011;32:83-92. |
|14.||Rudnick EF, Sie KC. Velopharyngeal insufficiency: Current concepts in diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2008;16:530-5. |
|15.||Shprintzen RJ, Marrinan E. Velopharyngeal insufficiency: Diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2009;17:302-7. |
|16.||Blocksma R. Silicone implants for velopharyngeal incompetence: A progress report. Cleft Palate J 1964;16:72-81. |
|17.||Brigger MT, Ashland JE, Hartnick CJ. Injection pharyngoplasty with calcium hydroxylapatite for velopharyngeal insufficiency: Patient selection and technique. Arch Otolaryngol Head Neck Surg 2010;136:666-70. |
|18.||Cao Y, Ma T, Wu D, Yin N, Zhao Z. Autologous fat injection combined with palatoplasty and pharyngoplasty for velopharyngeal insufficiency and cleft palate: Preliminary experience. Otolaryngol Head Neck Surg 2013;149:284-91. |
|19.||Eckstein H. Demonstration of paraffin prosthesis in defects of the face and palate. Dermatologica 1904;11:772-8. |
|20.||Furlow LT Jr, Williams WN, Eisenbach CR 2 nd , Bzoch KR. A long term study on treating velopharyngeal insufficiency by teflon injection. Cleft Palate J 1982;19:47-56. |
|21.||Girgis IH, Khalifa MS, Basiony A. Correction of velopharyngeal insufficiency by dermofat graft. J Laryngol Otol 1974;88:885-90. |
|22.||Hess DA, Hagerty RF, Mylin WK. Velar motility, velopharyngeal closure, and speech proficiency in cartilage pharyngoplasty: An eight year study. Cleft Palate J 1968;5:153-62. |
|23.||Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg 1950;3:128-35. |
|24.||Hynes W. The results of pharyngoplasty by muscle transplantation in failed cleft palate cases, with special reference to the influence of the pharynx on voice production; Hunterian lecture, 1953. Ann R Coll Surg Engl 1953;13:17-35. |
|25.||Jackson IT, Silverton JS. The sphincter pharyngoplasty as a secondary procedure in cleft palates. Plast Reconstr Surg 1977;59:518-24. |
|26.||James NK, Twist M, Turner MM, Milward TM. An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty. Br J Plast Surg 1996;49:197-201. |
|27.||Lypka M, Bidros R, Rizvi M, Gaon M, Rubenstein A, Fox D, et al. Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: A 40-year experience. Ann Plast Surg 2010;65:48-51. |
|28.||Moss AL, Pigott RW. Hynes' pharyngoplasty revisited. Plast Reconstr Surg 1987;80:866-7. |
|29.||Orticochea M. Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg 1968;41:323-7. |
|30.||Remacle M, Bertrand B, Eloy P, Marbaix E. The use of injectable collagen to correct velopharyngeal insufficiency. Laryngoscope 1990;100:269-74. |
|31.||Riski JE, Serafin D, Riefkohl R, Georgiade GS, Georgiade NG. A rationale for modifying the site of insertion of the orticochea pharyngoplasty. Plast Reconstr Surg 1984;73:882-94. |
|32.||Sipp JA, Ashland J, Hartnick CJ. Injection pharyngoplasty with calcium hydroxyapatite for treatment of velopalatal insufficiency. Arch Otolaryngol Head Neck Surg 2008;134:268-71. |
|33.||Ulkur E, Karagoz H, Uygur F, Celikoz B, Cincik H, Mutlu H, et al. Use of porous polyethylene implant for augmentation of the posterior pharynx in young adult patients with borderline velopharyngeal insufficiency. J Craniofac Surg 2008;19:573-9. |
|34.||Witt PD, D'Antonio LL, Zimmerman GJ, Marsh JL. Sphincter pharyngoplasty: A preoperative and postoperative analysis of perceptual speech characteristics and endoscopic studies of velopharyngeal function. Plast Reconstr Surg 1994;93:1154-68. |
|35.||Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of secondary velopharyngeal insufficiency in cleft palate patients with the Furlow palatoplasty. Plast Reconstr Surg 1994;94:933-41. |
|36.||Kaplan EN. The occult submucous cleft palate. Cleft Palate J 1975;12:356-68. |
|37.||Lewin ML, Croft CB, Shprintzen RJ. Velopharyngeal insufficiency due to hypoplasia of the musculus uvulae and occult submucous cleft palate. Plast Reconstr Surg 1980;65:585-91. |
|38.||Peterson-Falzone SJ. Velopharyngeal inadequacy in the absence of overt cleft palate. J Craniofac Genet Dev Biol Suppl 1985;1:97-124. |
|39.||Trier WC. Velopharyngeal incompetency in the absence of overt cleft palate: Anatomic and surgical considerations. Cleft Palate J 1983;20:209-17. |
|40.||Bohle G 3 rd , Rieger J, Huryn J, Verbel D, Hwang F, Zlotolow I. Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy - Clinical assessments and cephalometric analysis: A Memorial Sloan-Kettering Study. Head Neck 2005;27:195-207. |
|41.||Finkelstein Y, Shifman A, Nachmani A, Ophir D. Prosthetic management of velopharyngeal insufficiency induced by uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1995;113:611-6. |
|42.||Rilo B, Fernández-Formoso N, da Silva L, Pinho JC. A simplified palatal lift prosthesis for neurogenic velopharyngeal incompetence. J Prosthodont 2013;22:506-8. |
|43.||Riski JE, Gordon D. Prosthetic management of neurogenic velopharyngeal incompetency. N C Dent J 1979;62:24-6. |
|44.||Shifman A, Finkelstein Y, Nachmani A, Ophir D. Speech-aid prostheses for neurogenic velopharyngeal incompetence. J Prosthet Dent 2000;83:99-106. |
|45.||Yoshida H, Michi K, Ohsawa T. Prosthetic treatment for speech disorders due to surgically acquired maxillary defects. J Oral Rehabil 1990;17:565-71. |
|46.||Yoshida H, Michi K, Yamashita Y, Ohno K. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. J Oral Maxillofac Surg 1993;51:361-5. |
|47.||Dudas JR, Deleyiannis FW, Ford MD, Jiang S, Losee JE. Diagnosis and treatment of velopharyngeal insufficiency: Clinical utility of speech evaluation and videofluoroscopy. Ann Plast Surg 2006;56:511-7. |
|48.||Shapiro RS. Velopharyngeal insufficiency starting at puberty without adenoidectomy. Int J Pediatr Otorhinolaryngol 1980;2:255-60. |
|49.||Kummer AW. Perceptual assessment of resonance and velopharyngeal function. Semin Speech Lang 2011;32:159-67. |
|50.||Lam DJ, Starr JR, Perkins JA, Lewis CW, Eblen LE, Dunlap J, et al. A comparison of nasendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency. Otolaryngol Head Neck Surg 2006;134:394-402. |
|51.||Mason RM, Warren DW. Adenoid involution and developing hypernasality in cleft palate. J Speech Hear Disord 1980;45:469-80. |
|52.||Karnell MP. Instrumental assessment of velopharyngeal closure for speech. Semin Speech Lang 2011;32:168-78. |
|53.||Skolnick ML. Videofluoroscopic examination of the velopharyngeal portal during phonation in lateral and base projections - A new technique for studying the mechanics of closure. Cleft Palate J 1970;7:803-16. |
|54.||Shprintzen RJ, Lewin ML, Croft CB, Daniller AI, Argamaso RV, Ship AG, et al. A comprehensive study of pharyngeal flap surgery: Tailor made flaps. Cleft Palate J 1979;16:46-55. |
|55.||Kao DS, Soltysik DA, Hyde JS, Gosain AK. Magnetic resonance imaging as an aid in the dynamic assessment of the velopharyngeal mechanism in children. Plast Reconstr Surg 2008;122:572-7. |
|56.||Fletcher SG, Bishop ME. Measurement of nasality with tonar. Cleft Palate J 1970;7:610-21. |
|57.||Fletcher SG. "Nasalance" vs. listner judgements of nasality. Cleft Palate J 1976;13:31-44. |
|58.||Pinto JH, da Silva Dalben G, Pegoraro-Krook MI. Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis. Cleft Palate Craniofac J 2007;44:635-41. |
|59.||Tachimura T, Kotani Y, Wada T. Nasalance scores in wearers of a palatal lift prosthesis in comparison with normative data for Japanese. Cleft Palate Craniofac J 2004;41:315-9. |
|60.||La Velle WE, Hardy JC. Palatal lift prostheses for treatment of palatopharyngeal incompetence. J Prosthet Dent 1979;42:308-15. |
|61.||Marsh JL, Wray RC. Speech prosthesis versus pharyngeal flap: A randomized evaluation of the management of velopharyngeal incompetency. Plast Reconstr Surg 1980;65:592-4. |
|62.||Pinto JH, Pegoraro-Krook MI. Evaluation of palatal prosthesis for the treatment of velopharyngeal dysfunction. J Appl Oral Sci 2003;11:192-7. |
|63.||Tuna SH, Pekkan G, Gumus HO, Aktas A. Prosthetic rehabilitation of velopharyngeal insufficiency: Pharyngeal obturator prostheses with different retention mechanisms. Eur J Dent 2010;4:81-7. |
|64.||Gosain AK, Arneja JS. Management of the black hole in velopharyngeal incompetence: Combined use of a Furlow palatoplasty and sphincter pharyngoplasty. Plast Reconstr Surg 2007;119:1538-45. |
|65.||Arneja JS, Hettinger P, Gosain AK. Through-and-through dissection of the soft palate for high pharyngeal flap inset: A new technique for the treatment of velopharyngeal incompetence in velocardiofacial syndrome. Plast Reconstr Surg 2008;122:845-52. |
|66.||Losken A, Williams JK, Burstein FD, Malick DN, Riski JE. Surgical correction of velopharyngeal insufficiency in children with velocardiofacial syndrome. Plast Reconstr Surg 2006;117:1493-8. |
|67.||Witt P, Cohen D, Grames LM, Marsh J. Sphincter pharyngoplasty for the surgical management of speech dysfunction associated with velocardiofacial syndrome. Br J Plast Surg 1999;52:613-8. |
|68.||Mitnick RJ, Bello JA, Golding-Kushner KJ, Argamaso RV, Shprintzen RJ. The use of magnetic resonance angiography prior to pharyngeal flap surgery in patients with velocardiofacial syndrome. Plast Reconstr Surg 1996;97:908-19. |
|69.||Shprintzen RJ, Goldberg RB, Lewin ML, Sidoti EJ, Berkman MD, Argamaso RV, et al. A new syndrome involving cleft palate, cardiac anomalies, typical facies, and learning disabilities: Velo-cardio-facial syndrome. Cleft Palate J 1978;15:56-62. |
|70.||Tatum SA 3 rd , Chang J, Havkin N, Shprintzen RJ. Pharyngeal flap and the internal carotid in velocardiofacial syndrome. Arch Facial Plast Surg 2002;4:73-80. |
|71.||Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 1986;78:724-38. |
|72.||Furlow LT Jr. Flaps for cleft lip and palate surgery. Clin Plast Surg 1990;17:633-44. |
|73.||Jackson P, Whitaker LA, Randall P. Airway hazards associated with pharyngeal flaps in patients who have the Pierre Robin syndrome. Plast Reconstr Surg 1976;58:184-6. |
|74.||Kravath RE, Pollak CP, Borowiecki B, Weitzman ED. Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence. J Pediatr 1980;96:645-8. |
|75.||Robson MC, Stankiewicz JA, Mendelsohn JS. Cor pulmonale secondary to cleft palate repair. Case report. Plast Reconstr Surg 1977;59:754-7. |
|76.||Schettler D. Intra- and postoperative complications in surgical repair of clefts in infancy. J Maxillofac Surg 1973;1:40-4. |
|77.||Thurston JB, Larson DL, Shanks JC, Bennett JE, Parsons RW. Nasal obstruction as a complication of pharyngeal flap surgery. Cleft Palate J 1980;17:148-54. |
|78.||Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative complications of superior pharyngeal flap surgery in children. Plast Reconstr Surg 1994;93:954-8. |
|79.||Wray C, Dann J, Holtmann B. A comparison of three technics of palatorrhaphy: In-hospital morbidity. Cleft Palate J 1979;16:42-5. |
|80.||Hynes W. The results of pharyngoplasty by muscle transplantation in "failed cleft palate" cases, with special reference to the influence of the pharynx on voice production. 1953. Br J Plast Surg 1993;46:430-9. |
|81.||Witt PD, Marsh JL, Muntz HR, Marty-Grames L, Watchmaker GP. Acute obstructive sleep apnea as a complication of sphincter pharyngoplasty. Cleft Palate Craniofac J 1996;33:183-9. |
|82.||The classic reprint. Concerning a subcutaneous prosthesis: Robert Gersuny. (Uber eine subcutane Prothese. Zeitschrift f. Heilkunde Wien u Leipzig 21:199, 1900.). Translated from the German by Miss Rita Euerle. Plast Reconstr Surg 1980;65:525-7. |
|83.||Orticochea M. A review of 236 cleft palate patients treated with dynamic muscle sphincter. Plast Reconstr Surg 1983;71:180-8. |
|84.||Pigott RW. The results of pharyngoplasty by muscle transplantation by Wilfred Hynes. Br J Plast Surg 1993;46:440-2. |
|85.||Abyholm F, D'Antonio L, Davidson Ward SL, Kjøll L, Saeed M, Shaw W, et al. Pharyngeal flap and sphincterplasty for velopharyngeal insufficiency have equal outcome at 1 year postoperatively: Results of a randomized trial. Cleft Palate Craniofac J 2005;42:501-11. |
|86.||Cantarella G, Mazzola RF, Mantovani M, Baracca G, Pignataro L. Treatment of velopharyngeal insufficiency by pharyngeal and velar fat injections. Otolaryngol Head Neck Surg 2011;145:401-3. |
|87.||Cantarella G, Mazzola RF, Mantovani M, Mazzola IC, Baracca G, Pignataro L. Fat injections for the treatment of velopharyngeal insufficiency. J Craniofac Surg 2012;23:634-7. |
|88.||Leboulanger N, Blanchard M, Denoyelle F, Glynn F, Charrier JB, Roger G, et al. Autologous fat transfer in velopharyngeal insufficiency: Indications and results of a 25 procedures series. Int J Pediatr Otorhinolaryngol 2011;75:1404-7. |