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Soft palate released from hard palate
Flaps used to fill subsequent defect, with one
providing nasal closure and the other providing
oral closure
Decreased risk of sleep apnea compared with PPF
and DSP
Posterior pharyngeal fat grafting (PPFG)
Hand-assisted liposuction
Injection into submucosa of posterior pharyngeal
wall to narrow distance to velum
Usually indicated in very small defects identified
on nasendoscopy (0.5-1 cm2)
Obstructive sleep apnea (OSA)
Increasingly diagnosed in CP population
More likely following secondary speech operations: PPF,
DSP, and PPFG
PEARLS
1. Be prepared to place the Dingman mouth gag and mark the
incisions on the palate. All residents should attempt this, no
matter what PGY level.
2. At the University of Michigan, we place the Furlow incisions
more posteriorly in the soft palate in order to increase
mobilization and allows the surgeon to take advantage of the
laxity of the buccal mucosa, rather than the immobile hard
palate mucosa. We still dissect the entire muscle off the
posterior hard palate, such that the myomucosal flaps have a
“tongue” of muscle that extends beyond the mucosal flap tips.
3. In very wide clefts, you may need to consider a straight-line
repair as opposed to a Furlow palatoplasty. The Furlow
technique gains length at the expense of width (as do all Z
plasties), and if your cleft is extremely wide, you may not have
the freedom to sacrifice width.
4. Tag your oral Furlow flaps with a Vicryl and “hang” the Vicryl on
the Dingman. This keeps the flaps out of your way as you incise
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1.
2.
3.
4.
5.
the nasal flaps and helps keep you oriented when it is time to
close.
5. As you close the nasal mucosa, keep your knots on the nasal
side. This helps prevent irritation and inflammation between
your layers as the sutures dissolve and also prevents pooling of
mucus at the suture line within the nose.
QUESTIONS YOU WILL BE ASKED
1. What is the effect of palatoplasty on maxillary growth?
It causes maxillary growth restriction.
2. What is the most common location for a palatal fistula?
At the junction of hard and soft palates.
3. What is the blood supply to the hard and soft palate?
Hard palate: greater palatine artery. Soft palate: lesser palatine
artery, ascending pharyngeal artery, and ascending palatine
branch of facial artery.
4. What muscle is being reoriented and repaired?
Levator palatini.
THINGS TO DRAW
Draw out a Furlow palatoplasty. See Figure 14-4.
Recommended Readings
Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal
insufficiency. Plast Reconstr Surg. 2011;128(4):342e‐360e.
Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr
Surg. 1986;78(6):724‐738.
Liau JY, Sadove AM, van Aalst JA. An evidence-based approach to cleft palate
repair. Plast Reconstr Surg. 2010;126(6):2216‐2221.
Smith DM, Losee JE. Cleft palate repair. Clin Plast Surg. 2014;41(2):189‐210.
Woo AS. Evidence-based medicine: cleft palate. Plast Reconstr Surg.
2017;139(1):191e‐203e.
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*
Denotes common in-service examination topics.
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15
Velopharyngeal Insufficiency
Alexandra O. Luby
OVERVIEW
Children born with cleft lip and palate are at a high risk for
developing disorders of speech, language, resonance, and
voice. This can be due to abnormalities in dentition or occlusion,
hearing loss, upper airway obstruction, or velopharyngeal
insufficiency.
The primary goal of cleft palate repair: structural and functional
restoration of the palate to allow for normal speech. Yet,
~20%-30% of children with repaired palate develop
velopharyngeal dysfunction.
Velopharyngeal Dysfunction (VPD): inability of the velum (soft
palate) to completely close the nasal cavity from oral cavity
during production of oral sounds
Velopharyngeal Insufficiency (VPI): anatomic or structural
abnormality (ie, tissue deficit) that prevents complete
velopharyngeal closure, resulting in a persistent connection
between the nasal and oral cavities
Most common type of VPD.
Results in hypernasal speech, increased nasal resonance,
nasal air emission.
Often develop some degree of velopharyngeal mislearning
in attempt to compensate
Compensatory misarticulations: due to incorrect
articulation due to abnormal structure
Examples: glottal stops, pharyngeal fricatives
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Can dramatically impact overall speech intelligibility and
negatively impact quality of life including social interactions.
Most common cause of VPI: cleft palate. In repaired cleft
palates, VPI is most often due to inadequate velar length,
levator veli palatini (LVP) dysfunction, and scarring of the
velum.
Other causes: submucous cleft palate, iatrogenic VPI due
to adenoidectomy or uvulopalatopharyngoplasty (UP3),
palatopharyngeal imbalance as in 22q11.2 deletion.
VELOPHARYNGEAL ANATOMY AND
PHYSIOLOGY OF SPEECH
PRODUCTION
Velopharyngeal Sphincter (Fig. 15-1)
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Figure 15-1 Pharyngeal anatomy.
Nasopharynx, oropharynx, and
laryngopharynx. A. Parts of pharynx. B.
Anterior wall of pharynx. The posterior wall
has been incised along the midline and
spread apart. C. Muscles. The posterior
wall of the pharynx has been incised in the
midline and reflected laterally, and the
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mucous membrane has been removed
from the right side. (Based on Tank PW,
Gest TR. Lippincott Williams & Wilkins
Atlas of Anatomy. 2008:305, plate 7.10. In:
Agur AMR, Dalley AF II. Moore’s Essential
Clinical Anatomy. Wolters Kluwer; 2020.
Figure 9.22.)
Comprised of the soft palate anteriorly, lateral pharyngeal
walls, posterior pharyngeal wall
Muscles: LVP, tensor veli palatini, palatoglossus,
palatopharyngeus, muscularis uvulae, superior
constrictor muscles
Function: allows closure of the VP port to separate nasal
and oral cavities
Important for coordinated speech and swallow
Regulates air flow between nasal and oral cavities and
prevents regurgitation of food/drink
Physiology of VP closure: LVP contracts and pulls the
velum posteriorly and superiorly, while the lateral
pharyngeal walls move medially, and posterior pharyngeal
wall moves anteriorly
Sound Production
VP closure with adequate seal is important to be able to
direct air to the oral cavity with enough pressure to produce
certain sounds.
Oral sound production: palate must close off the nasal
cavity and so that all air is directed through the mouth.
Essentially all consonants except m, n, ng (p, b, t, s, d,
k, g, f, v, z, etc.) and vowel sounds
Enough oral pressure is required to produce oral
plosives (“p” sound), fricatives (“s” sound), and
affricatives (“ch” sound)
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Nasal sound production: palate remains open to allow air
through the nose (m, n, ng).
During spontaneous, connected speech, the palate must
move quickly to coordinate air movement through the air
and nose to produce appropriate sounds.
Resonance
Balance of sound energy as it travels through the vocal
cords, oral cavity, and nasal cavity.
Augmenting the size and shape of these cavities augments
the sound.
Types of resonance
Hypernasality: occurs when too much sound is
transmitted through the nasal cavity during speech
Presents as nasalization of voiced consonants
Examples: m for b, n for d
Note: patients with oronasal fistulas will often have
hypernasal speech but this is a separate etiology
from VPI
Hyponasality: occurs when obstruction in the
nasopharynx or nasal cavity prevents sound from
resonating in the nasal cavity
Mixed resonance: occurs when there is hypernasality
on oral consonants and hyponasality on nasal
consonants
PREOPERATIVE EVALUATION
Patient History
Past medical history: history of cleft palate, submucous
cleft, any syndromes including 22q11 deletion syndrome,
neurologic disorders
Past surgical history: adenoidectomy, tonsillectomy, prior
palate repair
Feeding/swallowing history
Airway history, history of snoring or obstructive sleep apnea
(OSA) diagnosis
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Developmental history (including motor, speech, language,
learning)
Otologic history: previous hearing assessment, history of
recurrent ear infections
Speech: previous or current speech therapy, current speech
concerns from parents, patient, teachers
Subjective Speech Assessment
Evaluate speech intelligibility, resonance, articulation, and
nasal air escape.
Many ways to assess speech: single word articulation tests,
syllable repetition, sentence repetition, counting,
spontaneous connected speech.
Examples of short sentences to assess hypernasality
“Do it today for dad,” “puppy pulls a rope,” “buy
baby a bib,” “sissy sees the sky,” “zip up the
zipper”
Counting: have the child count from 60 to 70 (“s”)
Facial grimace during speech: grimace constricts the nasal
passage to decrease nasal air escape.
Evaluate for air escape: hold a mirror under nose and look
at nasal air flow during speech.
Evaluate resonance
Nasal occlusion test: pinch nose to occlude the nares,
and have child say phrase without nasal constants (eg,
“buy baby a bib”)
In normal resonance, should be no change
In hypernasality, resonance will be improved with
nasal occlusion
Formal perceptual speech evaluation by a licensed speech
language pathologist
Remains the gold standard for diagnosis of VPI
Perceptual analysis can be used to predict VP gap size
Physical Exam
Palate
Assess size, shape, elevation, movement
Assess for any oronasal fistulas
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If no history of cleft palate, assess for signs of
submucous cleft: notching of hard palate, bivid uvula,
zona pellucida secondary to levator diastasis
Tonsils, uvula, dentition, occlusion, relationship of the tip of
the tongue to the alveolar ridge
Intranasal exam: assess nasal mucosa, turbinates, and
nasal septum
Further Diagnostics
Nasometry
Method of measuring nasal air emission and
calculating nasalance—the ratio between nasal and
oral sound emission through a computer-based
instrument
Produces a quantitative value that can be compared
with age normative values
Does not characterize VP gap (size, location, closure
pattern)
Nasoendoscopy
Nasal endoscopy allows direct visual observation of the
velopharyngeal mechanism during phonation
Determines the degree and pattern of VP closure, size
of VP gap, position and function of the LVP, length and
movement of the soft palate, movement of lateral and
posterior pharyngeal walls
Best procedure to visualize VP movement and closure
during speech to formulate patient specific treatment
plans, especially for surgical planning
VP closure patterns in VPI
Coronal closure: posterior pharyngeal wall and
palate
Sagittal closure: lateral pharyngeal walls
Circular closure: symmetric
Video fluoroscopy
Two-dimensional view of the velopharynx movement
during speech through a series of x-rays
Provides less information than nasoendoscopy but
better tolerated than nasoendoscopy
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