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Velopharyngeal incompetence: A guide for

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 CME

Velopharyngeal Incompetence: A Guide for

Clinical Evaluation
Donnell F. Johns, Ph.D., Rod J. Rohrich, M.D., and Mariam Awada, M.D.
Dallas, Texas

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the mechanism of speech
production. 2. Recognize the specific cause of a speech abnormality (structural deficit, neurogenic deficit, misarticulation,
or mechanical interference). 3. Perform a thorough clinical assessment using an intraoral examination and speech
production analysis. 4. Understand the advantages and disadvantages of various types of instrumental modalities and their
specific indications in diagnosing speech abnormalities.

Various causes of velopharyngeal disorders and the
myriad of diagnostic methods used by speech-language
pathologists and plastic surgeons for assessment are de-
scribed in this article. Velopharyngeal incompetence oc-
curs when the velum and lateral and posterior pharyngeal
walls fail to separate the oral cavity from the nasal cavity
during speech and deglutination. The functional goals of
cleft palate operations are to facilitate normal speech and
hearing without interfering with the facial growth of a
child. Basic and helpful techniques are presented to help
the cleft palate team identify preoperative or postopera-
tive velopharyngeal incompetence. This information will
enable any member of the multidisciplinary cleft palate
team to better assist in the differential diagnosis and man-
agement of patients with speech disorders. (Plast. Re-
constr. Surg. 112: 1890, 2003.)
The functional goals of cleft palate surgery
are to facilitate normal speech and hearing
without interfering with the facial growth of a
child. Unfortunately, after primary palato-
plasty, up to 20 percent of patients have unsat-
isfactory speech results and require secondary
management because of insufficient velopha-
ryngeal closure.111 The speech-language pa-
thologist plays a vital role in identifying this
group of patients. With early recognition and
intervention, the chances for development of
normal speech and hearing are increased. Fur-
ther, the specific treatment plan and surgical
procedure will be based on the causes of the
inadequate velopharyngeal closure. The pur-
pose of this article is to describe the various
causes of velopharyngeal disorders and the
myriad of diagnostic methods used by speech-
language pathologists and plastic surgeons for
assessment. This will enable any member of the
multidisciplinary cleft palate team to better as-
sist in the differential diagnosis and manage-
ment of patients with speech disorders.
Velopharyngeal closure refers to the normal
apposition of the soft palate, or velum, with the
posterior and lateral pharyngeal walls.1218 It is
primarily a sphincteric mechanism consisting
of a velar component and a pharyngeal com-
ponent. Movement of the velar component is
produced principally by the action of the leva-
tor veli palatini muscle. Movement of the pha-
ryngeal component is more dependent on the
contraction of the superior constrictor muscle
and the palatopharyngeal muscles. The up-
ward and backward movement of the velum,
coupled with the mesial movement of the lat-
eral pharyngeal walls and the slight anterior
movement of the posterior pharyngeal walls (at
the level of the first cervical vertebra), sepa-
rates the oral cavity from the nasal cavity dur-
ing deglutination and speech. Velopharyngeal
incompetence occurs when the velum and lat-
eral and posterior pharyngeal walls fail to sep-
arate the oral cavity from the nasal cavity dur-
ing speech and deglutination.

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication April 24, 2003; revised
May 30, 2003.
DOI: 10.1097/01.PRS.0000091245.32905.D5
1890
Vol. 112, No. 7 / EVALUATING VELOPHARYNGEAL INCOMPETENCE
ETIOLOGY
Different nomenclature exists that attempts
to describe subgroups of velopharyngeal disor-
ders based on etiology. We prefer the use of a
single generic term, velopharyngeal incompe-
tence, to denote any type of abnormal velopha-
ryngeal function in which the velum and lat-
eral and posterior pharyngeal walls fail to
separate the oral cavity from the nasal cavity.
The etiology of velopharyngeal incompetence
includes structural deficits, neurogenic impair-
ment, and mechanical interference to velopha-
ryngeal closure.19 30
Of particular concern to the craniofacial sur-
geon is velopharyngeal incompetence occur-
ring in patients with cleft palate secondary to a
structural deficit of the velum or pharyngeal
walls at the level of the nasopharynx with in-
sufficient tissue to accomplish closure. Struc-
tural congenital defects include gross tissue
deficiency, submucous or overt unoperated
clefts, a short or immobile soft palate, a large
and deep nasopharynx, or a palatal fistula.
Velopharyngeal incompetence may also be ac-
quired due to anatomic pathology as a result of
cancer treatment or maxillofacial trauma.
Similarly, neurogenic impairment can result
in partial or total immobility of the soft palate
and/or pharyngeal walls and lead to velopha-
ryngeal incompetence. This neurogenic, im-
paired velopharyngeal valve closure will pro-
duce dysarthric speech. Protective and
reflexive acts such as gagging and swallowing
may be impaired depending on the nature and
the level of the lesion. Velopharyngeal incom-
petence secondary to a neurogenic deficit may
be congenital, although it is most often ac-
quired after trauma. The disturbance in
speech production is caused by a weakness,
paralysis, or a lack of coordination of speech
musculature. The injury may be localized to
cranial nerves IX, X, or XI, lower motor nerves,
upper motor nerves, and/or the cerebellum.
The localization and severity of the impair-
ment will dictate whether speech intelligibility
will improve with velopharyngeal valve
remediation.
Velopharyngeal incompetence may also be
present secondary to mechanical interference
with the velopharyngeal valve closure. For ex-
ample, severely hypertrophied tonsils can
cause a mechanical interference resulting in
incomplete valve closure. Similarly, an exces-
1891
sively wide pharyngeal flap may inhibit apposi-
tion of the velum with the pharyngeal walls.
Misarticulations may present in a manner
similar to that seen in velopharyngeal incom-
petence.3133 Phoneme-specific misarticulations
refer to the occurrence of nasal emission on
certain (but not all) pressure consonants in the
absence of any hypernasal resonance. Frica-
tives (s, z) and affricates (ts, dz) are most vul-
nerable to this type of misarticulation. Recog-
nizing this selective phoneme emission is
crucial in identifying the cause of articular im-
pairment in patients with inconsistent nasal
emission, since a resonance disorder does not
exist.
VELOPHARYNGEAL FUNCTION
The ability to achieve properly articulated
speech pivots on the dynamic interaction of
the palatal and pharyngeal wall musculature,
which is driven by neural pathways to constrict
the velopharyngeal portal. Because the entire
vocal tract is a resonating cavity, coupling and
uncoupling of the nasal and oral cavity are
necessary to produce various sounds and intel-
ligible speech. The velum and pharynx act as a
valve that selectively channels airflow and
acoustic energy under different pressures into
the oral and nasal cavities. To produce nasal
sounds (m, n, ng), the velopharyngeal valve
channels airflow to the nasal cavity. Similarly,
for the oral sounds (all vowels and remaining
consonants), the valve closes off the nasal cav-
ity and selectively transmits airflow and energy
through the oral cavity. Thus, for normal
speech, one must have rapid and competent
velopharyngeal function in addition to being
able to produce appropriate airflow and ade-
quate pressure. With competent velopharyn-
geal valving, a pressure column of exhaled air
is shared with the oral cavity, where interrelat-
ing tongue, palatine shelves, dentition, and lips
fashion the various sound waves. Combined
intermittently with nasal resonance, these
sound waves characterize human speech.
Abnormal resonance can result from previ-
ously described structural, neurogenic, physio-
logic, or mechanical impairment. When the
normal space relationship or coupling between
the velum and nasopharynx is disturbed, velo-
pharyngeal incompetence results. This pro-
duces three common speech characteristics
secondary to increased transmission through
the nasal cavity: hypernasality, nasal emission,
and reduced aspiration and frication. Hyper-
1892
nasality is secondary to excess nasal resonance
(particularly with vowel production) just as tur-
bulent airflow through the nasal cavity is re-
sponsible for nasal emission. On the other
hand, stop plosives and fricatives are secondary
to a leak, which prohibits the accumulation of
sufficient oral pressures.
EVALUATION OF VELOPHARYNGEAL ACTIVITY
Two types of evaluation are used to obtain a
thorough assessment of velopharyngeal func-
tion: a clinical evaluation and an instrumental
evaluation. An understanding of the various
subjective and objective techniques of each
type of evaluation that are available to assess
velopharyngeal function will enable the practi-
tioner to identify the exact cause and deter-
mine the specific management of any velopha-
ryngeal disorder. As no single modality is
adequate for complete appraisal of velopharyn-
geal function, a variety of techniques should be
used for evaluation. Utilizing different modal-
ities will reveal the presence, size, location, and
contour of an opening between the oral and
nasal cavities during speech and delineate the
nature of the velar and pharyngeal wall move-
ments and interactions. The following is a de-
scription of the methods available, with partic-
ular focus on the approaches used most often
at our institution in the diagnosis and treat-
ment of velopharyngeal incompetence.
Clinical Assessment of Velopharyngeal Activity
The clinicians eyes and ears are used as the
first and primary diagnostic tools. As the most
valid measure of adequate velopharyngeal
function is sound produced during normal
speech, by simply listening, one can judge
whether further investigation is warranted.
When a patients speech deviates from normal,
a complete clinical evaluation is performed.
After a thorough history is obtained, the clini-
cal examination proceeds with an intraoral ex-
amination to assess structural integrity, reflex-
ive behavior, and voluntary phonetic behavior.
The speech production characteristics are then
assessed. Particular focus is paid to resonance
quality, airflow, air pressure, and whether com-
pensatory articulatory productions exist.
Intraoral Examination
The first step in the intraoral examination is
the direct visual assessment of structural integ-
rity. The lips, teeth, tongue, tonsils, hard and
soft palate, uvula, and pharyngeal walls should
PLASTIC AND RECONSTRUCTIVE SURGERY, December 2003
be carefully inspected. The symmetry of the
velum, tonsils, and nasopharynx is noted. Sub-
mucous clefts are revealed through palpation
of a notch in the hard palate, identification of
a zona pellucida in the soft palate, or a bifid
uvula. The presence of an oral nasal fistula
should be sought. A rhinoscopic examination
should be included to check for hypertrophied
turbinates, septal deviation, and nasal
obstruction.
The second step in the intraoral examina-
tion is to assess reflexive and voluntary behav-
ior. Reflexive behavior assists in determining
the overall dysarthric status. This assessment is
performed by repetitive stimulation of a gag
reflex at different loci. Delay, fatigue, asymme-
try, or lack of response is noted. The presence
or absence of nasal regurgitation during swal-
lowing of liquids should also be determined.
Unlike reflexive behavior, a voluntary behav-
ioral assessment is limited to competent, coop-
erative patients. Visual intraoral assessment
during sustained phonation of a assists in
determining velar motion (elevation, length,
asymmetry, amplitude, fatigue, and speed).
Speech Production Characteristics
Upon completion of a thorough intraoral
examination, the clinical examination pro-
ceeds with an assessment of speech production
characteristics. Four specific characteristics are
assessed: resonance quality, airflow, air pres-
sure, and compensatory articulation. Devia-
tions in the normal movement of a pressurized
airstream through the resonating vocal tract
will cause specific alterations in these four
characteristics. The recognition of these alter-
ations will assist in obtaining the correct
diagnosis.
The first characteristic, resonance quality, is
assessed by checking for the presence of nasal
vibration during vowel production (i, u, and e).
With an incomplete velopharyngeal seal, the
nasal cavity becomes coupled with the oral cav-
ity and the airstream escapes through the open
velopharyngeal port, causing hypernasal reso-
nance. This resonance can be detected clini-
cally by comparing occluded and unoccluded
nares for the presence of a nasal vibration dur-
ing vowel production.
The presence or absence of nasal emission of
the airstream is the second speech production
characteristic to assess. Nasal emission may be
audible or inaudible. In addition to the noise
that may be produced, the occurrence of nasal
Vol. 112, No. 7 / EVALUATING VELOPHARYNGEAL INCOMPETENCE
flaring assists in identification. Other methods
helpful in diagnosing inaudible nasal emission
include a mirror that fogs when placed under
the nares during vowel production and the
deflection of tissue paper.
The third characteristic is the adequacy of
intraoral air pressure build-up. The average
adult requires 5 to 7 cm of water pressure
build-up in the oral cavity behind the site of
constriction to produce most oral consonants,
particularly plosives (p) and fricatives (f).
When velopharyngeal insufficiency is present,
an inadequate amount of pressure is accrued
in the oral cavity secondary to incomplete clo-
sure of the velopharyngeal valve. The phrase
used frequently at our institution to test air
pressure is I pet puppies.
To complete the speech production assess-
ment, the presence or absence of compensa-
tory articulation productions should be sought.
Patients with cleft palate will derive compensa-
tory articulation in a different anatomic area
that will compensate for a poor or absent velo-
pharyngeal valve. Specific types of compensa-
tory articulations used by these patients in-
clude glottal stops, pharyngeal fricatives,
pharyngeal stops, velar fricatives, posterior na-
sal fricatives, and middorsal palatal stops (Ta-
ble I). In other words, the patient substitutes a
functioning glottis or pharynx or uses the mid
dorsum and the back of the tongue to valve the
airflow. The neurogenic patient, however, will
have compensatory productions occurring at
the same anatomic level but deviating in the
manner of speech production. Thus, glottal
and pharyngeal productions are absent.
Rather, labial substitution is performed for
tongue inadequacy. Regardless of the deriva-
tion of compensatory productions, they are all
learned behaviors, which frequently persist
even after adequate surgical or prosthetic
management.
Instrumental Assessment of Velopharyngeal Activity
The subjective yet invaluable information
gathered from the clinical examination should
The Phonetic Alphabet: Consonants
Bilabial Labiodental
Nasals m n
Plosives p-b (pat-bat)
Fricatives f-v (fat-vat)
Sibilants
Affricates
1893
be used to complement objective structural
data obtained from an instrumental assess-
ment. The goal of the instrumental assessment
is to obtain anatomic data regarding the ade-
quacy of velar length, palatal elevation, velo-
pharyngeal gap, excursion of the lateral and
posterior pharyngeal walls, nasopharyngeal
depth, pattern, and level of attempted closure.
Two subgroups of techniques are used in the
diagnostic process: direct and indirect. Direct
instrumental techniques are those that enable
the investigator to observe activity at the velo-
pharyngeal port. Examples of direct tech-
niques include lateral cephalogram, cinera-
diography, multiview videofluoroscopy, oral-
nasal panendoscopy, and magnetic resonance
imaging. Indirect instrumental techniques pro-
vide information about vocal tract behavior,
and gathered data are used to make relative
inferences. Phototransduction, electromyogra-
phy, and movement transduction are a few
examples of indirect instrumental techniques.
Direct Instrumental Techniques
Lateral cephalometric radiography. The lateral
cephalometric radiograph continues to be a
mainstay of the evaluation process at our insti-
tution as well as many others. It is the primary
direct method of assessing structures of the
velopharynx and the surrounding tissues. Ob-
tained at a constant magnification factor both at
rest and during a sustained -ee production,
lateral cephalogram views permit visualization
of soft palate elevation and its contact with the
posterior pharyngeal wall. The addition of bar-
ium allows for enhanced visualization of the
margins of the velum and pharyngeal wall. Us-
ing this technique, we have had a greater than
90 percent rate of accurate prediction of the
need for a pharyngeal flap based solely on this
radiographic study.
Obvious advantages include the ability to as-
sess structural features and velopharyngeal re-
lationships in a simple, reliable, and quantifi-
able method. The length of a pharyngeal flap is
TABLE I
Dentoalveolar Palatoalveolar Velar
ng (sing)
t-d (tot-dot) k-g (coat-goat)
th-th (thank-than) sh-zh (ash-azure)
s-z (sue-zoo) sh-z (ash-azure)
ts-dz (cheap-jeep) ts-dz (cheap-jeep)
1894 PLASTIC AND RECONSTRUCTIVE SURGERY, December 2003
determined by assessing the relationships pro-
vided.34,35 Because the velopharyngeal mecha-
nism is three-dimensional and dynamic, the
disadvantages of a lateral still radiograph are
obvious: it is a two-dimensional study represen-
tative of structural features only in the sagittal
plane. Hence, the width of a pharyngeal flap
cannot be determined by this method. Further,
because it is a static study, the events occurring
between the two extremes of movement (be-
tween the resting state and the -ee produc-
tion) are not visualized. Despite its limitations,
it continues to be a vital part of the diagnostic
battery at multidisciplinary cleft palate centers.
Multiview videofluoroscopy. In response to the
limitations of the lateral still radiograph, lateral
view motion picture radiography was intro-
duced to study velopharyngeal function in mo-
tion. With advances in technology, this evolved
from cine (motion picture films) to multiview
videofluoroscopy. Multiview videofluoroscopy
has distinct advantages, such as less radiation
exposure (10 times less than cinefluoroscopy),
the ability to record and replay immediately,
assessment of velopharyngeal function in three
FIG. 1. Diagrammatic frontal view of the oropharynx
planes (sagittal, coronal, and transverse), and a demonstrates gradations of mesial motion of the lateral pha-
dynamic view during connected speech from ryngeal walls. Zero represents no motion during quiet res-
beginning to end.36 42 The lateral views depict piration, and 5 depicts maximal motion of each lateral pha-
movements of the velum and posterior pharyn- ryngeal wall to the midline. Reprinted from Johns, D. F.,
geal walls. The frontal view of the oropharynx Cannito, M. P., Rohrich, R. J., and Tebbetts, J. B. The self-
lined superiorly based pull-through velopharyngoplasty: Plas-
demonstrates gradations of mesial motion of tic surgery-speech pathology interaction in the management
the lateral pharyngeal walls, which ultimately of velopharyngeal insufficiency. Plast. Reconstr. Surg. 94: 436,
determines the width of a proposed pharyngeal 1994.
flap. Although its primary limitation is the in-
ability to provide an absolute measurement of copy provides a substantial amount of informa-
structural relationships, the width of a proposed tion through visualization of the velum and
pharyngeal flap is easily determined by a rela- pharyngeal walls, it is difficult to obtain stan-
tive scale. The degree of lateral pharyngeal wall dardized views or infer relative dimensions.
motion ranges from zero (no motion during Other limitations include the inability to iden-
quiet respiration) to five (maximal motion to tify small velopharyngeal gaps or pinpoint the
the midline; Fig. 1). This ability to obtain an exact anatomical location of the gap. Patient
accurate preoperative assessment of lateral pha- cooperation becomes a critical factor that fur-
ryngeal wall motion appears to be a prime de- ther limits the use of nasopharyngoscopy in the
terminant of postoperative success after a pha- pediatric population unless the patient is anes-
ryngeal flap operation. In addition to being thetized. DAntonio et al.43,44 have described the
excellent in depicting necessary information on criteria, indications, and impact of nasal endos-
velopharyngeal function and dictating surgical copy on tailoring pharyngeal flaps, flap revi-
management, compared with other techniques, sions, and the fitting of palatal prostheses. Sim-
it has the least variability and is most reflective ilarly, Pigott finds the 70-degree endoscope to
of actual speech pattern. be indispensable and complementary to multi-
Nasopharyngoscopy. The limitations of naso- view videofluoroscopy in the evaluation of the
pharyngoscopy are similar to those of video- velopharyngeal sphincter.45,46
fluoroscopy. The information obtained to as- Magnetic resonance imaging. Magnetic reso-
sess gap size is in the form of a ratio than an nance imaging uses the resonant absorption and
absolute number. Although nasopharyngos- remission of radio waves by hydrogen nuclei to
Vol. 112, No. 7 / EVALUATING VELOPHARYNGEAL INCOMPETENCE
obtain images. It has a number of advantages over
the methodologies currently used to study the
vocal tract and velopharyngeal mechanism.47,48
Magnetic resonance imaging technology allows
noninvasive visualization of the vocal tract without
exposure to radiation or any known biohazards
and provides better soft-tissue resolution. Func-
tional images at any chosen level can be obtained
in the sagittal, frontal, and transaxial views with-
out changing the position of the patient. The
current limitations of this method for imaging
include the potential distortion of the velopha-
ryngeal mechanism by gravitational forces in the
supine position, the need for patient cooperation,
and cost. It is hoped that further technological
developments will result in nearreal-time func-
tional imaging that will soon reach its full poten-
tial and provide unique full-range vocal tract con-
figuration data.
Indirect Instrumental Techniques
Indirect techniques used to study the velo-
pharyngeal mechanism are those that provide
inferences through data about the structure
and kinematics of the velopharyngeal mecha-
nism. Examples include phototransduction,
electromyography, and movement transduc-
tion. Other types of indirect measures study
the effects of velopharyngeal function on other
physiologic parameters. Aerodynamics, acous-
tics, sound pressure, and spectrography fall un-
der this category. Although indirect measures
provide objective information, they do not nec-
essarily dictate the decision-making process.
Phototransduction. Photoelectric technology
uses light transmission to obtain relative infor-
mation on the velopharyngeal port. A fiberoptic
device couples a light source to an electronic
detector. The two fibers are introduced
through the nasal cavity until the light source is
below the velopharyngeal port and the detector
fiber is above the velopharyngeal port. Quan-
tifiable data are produced that provide infor-
mation regarding the opening and closing
movements of the velopharyngeal port.
Electromyography. Electromyography studies
the electrical activity produced by muscle con-
traction using hooked wire electrodes. The lim-
itations of electromyography are intuitive, such
as discomfort from placement of needle elec-
trodes, small and malpositioned muscles in cleft
patients, and multiple passive and active forces
acting on the velopharynx.
Movement transduction. Movement transduc-
tion combines the use of mechanical and elec-
1895
trical devices to transduce velopharyngeal
movement. The second maxillary molar acts as
an anchor, with placement of a bar/spring at-
tachment along the oral midline. With velar
motion, the spring sensor converts motion into
an electrical output along the strain gauge re-
sistor. Although this technique is not currently
used as an evaluation tool, it has been helpful
as a biofeedback device.
Aerodynamics. The study of pressure and
flow provides significant information that al-
lows a distinction to be made between velopha-
ryngeal insufficiency and dysfunction second-
ary to other anatomic valve abnormalities. In
addition, it helps determine the presence and
magnitude of velopharyngeal incompetence
and obstruction (nasal or pharyngeal). Specific
information details the relative contributions of
velopharyngeal components and nasal compo-
nents to total airway resistance. In a complex
case, this technique may be useful before sur-
gical intervention to isolate and determine var-
ious contributions to insufficiency. Similarly, it
is helpful after surgical intervention to deter-
mine whether a pharyngeal flap is the cause of
a patients difficulty with nasal respiration.
Acoustics. Quantitative changes in nasal res-
onance that occur with different degrees of cou-
pling (the nasal and oral cavities) provide in-
formation about the presence and degree of
velopharyngeal incompetence. In these pa-
tients, excessive acoustic energy in the nasal
cavity is observed during reading from passages
with oral sounds. In children with velopharyn-
geal obstruction, lack of acoustic energy in the
nasal cavity is observed during reading from
passages containing many nasal sounds. In ad-
dition to deciphering the location and degree
of abnormal resonance, the information is pro-
vided instantaneously. Therefore, the acoustic
assessment is a helpful method used for
biofeedback during treatment sessions. Fur-
ther, acoustic analyses with a sound spectro-
graph will identify subtle changes in the acous-
tic signal and can be used to monitor speech
characteristics objectively. These acoustic find-
ings should validate the more subjective per-
ceptual ratings.
DISCUSSION
The multidisciplinary cleft palate team is in-
dispensable in coordinating evaluation, diag-
nosis, and management of velopharyngeal in-
sufficiency, as is the speech pathologist. The
focus of this article is to present basic and
1896
helpful techniques to improve the capabilities
of any member of the cleft palate team in
identifying preoperative or postoperative velo-
pharyngeal incompetence. Through improve-
ments in preoperative diagnostic techniques,
improvements in outcomes are sure to follow.
Similarly, the ability to critique a speech out-
come after surgical intervention and to identify
factors in patients with poor outcomes that
may be avoided or modified in the future will
lead to an improvement in outcomes. A thor-
ough understanding of the mechanism of velo-
pharyngeal function and the instrumental
techniques used for evaluation may inspire
new treatment modalities or improve those
that currently exist. It is hoped that the multi-
disciplinary team will use the thorough clinical
assessment and data obtained from instrumen-
tal techniques discussed in this article to deter-
mine the most appropriate intervention for a
given patient. Clearly, without an armamentar-
ium of several surgical techniques, the surgeon
will be limited to applying a single treatment
modality to a problem with varied physiological
and structural causes.
Rod J. Rohrich, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard, E7.212
Dallas, Texas 75390-9132
rod.rohrich@utsouthwestern.edu
ACKNOWLEDGMENT
This is the last paper written by Dr. Donnell F. Johns before
his untimely death. He left it on his desk, almost completed.
The last time I spoke with him, he reminded me that he
needed to finish it. His dedication to the correction of neu-
rogenic velopharyngeal insufficiency, particularly in under-
privileged children, demonstrated his humanity. His dedica-
tion exemplified who he was as an individual. He was a
tremendous asset to us and to our profession. We miss him.
REFERENCES
1. Dorf, D., and Curtain, J. W. Early cleft palate repair and
speech outcome. Plast. Reconstr. Surg. 70: 74, 1982.
2. Rohrich, R. J., Johns, D., and Shewmake, K. Optimal
management of the cleft palate patient with plastic
surgery/speech pathology interaction. Tex. J. Audiol.
Speech Pathol. 17: 44, 1991.
3. Rohrich, R. J., Love, E. J., Byrd, H. S., and Johns, D. F.
Optimal timing of cleft palate closure. Plast. Reconstr.
Surg. 106: 413, 2000.
4. Witt, P., and DAntonio, L. Velopharyngeal insuffi-
ciency and secondary palatal management. Clin. Plast.
Surg. 4: 707, 1993.
5. Ysunza, A., Pamplona, C., and Mendoza, M. Speech
outcome and maxillary growth in patients with uni-
lateral complete cleft lip. Plast. Reconstr. Surg. 102: 675,
1998.
PLASTIC AND RECONSTRUCTIVE SURGERY, December 2003
6. Rohrich, R. J., Rowsell, A. R., Johns, D. F., et al. Timing
of hard palatal closure: A critical long-term analysis.
Plast. Reconstr. Surg. 98: 236, 1996.
7. Owsley, J. Poor speech following the pharyngeal flap
operation. Cleft Palate J. 9: 32, 1972.
8. Hollier, L. Cleft palate and velopharyngeal incompe-
tence. Selected Readings Plast. Surg. 8: 1, 1997.
9. Spriestersbach, D. C. Clinical research in cleft lip and
cleft palate. Cleft Palate J. 10: 113, 1973.
10. Johns, D., Tebbetts, J. B., and Cannito, M. Cleft Lip and
Palate: Long-Term Results and Future Prospects. Manches-
ter, United Kingdom: Manchester University Press,
1990.
11. DAntonio, L., and Marsh, J. L. Evaluation and man-
agement of velopharyngeal dysfunction. Probl. Plast.
Reconstr. Surg. 2: 86, 1992.
12. Trost, J. E. Articulatory additions to the classical de-
scriptions of speech in patients with cleft palate. Cleft
Palate J. 18: 193, 1981.
13. Johns, D. Anatomy and Physiology of the Velopharyngeal
Valving Mechanism. Dallas, Texas: Department of Plas-
tic Surgery, University of Texas Southwestern Medical
Center Grand Rounds, 2001.
14. Warren, D. Aerodynamics of speech production. In
N. J. Lass, L. V. McReynolds, J. L. Northern, and D. E.
Yoder (Eds.), Speech, Language, and Hearing. Philadel-
phia: Saunders, 1982.
15. Brooks, A., and Shelton, R. Compensatory tongue-pal-
ate-posterior pharyngeal wall relationships in cleft pal-
ate. J. Speech Hear. Disord. 30: 166, 1965.
16. Locke, J. The explanation and treatment of sound dis-
orders. J. Speech Hear. Disord. 48: 339, 1983.
17. Oller, D. K. The emergence of sounds of speech in
infancy. In G. H. Yeni-Komshian, J. F. Kavanagh, and
C. A. Ferguson (Eds.), Child Phonology, Vol. 1. New
York: Academic Press, 1980.
18. Iglesisas, A., and Morris, H. Simultaneous assessment of
pharyngeal wall and velar displacement for selected
speech sounds. J. Speech Hear. Res. 23: 429, 1980.
19. Morris, H. L. Communicative Disorders Related to Cleft Pal-
ate, 2nd Ed. Boston: Little, Brown, 1979.
20. Bernthal, J. Articulation and Phonological Disorders. Engle-
wood Cliffs, N. J.: Prentice Hall, 1988.
21. Bzoch, K. Articulatory proficiency and error patterns of
preschool cleft and normal children. Cleft Palate J. 2:
340, 1965.
22. Johns, D. Clinical Management of Neurogenic Communica-
tive Disorders. Boston: Little, Brown, 1985.
23. Lewin, M. L., Croft, C. B., and Shprintzen, R. J. Velo-
pharyngeal insufficiency due to hypoplasia of the mus-
cular uvula and occult submucous cleft palate. Plast.
Reconstr. Surg. 65: 585, 1980.
24. Darley, F. L., and Aronson, A. E. Motor Speech Disorders.
Philadelphia: Saunders, 1975.
25. Noordhoff, M. S. Development of articulation before
delayed hard palate closure in children with cleft pal-
ate. Plast. Reconstr. Surg. 80: 518, 1987.
26. Penslar, K. M., and Bauer, B. Levator repositioning and
palatal lengthening for submucous clefts. Plast. Recon-
str. Surg. 82: 765, 1988.
27. Powers, G., and Starr, C. The effects of muscle exercises
on velopharyngeal gap and nasality. Cleft Palate J. 11:
28, 1984.
28. Trier, W. The pharyngeal flap operation. Clin. Plast.
Surg. 12: 4, 1985.
29. Smith, J. Teflon injection in the nasopharynx to im-
Vol. 112, No. 7 / EVALUATING VELOPHARYNGEAL INCOMPETENCE
prove velopharyngeal closure. Ann. Otolaryngol. 86:
559, 1977.
30. Croft, C. B., and Shprintzen, R. J. Velopharyngeal Insuf-
ficiency Relieved by Tonsillectomy. Atlanta, Ga.: American
Cleft Palate Association, April 1978.
31. Peterson, S. J. Nasal emission as a component of the
misarticulations of sibilants and affricates. J. Speech
Hear. Disord. 40: 106, 1975.
32. Trost, J. E. Articulatory additions to the classic descrip-
tions of speech of persons with cleft palate. Cleft Palate
J. 18: 193, 1981.
33. Johns, D., Tebbetts, J. B., and Cannito, M. Perceptual
acoustic analysis. Cleft Lip Palate 69: 1990.
34. Johns, D., Rohrich, R. J., and Tebbetts, J. B. The self-
lined superiorly based pull-through velopharyngo-
plasty. Plast. Reconstr. Surg. 94: 436, 1994.
35. Shprintzen, R. A comprehensive study of pharyngeal
flap surgery: Tailor made flaps. Cleft Palate J. 16: 1,
1979.
36. Stringer, D. A., and Witzel, M. A. Velopharyngeal in-
sufficiency on videofluoroscopy: Comparison of pro-
jections. Am. J. Radiol. 146: 15, 1986.
37. Cohn, E. R., Rood, S. R., McWilliams, B. J., Skolnick,
M. L., and Abdelmalek, L. R. Barium sulphate coat-
ing on the nasopharynx in lateral view videofluoros-
copy. Cleft Palate J. 21: 7, 1984.
38. Skolnick, M. L. Videofluoroscopy with nasal speech,
emphasis on lateral pharyngeal motion in velopha-
ryngeal closure. Radiology 93: 747, 1984.
39. McWilliams, B. J., Glaser, E. R., Philips, B. J., et al. A
comparative study of four methods of evaluating velo-
pharyngeal adequacy. Plast. Reconstr. Surg. 68: 1, 1981.
1897
40. Harington, J. A cinefluorographic study of the pharyn-
geal flap. Cleft Palate J. 9: 127, 1975.
41. Hoopes, J. E., Dellon, A. L., Fabrikant, J. I., and Soliman,
A. H. Idiopathic hypernasality: Cineradiographic
and etiologic considerations. J. Speech Hear. Disord. 35:
44, 1970.
42. Hoopes, J. E., Dellon, A. L., Fabrikant, J. I., Edgerton,
M. T., Jr., and Soliman, A. H. Cineradiographic def-
inition of the functional anatomy and pathophysiol-
ogy of the velopharynx. Cleft Palate J. 7: 443, 1970.
43. DAntonio, L., Muntz, H. R., Marsh, J. L., Marty-Grames,
L., and Backensto-Marsh, R. Practical application of
flexible fiberoptic nasopharyngoscopy for evaluating
velopharyngeal function. Plast. Reconstr. Surg. 82: 611,
1988.
44. DAntonio, L. L., Achauer, B. M., and Vander Kam, V. M.
Results of a survey of a cleft palate teams concerning
the use of nasendoscopy. Cleft Palate Craniofac. J. 30: 35,
1993.
45. Pigott, R. The results of nasopharyngoscopic assess-
ment of pharyngoplasty. Scand. J. Plast. Reconstr. Surg.
8: 148, 1980.
46. Pigott, R. W., and Makepeace, A. P. Some characteris-
tics of endoscopic and radiological systems used in
elaboration of the diagnosis of velopharyngeal incom-
petence. Br. J. Plast. Surg. 35: 19, 1982.
47. Johns, D., and Rohrich, R. J. Use of MRI in vocal tract
imaging for assessing velopharyngeal incompetency:
Technique and future applications. Plast. Reconstr.
Surg. 8: 1, 1994.
48. Baer, T. Application of MRI to the analysis of speech
production. Magn. Reson. Imag. 5: 1, 1987.
Self-Assessment Examination follows on
the next page.
 Self Assessment Examination

Velopharyngeal Incompetence: A Guide for Clinical Evaluation

by Donnell F. Johns, Ph.D., Rod J. Rohrich, M.D., and Mariam Awada, M.D.

1. WHICH OF THE FOLLOWING IS THE MOST COMMON CAUSE OF VELOPHARYNGEAL INCOMPETENCE?

A) Undiagnosed submucous cleft palate
B) Short or immobile palate following primary cleft repair
C) Mechanical obstruction
D) Neurologic deficit
E) Palatal fistula

2. DURING VELOPHARYNGEAL CLOSURE, MOVEMENT OF SOFT PALATE IS PRINCIPALLY DUE TO ACTION

OF WHICH MUSCLE?
A) Tensor veli palatini
B) Levator veli palatini
C) Pharyngopalatinus
D) Palatoglossus
E) Superior constrictor

3. SINCE THE ENTIRE VOCAL TRACT IS A RESONATING CAVITY, NORMAL SPEECH PRODUCTION REQUIRES
THE VELOPHARYNGEAL PORT COUPLING AND UNCOUPLING OF THE NASAL AND ORAL CAVITIES.
A) True
B) False

4. SURGICAL CORRECTION OF VELOPHARYNGEAL INCOMPETENCE WILL IMPROVE EACH OF THE

FOLLOWING EXCEPT:
A) Resonance quality
B) Nasal airflow
C) Intraoral air pressure
D) Articulation errors
E) Nasal regurgitation

5. ACCORDING TO THE AUTHORS, THE BEST METHOD TO ASSESS SOFT-PALATE ELEVATION AND
CONTACT WITH THE POSTERIOR PHARYNGEAL WALL IS:
A) Lateral cephalometric radiography
B) Magnetic resonance imaging
C) Multiview videofluoroscopy
D) Nasopharyngoscopy
E) Aerodynamics

6. ACCORDING TO THE AUTHORS, THE DEGREE OF LATERAL WALL MOTION USED TO DETERMINE THE
WIDTH OF A PLANNED PHARYNGEAL FLAP IS BEST DETERMINED USING:
A) Lateral cephalometric radiography
B) Magnetic resonance imaging
C) Multiview videofluoroscopy
D) Nasopharyngoscopy
E) Movement transduction

To complete the examination for CME credit, turn to page 1982 for instructions and the response form.

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