OBJECTIVE: Development of an AI tool to assess velopharyngeal competence (VPC) in children with cleft palate, with/without cleft lip.
METHODS: Innovation of an AI tool using retrospective audio recordings and assessments of VPC.
METHODS: Two datasets were used. The first, named the SR dataset, included data from follow-up visits to Skåne University Hospital, Sweden. The second, named the SC + IC dataset, was a combined dataset (SC + IC dataset) with data from the Scandcleft randomized trials across five countries and an intercenter study performed at six Swedish CL/P centers.
METHODS: SR dataset included 153 recordings from 162 children, and SC + IC dataset included 308 recordings from 399 children. All recordings were from ages 5 or 10, with corresponding VPC assessments.
METHODS: Development of two networks, a convolutional neural network (CNN) and a pre-trained CNN (VGGish). After initial testing using the SR dataset, the networks were re-tested using the SC + IC dataset and modified to improve performance.
METHODS: Accuracy of the networks\' VPC scores, with speech and language pathologistś scores seen as the true values. A three-point scale was used for VPC assessments.
RESULTS: VGGish outperformed CNN, achieving 57.1% accuracy compared to 39.8%. Minor adjustments in data pre-processing and network characteristics improved accuracies.
CONCLUSIONS: Network accuracies were too low for the networks to be useful alternatives for VPC assessment in clinical practice. Suggestions for future research with regards to study design and dataset optimization were discussed.

OBJECTIVE: Compare the effectiveness of palatoplasty and pharyngoplasty procedures at resolving hypernasality in patients with 22q11.2 deletion syndrome (22q).
METHODS: Retrospective cohort study.
METHODS: Metropolitan children\'s hospital.
METHODS: Fourteen patients with 22q presenting for management of velopharyngeal insufficiency.
METHODS: Palatoplasty or pharyngoplasty procedure.
METHODS: Resolution of hypernasality 12 months postoperatively.
RESULTS: Both procedure groups had a mean preoperative velopharyngeal gap of 6.2 mm during phonation. No patient who underwent palatoplasty achieved resolution of hypernasality; 1/7 patients had worse hypernasality, 4/7 had no change, and 2/7 had improved hypernasality. In contrast, hypernasality was resolved in 6/7 patients in the pharyngoplasty group, which was significantly (P = .03) higher than the palatoplasty group.
CONCLUSIONS: In patients with 22q, palatoplasty procedures may be less effective than pharyngoplasty procedures at resolving hypernasality. This may be due to underlying anatomic or physiologic differences, such as increased pharyngeal depth and hypodynamic muscles.

UNASSIGNED: During articulation the velopharynx needs to be opened and closed rapidly and a tight closure is needed. Based on the hypothesis that patients with cleft lip and palate (CLP) produce lower pressures in the velopharynx than healthy individuals, this study compared pressure profiles of the velopharyngeal closure during articulation of different sounds between healthy participants and patients with surgically closed unilateral CLP (UCLP) using high resolution manometry (HRM).
UNASSIGNED: Ten healthy adult volunteers (group 1: 20-25.5 years) and ten patients with a non-syndromic surgically reconstructed UCLP (group 2: 19.1-26.9 years) were included in this study. Pressure profiles during the articulation of four sounds (/i:/, /s/, /ʃ/ and /n/) were measured by HRM. Maximum, minimum and average pressures, time intervals as well as detection of a previously described 3-phase-model were compared.
UNASSIGNED: Both groups presented with similar pressure curves for each phoneme with regards to the phases described and pressure peaks, but differed in total pressures. An exception was noted for the sound /i:/, where a 3-phase-model could not be seen for most patients with UCLP. Differences in velopharynx pressures of 50% and more were found between the two groups. Maximum and average pressures in the production of the alveolar fricative reached statistical significance.
UNASSIGNED: It can be concluded that velopharyngeal pressures of patients with UCLP are not sufficient to eliminate nasal resonance or turbulence during articulation, especially for more complex sounds. These results support a general understanding of hypernasality during speech implying a (relative) velopharyngeal insufficiency.
UNASSIGNED: Während der Artikulation öffnet und schließt sich der velopharyngeale Abschluss in schnellen Bewegungsabfolgen und für die Bildung einiger Laute ist ein vollständiger Abschluss notwendig. Für Patient_innen mit Lippen-, Kiefer-, Gaumenspalte (LKG) ist bekannt, dass die Verschlussdrücke im Velopharynx beim Schlucken reduziert sind. Ziel dieser Studie war es, die Druckprofile von Patient_innen mit unilateraler LKG und gesunden Proband_innen mittels Hochauflösungsmanometrie (HRM) zu vergleichen und zu evaluieren, ob bei der Produktion verschiedener Sprachlaute ebenfalls Druckunterschiede im Velopharynx bestehen.
UNASSIGNED: Es wurden 10 gesunde Erwachsene (Gruppe 1: 20–25,5 Jahre) und 10 Patient_innen mit einer nicht-syndromalen operativ verschlossenen unilateralen LKG (Gruppe 2: 19,1–26,9 Jahre) untersucht. HRM-Verschlussdruckprofile wurden während der Artikulation von 4 Sprachlauten (/i:/, /s/, /ʃ/ und /n/) aufgezeichnet. Es wurden Maximal-, Minimal- und Durchschnittsdrücke sowie Zeitintervalle ermittelt. Zudem wurden die Druckprofile mit einem zuvor beschriebenen 3-Phasen-Phonationsmodell verglichen.
UNASSIGNED: In beiden Gruppen zeigten sich in Bezug auf die Phonationsphasen ähnliche Druckprofile für die produzierten Laute, allerdings lagen unterschiedliche Gesamtdrücke vor. Eine Ausnahme stellte die Realisation des Lautes /i:/ dar, bei der sich bei den meisten Patient_innen mit LKG keine drei Phonationsphasen erkennen ließen. Zwischen den beiden Gruppen existierten Druckunterschiede in der Velopharynxregion von 50% und mehr. Es fanden sich statistisch signifikante Unterschiede bei den Maximaldruck- und durchschnittlichen Druckwerten bei der Produktion von alveolaren Frikativen.
UNASSIGNED: Die reduzierten velopharyngealen Verschlussdrücke bei Patient_innen mit LKG tragen wahrscheinlich dazu bei, dass nasale Resonanzen und Turbulenzen nicht ausreichend eliminiert und komplexere Laute dadurch nicht korrekt gebildet werden. Die hier erhobenen Ergebnisse unterstützen die Annahme, dass die bei Patient_innen mit LKG häufig beobachtete Hypernasalität während der Sprachproduktion auf eine (relative) velopharyngeale Insuffizienz zurückzuführen ist.

UNASSIGNED: Rhinophonia aperta may result from velopharyngeal insufficiency. Neuromuscular electrical stimulation (NMES) has been discussed in the context of muscle strengthening. The aim of this study was to evaluate in healthy subjects whether NMES can change the velopharyngeal closure pattern during phonation and increase muscle strength.
UNASSIGNED: Eleven healthy adult volunteers (21-57 years) were included. Pressure profiles were measured by high resolution manometry (HRM): isolated sustained articulation of /a/ over 5 s (protocol 1), isolated NMES applied to soft palate above motor threshold (protocol 2) and combined articulation with NMES (protocol 3). Mean activation pressures (MeanAct), maximum pressures (Max), Area under curve (AUC) and type of velum reactions were compared. A statistical comparison of mean values of protocol 1 versus protocol 3 was carried out using the Wilcoxon signed rank test. Ordinally scaled parameters were analyzed by cross table.
UNASSIGNED: MeanAct values measured: 17.15±20.69 mmHg (protocol 1), 34.59±25.75 mmHg (protocol 3) on average, Max: 37.86±49.17 mmHg (protocol 1), 87.24±59.53 mmHg (protocol 3) and AUC: 17.06±20.70 mmHg.s (protocol 1), 33.76±23.81 mmHg.s (protocol 3). Protocol 2 produced velum reactions on 32 occasions. These presented with MeanAct values of 13.58±12.40 mmHg, Max values of 56.14±53.14 mmHg and AUC values of 13.84±12.78 mmHg.s on average. Statistical analysis comparing protocol 1 and 3 showed more positive ranks for MeanAct, Max and AUC. This difference reached statistical significance (p=0.026) for maximum pressure values.
UNASSIGNED: NMES in combination with articulation results in a change of the velopharyngeal closure pattern with a pressure increase of around 200% in healthy individuals. This might be of therapeutic benefit for patients with velopharyngeal insufficiency.
UNASSIGNED: Offene Rhinophonien können aufgrund einer velopharyngealen Insuffizienz entstehen. Die neuromuskuläre Elektrostimulation (NMES) wird seit einiger Zeit als Therapieform zur Muskelkräftigung angewendet. Ziel dieser Studie war es, an gesunden Proband_innen zu untersuchen, ob NMES das velopharygeale Verschlussmuster während der Phonation verändern und die Muskelkraft erhöhen kann.
UNASSIGNED: In die Studie wurden 11 gesunde Proband_innen eingeschlossen (21–57 Jahre). Mit der Hochauflösungsmanometrie wurden Druckprofile unter verschiedenen Bedingungen aufgezeichnet: die isolierte Phonation des Lautes /a/ über 5 s (Protokoll 1), die isolierte, motorisch überschwellig applizierte NMES auf das Velum (Protokoll 2) sowie die Phonation und die NMES in Kombination (Protokoll 3). Verglichen wurden der durchschnittliche Druck während der Aktivierung (MeanAct), die durchschnittlichen Maximaldrücke (Max), die durchschnittlichen Integrale unter der Druckkurve (Area under curve (AUC)) und die Art der Velumreaktion. Der Vergleich der Durchschnittswerte von Protokoll 1 und 3 wurden mithilfe des Wilcoxon-Vorzeichen-Rang-Tests durchgeführt. Ordinär skalierte Parameter wurden über eine Kreuztabelle analysiert.
UNASSIGNED: MeanAct Mittelwerte lagen bei 17,15±20,69 mmHg (Protokoll 1), 34,59±25,75 mmHg (Protokoll 3), Max bei 37,86±49,17 mmHg (Protokoll 1), 87,24±59,53 mmHg (Protokoll 3) und AUC bei 17,06±20,70 mmHg.s (Protokoll 1), 33.76±23.81 mmHg.s (Protokoll 3). Im Protokoll 2 zeigten sich 32 Velumreaktionen mit durchschnittlichen MeanAct-Werten von 13,58±12,40 mmHg, Maximalwerten von 56,14±53,14 mmHg und Mean-AUC-Werten von 13,84±12,78 mmHg.s. Der Vergleich der Protokolle 1 und 3 ergab mehr positive Ränge für die Kombination aus Phonation und NMES und für die Parameter MeanAct, Max und AUC. Dieser Unterschied zeigte mit p=0.026 statistische Signifikanz in Bezug auf den Parameter Max.
UNASSIGNED: NMES in Kombination mit Phonation führt bei Gesunden zu einer Veränderung des velopharyngealen Verschlussmusters mit einer Druckerhöhung von etwa 200%. Dies könnte für Patient_innen mit velopharyngealer Insuffizienz von therapeutischem Nutzen sein.

OBJECTIVE: To describe a comprehensive decision-making process for surgical correction of structural Velopharyngeal Dysfunction (VPD) following cleft palate repair and evaluate its efficacy.
METHODS: Retrospective study.
METHODS: Tertiary care hospital.
METHODS: 300 consecutive patients with unilateral or bilateral cleft lip and palate (CLP) or isolated cleft palate (CP) diagnosed with clinical VPD following cleft palate repair between 2009 and 2014. Of these 206 patients had structural VPD and underwent surgical correction.
METHODS: Surgical corrections were carried out according to the comprehensive two stage decision making process developed by the investigators. Step 1 of decision-making involved visualisation of the VP sphincter function by nasoendoscopy. This was followed by step 2 which involved per-operative identification of scarring, tissue loss, hypoplasia and other structural deficiencies in the soft palate and septal mucoperiosteum. The choice of operation was then made from a repertoire of interrelated and escalating surgical procedures consisting of palate revision and pharyngoplasties ranging from most anatomical to the least.
METHODS: Evidence of postoperative restoration of VP function on nasoendoscopy, evaluation of speech for hypernasality, understandability, acceptability and symptoms of obstructive sleep apnea.
RESULTS: Complete VP closure was demonstrated in 94% of patients treated using this algorithm. There was significant improvement in all speech parameters (p < 0.00001).
CONCLUSIONS: Our comprehensive decision-making process is designed to effectively correct structural VPD according to the severity of structural and functional deficiencies in the soft palate and avoid over treatment.

OBJECTIVE: To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.
METHODS: Cross-sectional analysis of prospectively collected data from 2019-2022.
METHODS: Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.
METHODS: 714 English-speaking children and adolescents with non-syndromic cleft lip/palate.
METHODS: Routine multidisciplinary care and systematic outcomes measurement by cleft teams.
METHODS: Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.
RESULTS: 12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.
CONCLUSIONS: This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of \"real-world\" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Challenges providing cleft/craniofacial care in rural communities are often reported, leading to disparities in resources available to clinicians. The purpose of this study was to identify the impact of rurality on caseloads and practice patterns of speech-language pathologists (SLPs) regarding speech and velopharyngeal function for children with cleft lip and/or palate (CL/P).
A national, survey of US-based SLPs (N = 359 respondents) investigated resources, comfort level, caseloads, and practice patterns for children with CL/P. Sub-county classifications that delineated levels of rurality were utilized. Descriptive statistics and chi-square analyses were conducted to determine the impact of population density on assessment and referral decisions.
Nearly 83% of SLPs reported providing care for a child with CL/P and 41.4% of these SLPs reported five or more children with CL/P on caseload throughout their career. There were no significant differences in rurality of practice setting and the likelihood of treating a child with CL/P. Significant differences were present between rural, town, suburban, and metropolitan-based SLPs regarding available resources (p = 0.035). SLPs in rural settings reported feeling uncomfortable treating children with CL/P compared to those in metropolitan settings (p = 0.02). Distance to the cleft/craniofacial team and comfort levels impacted referral decisions.
Most SLPs report having children with CL/P on caseload regardless of practice location. Rurality impacted assessment and referral decisions, especially surrounding access to resources and comfort levels engaging in team care. Findings have implications for developing support systems and reducing barriers for rural SLPs working with children born with CL/P.

OBJECTIVE: Patients with a cleft palate often experience a velopharyngeal dysfunction known as velopharyngeal insufficiency (VPI). The purpose of this study was to examine the development of velopharyngeal function (VPF) following primary palatoplasty and the factors that are linked to it.
METHODS: A retrospective study was conducted to examine the medical records of patients who had cleft palate, with or without cleft lip (CP ± L) and underwent palatoplasty at a Tertiary Affiliated Hospital between 2004 and 2017. Postoperative evaluation of VPF was conducted at two follow-up times (T1, T2) and was classified as either normal VPF, mild VPI, or moderate/severe VPI. The consistency of VPF evaluations between the two time points was then assessed, and patients were categorized into either the consistent or inconsistent group. The study collected and analyzed data on gender, cleft type, age at operation, follow-up duration, and speech records.
RESULTS: The study included 188 patients with CP ± L. Out of these, 138 patients (73.4%) showed consistent VPF evaluations, while 50 patients (26.6%) showed inconsistent VPF evaluations. Among those with VPI at T1 (91 patients), 36 patients (39.6%) had normal VPF at T2. The rate of VPI decreased from 48.40% at T1 to 27.13% at T2, whereas the rate of normal VPF increased from 44.68% at T1 to 68.09% at T2. The consistent group had a significantly younger age at operation (2.90 ± 3.82 vs 3.68 ± 4.02), a longer duration of T1 (1.67 ± 0.97 vs 1.04 ± 0.59), and a lower comprehensive score of speech performance (1.86 ± 1.27 vs 2.60 ± 1.07) than the inconsistent group.
CONCLUSIONS: It has been verified that there are changes in the development of VPF over time. Patients who underwent palatoplasty at a younger age were more likely to have confirmed VPF diagnosis at the first evaluation. The duration of follow-up was identified as a critical factor that affects the confirmation of VPF diagnosis.

The purpose of this study was to introduce the surgical process of Sommerlad-Furlow modified (S-F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty. Patients with non-syndromic cleft palate who had undergone either S-F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted. 1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S-F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S-F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S-F palatoplasty was 4.3%. This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad-Furlow modified technique is an option for cleft palate repair.

OBJECTIVE: The addition of a uvular flap (PFU) was hypothesized to improve outcomes over standard pharyngeal flap (PF) for correction of velopharyngeal dysfunction. We report differences in outcomes of PF vs PFU at our institution.
METHODS: Retrospective cohort study.
METHODS: Tertiary children\'s hospital.
METHODS: Children who underwent PF or PFU with the three highest-volume surgeons at our institution in 2004-2017.
METHODS: We examined differences in complications between groups, frequency and type of revision surgery, and speech-related measures including nasometry, pressure-flow testing (PFT) and perceptual speech analysis (PSA).
RESULTS: 160 patients were included, 41 PF and 119 PFU (including 18 with Hogan technique). Patients undergoing PFU were older (7.6 yr vs 6.0 yr; p  =  0.037) and more likely to have cleft palate (63/119 vs 14/41; p  =  0.047). There was no significant difference in complications. With PFU, a decrease in airspace contracting revision surgeries was noted, (4/119 vs 8/41; p  =  0.002) which drove a reduction in revision surgery of all types (7/119 vs 13/41; p  =  0.033). However, patients that did undergo revision surgery after PFU underwent more revision procedures (p  =  0.032). PSA scores were found to be lower (less hypernasal) after PFU (p  =  0.009) compared to PF. Objective speech measures had varying results, with nasometry demonstrating a significant difference between groups (p  =  0.001), while PFT (p  =  0.525) did not demonstrate a statistical difference.
CONCLUSIONS: The use of a uvular lining flap in pharyngeal flap surgery may be associated with improved long term surgical outcomes, including both improvements in subjective and objective testing and a lower rate of revision surgery, without increased complications.