Inability of the velopharyngeal sphincter to close completely during production of the oral (nonnasal) sounds of speech

1. 
   obturators (speech bulb) - provides a bulky apparatus for the pharynx against which the lateral walls and the palate can close during speech
   
2. 
   Palatal lifts - attaches to the patient’s teeth and roof of the mouth. Reserved for patients with adequate tissue to effect closure but there is poor control or coordination. May also be used as a preoperative trial to see if VP closure alone will improve the speech disturbance. Elevates the palate towards the pharyngeal walls during speech and the residual palate motion does the rest. Used mainly in amyotrophic lateral sclerosis
   

Main treatment methods

1. 
   pharyngeal flap surgery
   
   • 
     benefit patients with sagittal closure patterns.
     
2. 
   sphincter pharygoplasty
   
   • 
     those with circular and coronal closure patterns as it does not interfere with the posterior motion of the palate.
     
3. 
   Furlow palatoplasty
   
4. 
   Others
   
   • 
     Intravelar veloplasty – if not already performed
     
   • 
     post pharyngeal wall augmentation
     
   • 
     prosthetic speech appliances
     

• 
  most surgeons regard lateral pharyngeal wall motion as the single most important determinant with regard to surgical planning.
  

• 
  Armour A, Fisher D; Does Velopharyngeal Closure Pattern Affect the Success of Pharyngeal Flap Pharyngoplasty? PRS Jan 2005
  
  • 
    pharyngeal flap pharyngoplasty was successful in correcting nasalance in a significantly greater percentage of patients with noncoronal closure pattern velopharyngeal insufficiency (57%) than with coronal pattern velopharyngeal insufficiency (35%)
    
  • 
    Sphincter pharyngoplasty is thus recommended for coronal closure patterns
    

• 
  Pre-VP management tonsillectomy and/or adenoidectomy are advised if the initial airway evaluation findings indicate that the lymphoid mass will compromise the operation or patency of the ports.
  

• 
  first true pharyngeal flap operation was described by Schoenborn (1875) and was an inferiorly based flap, he then changed to a superiorly based flap.
  
• 
  Use of a pharyngeal flap is best when a sagittal closure pattern exists (ie, when the greatest contribution to velar closure is lateral wall movement).
  
• 
  May also be used for circular closure patterns
  
• 
  No additional benefit with intravelar veloplasty
  

• 
  tissue/flap from the post pharyngeal wall is attached to the soft palate creating a midline obstruction of the oral and nasal cavities with two patent lateral ports that ideally remain patent during respiration and nasal consonant production
  
• 
  depth of the flap is down to the prevertebral fascia so it includes the superior constrictor muscle
  

1. 
   construction of the appropriate width of flap
   
2. 
   the use of a superiorly or inferiorly based flap
   
3. 
   whether the flap should be lined to reduce post op contraction of the flap
   
4. 
   correct width and level of attachment to the flap