vpi evaluation

CME

Velopharyngeal Incompetence: A Guide forClinical EvaluationDonnell 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 speechproduction. 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 speechproduction analysis. 4. Understand the advantages and disadvantages of various types of instrumental modalities and theirspecific indications in diagnosing speech abnormalities.

Various causes of velopharyngeal disorders and themyriad of diagnostic methods used by speech-languagepathologists and plastic surgeons for assessment are de-scribed in this article. Velopharyngeal incompetence oc-curs when the velum and lateral and posterior pharyngealwalls fail to separate the oral cavity from the nasal cavityduring speech and deglutination. The functional goals ofcleft palate operations are to facilitate normal speech andhearing without interfering with the facial growth of achild. Basic and helpful techniques are presented to helpthe cleft palate team identify preoperative or postopera-tive velopharyngeal incompetence. This information willenable any member of the multidisciplinary cleft palateteam 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 surgeryare to facilitate normal speech and hearingwithout interfering with the facial growth of achild. Unfortunately, after primary palato-plasty, up to 20 percent of patients have unsat-isfactory speech results and require secondarymanagement because of insufficient velopha-ryngeal closure.1–11 The speech-language pa-thologist plays a vital role in identifying thisgroup of patients. With early recognition andintervention, the chances for development ofnormal speech and hearing are increased. Fur-ther, the specific treatment plan and surgicalprocedure will be based on the causes of theinadequate velopharyngeal closure. The pur-

pose of this article is to describe the variouscauses of velopharyngeal disorders and themyriad of diagnostic methods used by speech-language pathologists and plastic surgeons forassessment. This will enable any member of themultidisciplinary cleft palate team to better as-sist in the differential diagnosis and manage-ment of patients with speech disorders.

Velopharyngeal closure refers to the normalapposition of the soft palate, or velum, with theposterior and lateral pharyngeal walls.12–18 It isprimarily a sphincteric mechanism consistingof a velar component and a pharyngeal com-ponent. Movement of the velar component isproduced principally by the action of the leva-tor veli palatini muscle. Movement of the pha-ryngeal component is more dependent on thecontraction of the superior constrictor muscleand 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 anteriormovement of the posterior pharyngeal walls (atthe level of the first cervical vertebra), sepa-rates the oral cavity from the nasal cavity dur-ing deglutination and speech. Velopharyngealincompetence 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; revisedMay 30, 2003.

DOI: 10.1097/01.PRS.0000091245.32905.D5

1890

ETIOLOGY

Different nomenclature exists that attemptsto describe subgroups of velopharyngeal disor-ders based on etiology. We prefer the use of asingle 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 toseparate the oral cavity from the nasal cavity.The etiology of velopharyngeal incompetenceincludes 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 astructural deficit of the velum or pharyngealwalls at the level of the nasopharynx with in-sufficient tissue to accomplish closure. Struc-tural congenital defects include gross tissuedeficiency, submucous or overt unoperatedclefts, a short or immobile soft palate, a largeand deep nasopharynx, or a palatal fistula.Velopharyngeal incompetence may also be ac-quired due to anatomic pathology as a result ofcancer treatment or maxillofacial trauma.

Similarly, neurogenic impairment can resultin partial or total immobility of the soft palateand/or pharyngeal walls and lead to velopha-ryngeal incompetence. This neurogenic, im-paired velopharyngeal valve closure will pro-duce dysarthric speech. Protective andreflexive acts such as gagging and swallowingmay be impaired depending on the nature andthe level of the lesion. Velopharyngeal incom-petence secondary to a neurogenic deficit maybe congenital, although it is most often ac-quired after trauma. The disturbance inspeech production is caused by a weakness,paralysis, or a lack of coordination of speechmusculature. The injury may be localized tocranial 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 intelligibilitywill improve with velopharyngeal valveremediation.

Velopharyngeal incompetence may also bepresent secondary to mechanical interferencewith the velopharyngeal valve closure. For ex-ample, severely hypertrophied tonsils cancause a mechanical interference resulting inincomplete valve closure. Similarly, an exces-

sively wide pharyngeal flap may inhibit apposi-tion of the velum with the pharyngeal walls.

Misarticulations may present in a mannersimilar to that seen in velopharyngeal incom-petence.31–33 Phoneme-specific misarticulationsrefer to the occurrence of nasal emission oncertain (but not all) pressure consonants in theabsence 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 iscrucial in identifying the cause of articular im-pairment in patients with inconsistent nasalemission, since a resonance disorder does notexist.

VELOPHARYNGEAL FUNCTION

The ability to achieve properly articulatedspeech pivots on the dynamic interaction ofthe palatal and pharyngeal wall musculature,which is driven by neural pathways to constrictthe velopharyngeal portal. Because the entirevocal tract is a resonating cavity, coupling anduncoupling of the nasal and oral cavity arenecessary to produce various sounds and intel-ligible speech. The velum and pharynx act as avalve that selectively channels airflow andacoustic energy under different pressures intothe oral and nasal cavities. To produce nasalsounds (m, n, ng), the velopharyngeal valvechannels airflow to the nasal cavity. Similarly,for the oral sounds (all vowels and remainingconsonants), the valve closes off the nasal cav-ity and selectively transmits airflow and energythrough the oral cavity. Thus, for normalspeech, one must have rapid and competentvelopharyngeal function in addition to beingable to produce appropriate airflow and ade-quate pressure. With competent velopharyn-geal valving, a pressure column of exhaled airis shared with the oral cavity, where interrelat-ing tongue, palatine shelves, dentition, and lipsfashion the various sound waves. Combinedintermittently with nasal resonance, thesesound waves characterize human speech.

Abnormal resonance can result from previ-ously described structural, neurogenic, physio-logic, or mechanical impairment. When thenormal space relationship or coupling betweenthe velum and nasopharynx is disturbed, velo-pharyngeal incompetence results. This pro-duces three common speech characteristicssecondary to increased transmission throughthe nasal cavity: hypernasality, nasal emission,and reduced aspiration and frication. Hyper-

Vol. 112, No. 7 / EVALUATING VELOPHARYNGEAL INCOMPETENCE 1891

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 otherhand, stop plosives and fricatives are secondaryto a leak, which prohibits the accumulation ofsufficient oral pressures.

EVALUATION OF VELOPHARYNGEAL ACTIVITY

Two types of evaluation are used to obtain athorough assessment of velopharyngeal func-tion: a clinical evaluation and an instrumentalevaluation. An understanding of the varioussubjective and objective techniques of eachtype of evaluation that are available to assessvelopharyngeal 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 isadequate for complete appraisal of velopharyn-geal function, a variety of techniques should beused for evaluation. Utilizing different modal-ities will reveal the presence, size, location, andcontour of an opening between the oral andnasal cavities during speech and delineate thenature 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 oftenat our institution in the diagnosis and treat-ment of velopharyngeal incompetence.

Clinical Assessment of Velopharyngeal Activity

The clinician’s eyes and ears are used as thefirst and primary diagnostic tools. As the mostvalid measure of adequate velopharyngealfunction is sound produced during normalspeech, by simply listening, one can judgewhether further investigation is warranted.When a patient’s 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 thenassessed. Particular focus is paid to resonancequality, airflow, air pressure, and whether com-pensatory articulatory productions exist.

Intraoral Examination

The first step in the intraoral examination isthe direct visual assessment of structural integ-rity. The lips, teeth, tongue, tonsils, hard andsoft palate, uvula, and pharyngeal walls should

be carefully inspected. The symmetry of thevelum, tonsils, and nasopharynx is noted. Sub-mucous clefts are revealed through palpationof a notch in the hard palate, identification ofa zona pellucida in the soft palate, or a bifiduvula. The presence of an oral nasal fistulashould be sought. A rhinoscopic examinationshould be included to check for hypertrophiedturbinates, septal deviation, and nasalobstruction.

The second step in the intraoral examina-tion is to assess reflexive and voluntary behav-ior. Reflexive behavior assists in determiningthe overall dysarthric status. This assessment isperformed by repetitive stimulation of a gagreflex at different loci. Delay, fatigue, asymme-try, or lack of response is noted. The presenceor 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 assessmentduring sustained phonation of “a” assists indetermining velar motion (elevation, length,asymmetry, amplitude, fatigue, and speed).

Speech Production Characteristics

Upon completion of a thorough intraoralexamination, the clinical examination pro-ceeds with an assessment of speech productioncharacteristics. Four specific characteristics areassessed: resonance quality, airflow, air pres-sure, and compensatory articulation. Devia-tions in the normal movement of a pressurizedairstream through the resonating vocal tractwill cause specific alterations in these fourcharacteristics. The recognition of these alter-ations will assist in obtaining the correctdiagnosis.

The first characteristic, resonance quality, isassessed by checking for the presence of nasalvibration during vowel production (i, u, and e).With an incomplete velopharyngeal seal, thenasal cavity becomes coupled with the oral cav-ity and the airstream escapes through the openvelopharyngeal port, causing hypernasal reso-nance. This resonance can be detected clini-cally by comparing occluded and unoccludednares for the presence of a nasal vibration dur-ing vowel production.

The presence or absence of nasal emission ofthe airstream is the second speech productioncharacteristic to assess. Nasal emission may beaudible or inaudible. In addition to the noisethat may be produced, the occurrence of nasal

1892 PLASTIC AND RECONSTRUCTIVE SURGERY, December 2003

flaring assists in identification. Other methodshelpful in diagnosing inaudible nasal emissioninclude a mirror that fogs when placed underthe nares during vowel production and thedeflection of tissue paper.

The third characteristic is the adequacy ofintraoral air pressure build-up. The averageadult requires 5 to 7 cm of water pressurebuild-up in the oral cavity behind the site ofconstriction to produce most oral consonants,particularly plosives (p) and fricatives (f).When velopharyngeal insufficiency is present,an inadequate amount of pressure is accruedin the oral cavity secondary to incomplete clo-sure of the velopharyngeal valve. The phraseused frequently at our institution to test airpressure 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 areathat 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 afunctioning glottis or pharynx or uses the middorsum and the back of the tongue to valve theairflow. The neurogenic patient, however, willhave compensatory productions occurring atthe same anatomic level but deviating in themanner of speech production. Thus, glottaland pharyngeal productions are absent.Rather, labial substitution is performed fortongue inadequacy. Regardless of the deriva-tion of compensatory productions, they are alllearned behaviors, which frequently persisteven after adequate surgical or prostheticmanagement.

Instrumental Assessment of Velopharyngeal Activity

The subjective yet invaluable informationgathered from the clinical examination should

be used to complement objective structuraldata obtained from an instrumental assess-ment. The goal of the instrumental assessmentis to obtain anatomic data regarding the ade-quacy of velar length, palatal elevation, velo-pharyngeal gap, excursion of the lateral andposterior pharyngeal walls, nasopharyngealdepth, pattern, and level of attempted closure.Two subgroups of techniques are used in thediagnostic process: direct and indirect. Directinstrumental techniques are those that enablethe 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 resonanceimaging. Indirect instrumental techniques pro-vide information about vocal tract behavior,and gathered data are used to make relativeinferences. Phototransduction, electromyogra-phy, and movement transduction are a fewexamples of indirect instrumental techniques.

Direct Instrumental Techniques

Lateral cephalometric radiography. The lateralcephalometric radiograph continues to be amainstay of the evaluation process at our insti-tution as well as many others. It is the primarydirect method of assessing structures of thevelopharynx and the surrounding tissues. Ob-tained at a constant magnification factor both atrest and during a sustained “-ee” production,lateral cephalogram views permit visualizationof soft palate elevation and its contact with theposterior pharyngeal wall. The addition of bar-ium allows for enhanced visualization of themargins of the velum and pharyngeal wall. Us-ing this technique, we have had a greater than90 percent rate of accurate prediction of theneed for a pharyngeal flap based solely on thisradiographic 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 IThe Phonetic Alphabet: Consonants

Bilabial Labiodental Dentoalveolar Palatoalveolar Velar

Nasals m n ng (sing)Plosives p-b (pat-bat) t-d (tot-dot) k-g (coat-goat)Fricatives f-v (fat-vat) th-th (thank-than) sh-zh (ash-azure)Sibilants s-z (sue-zoo) sh-z (ash-azure)Affricates ts-dz (cheap-jeep) ts-dz (cheap-jeep)


determined by assessing the relationships pro-vided.34,35 Because the velopharyngeal mecha-nism is three-dimensional and dynamic, thedisadvantages of a lateral still radiograph areobvious: it is a two-dimensional study represen-tative of structural features only in the sagittalplane. Hence, the width of a pharyngeal flapcannot be determined by this method. Further,because it is a static study, the events occurringbetween 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 diagnosticbattery at multidisciplinary cleft palate centers.

Multiview videofluoroscopy. In response to thelimitations of the lateral still radiograph, lateralview motion picture radiography was intro-duced to study velopharyngeal function in mo-tion. With advances in technology, this evolvedfrom cine (motion picture films) to multiviewvideofluoroscopy. Multiview videofluoroscopyhas distinct advantages, such as less radiationexposure (10 times less than cinefluoroscopy),the ability to record and replay immediately,assessment of velopharyngeal function in threeplanes (sagittal, coronal, and transverse), and adynamic view during connected speech frombeginning to end.36–42 The lateral views depictmovements of the velum and posterior pharyn-geal walls. The frontal view of the oropharynxdemonstrates gradations of mesial motion ofthe lateral pharyngeal walls, which ultimatelydetermines the width of a proposed pharyngealflap. Although its primary limitation is the in-ability to provide an absolute measurement ofstructural relationships, the width of a proposedpharyngeal flap is easily determined by a rela-tive scale. The degree of lateral pharyngeal wallmotion ranges from zero (no motion duringquiet respiration) to five (maximal motion tothe midline; Fig. 1). This ability to obtain anaccurate preoperative assessment of lateral pha-ryngeal wall motion appears to be a prime de-terminant of postoperative success after a pha-ryngeal flap operation. In addition to beingexcellent in depicting necessary information onvelopharyngeal function and dictating surgicalmanagement, compared with other techniques,it has the least variability and is most reflectiveof actual speech pattern.

Nasopharyngoscopy. The limitations of naso-pharyngoscopy are similar to those of video-fluoroscopy. The information obtained to as-sess gap size is in the form of a ratio than anabsolute number. Although nasopharyngos-

copy provides a substantial amount of informa-tion through visualization of the velum andpharyngeal walls, it is difficult to obtain stan-dardized views or infer relative dimensions.Other limitations include the inability to iden-tify small velopharyngeal gaps or pinpoint theexact anatomical location of the gap. Patientcooperation becomes a critical factor that fur-ther limits the use of nasopharyngoscopy in thepediatric population unless the patient is anes-thetized. D’Antonio et al.43,44 have described thecriteria, indications, and impact of nasal endos-copy on tailoring pharyngeal flaps, flap revi-sions, and the fitting of palatal prostheses. Sim-ilarly, Pigott finds the 70-degree endoscope tobe indispensable and complementary to multi-view videofluoroscopy in the evaluation of thevelopharyngeal sphincter.45,46

Magnetic resonance imaging. Magnetic reso-nance imaging uses the resonant absorption andremission of radio waves by hydrogen nuclei to

FIG. 1. Diagrammatic frontal view of the oropharynxdemonstrates gradations of mesial motion of the lateral pha-ryngeal walls. Zero represents no motion during quiet res-piration, and 5 depicts maximal motion of each lateral pha-ryngeal wall to the midline. Reprinted from Johns, D. F.,Cannito, M. P., Rohrich, R. J., and Tebbetts, J. B. The self-lined superiorly based pull-through velopharyngoplasty: Plas-tic surgery-speech pathology interaction in the managementof velopharyngeal insufficiency. Plast. Reconstr. Surg. 94: 436,1994.


obtain images. It has a number of advantages overthe methodologies currently used to study thevocal tract and velopharyngeal mechanism.47,48

Magnetic resonance imaging technology allowsnoninvasive visualization of the vocal tract withoutexposure to radiation or any known biohazardsand provides better soft-tissue resolution. Func-tional images at any chosen level can be obtainedin the sagittal, frontal, and transaxial views with-out changing the position of the patient. Thecurrent limitations of this method for imaginginclude the potential distortion of the velopha-ryngeal mechanism by gravitational forces in thesupine position, the need for patient cooperation,and cost. It is hoped that further technologicaldevelopments will result in near–real-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 provideinferences through data about the structureand kinematics of the velopharyngeal mecha-nism. Examples include phototransduction,electromyography, and movement transduc-tion. Other types of indirect measures studythe effects of velopharyngeal function on otherphysiologic parameters. Aerodynamics, acous-tics, sound pressure, and spectrography fall un-der this category. Although indirect measuresprovide objective information, they do not nec-essarily dictate the decision-making process.

Phototransduction. Photoelectric technologyuses light transmission to obtain relative infor-mation on the velopharyngeal port. A fiberopticdevice couples a light source to an electronicdetector. The two fibers are introducedthrough the nasal cavity until the light source isbelow the velopharyngeal port and the detectorfiber is above the velopharyngeal port. Quan-tifiable data are produced that provide infor-mation regarding the opening and closingmovements of the velopharyngeal port.

Electromyography. Electromyography studiesthe electrical activity produced by muscle con-traction using hooked wire electrodes. The lim-itations of electromyography are intuitive, suchas discomfort from placement of needle elec-trodes, small and malpositioned muscles in cleftpatients, and multiple passive and active forcesacting on the velopharynx.

Movement transduction. Movement transduc-tion combines the use of mechanical and elec-

trical devices to transduce velopharyngealmovement. The second maxillary molar acts asan anchor, with placement of a bar/spring at-tachment along the oral midline. With velarmotion, the spring sensor converts motion intoan electrical output along the strain gauge re-sistor. Although this technique is not currentlyused as an evaluation tool, it has been helpfulas a biofeedback device.

Aerodynamics. The study of pressure andflow provides significant information that al-lows a distinction to be made between velopha-ryngeal insufficiency and dysfunction second-ary to other anatomic valve abnormalities. Inaddition, it helps determine the presence andmagnitude of velopharyngeal incompetenceand obstruction (nasal or pharyngeal). Specificinformation details the relative contributions ofvelopharyngeal components and nasal compo-nents to total airway resistance. In a complexcase, this technique may be useful before sur-gical intervention to isolate and determine var-ious contributions to insufficiency. Similarly, itis helpful after surgical intervention to deter-mine whether a pharyngeal flap is the cause ofa patient’s 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 ofvelopharyngeal incompetence. In these pa-tients, excessive acoustic energy in the nasalcavity is observed during reading from passageswith oral sounds. In children with velopharyn-geal obstruction, lack of acoustic energy in thenasal cavity is observed during reading frompassages containing many nasal sounds. In ad-dition to deciphering the location and degreeof abnormal resonance, the information is pro-vided instantaneously. Therefore, the acousticassessment is a helpful method used forbiofeedback 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 speechcharacteristics 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. Thefocus of this article is to present basic and


helpful techniques to improve the capabilitiesof any member of the cleft palate team inidentifying 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 identifyfactors in patients with poor outcomes thatmay be avoided or modified in the future willlead to an improvement in outcomes. A thor-ough understanding of the mechanism of velo-pharyngeal function and the instrumentaltechniques used for evaluation may inspirenew treatment modalities or improve thosethat currently exist. It is hoped that the multi-disciplinary team will use the thorough clinicalassessment and data obtained from instrumen-tal techniques discussed in this article to deter-mine the most appropriate intervention for agiven patient. Clearly, without an armamentar-ium of several surgical techniques, the surgeonwill be limited to applying a single treatmentmodality to a problem with varied physiologicaland structural causes.

Rod J. Rohrich, M.D.Department of Plastic SurgeryUniversity of Texas Southwestern Medical Center5323 Harry Hines Boulevard, E7.212Dallas, Texas [email protected]

ACKNOWLEDGMENT

This is the last paper written by Dr. Donnell F. Johns beforehis untimely death. He left it on his desk, almost completed.The last time I spoke with him, he reminded me that heneeded 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 atremendous asset to us and to our profession. We miss him.

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Self-Assessment Examination follows onthe next page.


Self Assessment Examination

Velopharyngeal Incompetence: A Guide for Clinical Evaluationby 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 palateB) Short or immobile palate following primary cleft repairC) Mechanical obstructionD) Neurologic deficitE) Palatal fistula

2. DURING VELOPHARYNGEAL CLOSURE, MOVEMENT OF SOFT PALATE IS PRINCIPALLY DUE TO ACTIONOF WHICH MUSCLE?A) Tensor veli palatiniB) Levator veli palatiniC) PharyngopalatinusD) PalatoglossusE) Superior constrictor

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

4. SURGICAL CORRECTION OF VELOPHARYNGEAL INCOMPETENCE WILL IMPROVE EACH OF THEFOLLOWING EXCEPT:A) Resonance qualityB) Nasal airflowC) Intraoral air pressureD) Articulation errorsE) Nasal regurgitation

5. ACCORDING TO THE AUTHORS, THE BEST METHOD TO ASSESS SOFT-PALATE ELEVATION ANDCONTACT WITH THE POSTERIOR PHARYNGEAL WALL IS:A) Lateral cephalometric radiographyB) Magnetic resonance imagingC) Multiview videofluoroscopyD) NasopharyngoscopyE) Aerodynamics

6. ACCORDING TO THE AUTHORS, THE DEGREE OF LATERAL WALL MOTION USED TO DETERMINE THEWIDTH OF A PLANNED PHARYNGEAL FLAP IS BEST DETERMINED USING:A) Lateral cephalometric radiographyB) Magnetic resonance imagingC) Multiview videofluoroscopyD) NasopharyngoscopyE) Movement transduction

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

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