Velopharyngeal insufficiency (VPI) poses challenges for normal speech production, often necessitating surgical intervention. Determining optimal candidates for surgery remains complex and requires a nuanced understanding of underlying anatomic factors contributing to VPI. This study aimed to identify anatomic predictors that drive surgical recommendations for VPI.
Design
Prospective observational cohort study.
Setting
Pediatric tertiary care hospital.
Methods
Magnetic resonance imaging data were acquired from 150 children (aged 4–17) to identify anatomic predictors of VPI and surgical need. Fourteen velopharyngeal variables were measured in the oblique coronal and midsagittal imaging planes. Calculations included differences in levator veli palatini (LVP) muscle angles of origin, mean extravelar length, differences between left and right extravelar segments, the VP Needs ratio, and a newly developed LVP ratio. Multivariate logistic regression models with k-fold cross validation were utilized to identify anatomic profiles predictive of VPI and receiving a surgical recommendation.
Results
The models demonstrated high accuracy, sensitivity, and specificity. Among anatomic variables, the LVP ratio emerged as the strongest determinant of surgical need (β = 11.256, p < .001). Notably, an increase in the LVP ratio of 0.10 is associated with a 3.08-fold increase in the likelihood of receiving a surgical recommendation. LVP ratios above 1.0 were significant for both VPI classification and surgical need.
Conclusions
The LVP ratio significantly differentiates individuals with VPI and is predictive of surgical need for VPI management. Inclusion of the LVP ratio into clinical evaluations may refine patient stratification, enabling more precise surgical decision-making tailored to individual anatomic variations.
KummerAW. Speech and resonance disorders related to cleft palate and velopharyngeal dysfunction: A guide to evaluation and treatment. SIG16Perspectives on School-Based Issues. 2014;15(2):57-74.
2.
NachmaniABiadseeAMasalhaMKassemF. Compensatory articulation errors in patients with velopharyngeal dysfunction and palatal anomalies. Journal of Speech, Language, and Hearing Research. 2022;65(7):2518–2539. doi:10.1044/2022_JSLHR-21-00679
3.
GartMSGosainAK. Surgical management of velopharyngeal insufficiency. ClinPlastSurg. 2014;41(2):253–270. doi:10.1016/j.cps.2013.12.010
4.
RudnickEFSieKC. Velopharyngeal insufficiency: Current concepts in diagnosis and management. Current Opinion in Otolaryngology & Head and Neck Surgery. 2008;16(6):530–535. doi:10.1097/MOO.0b013e328316bd68
5.
de BlacamCSmithSOrrD. Surgery for Velopharyngeal Dysfunction: A Systematic Review of Interventions and Outcomes. The Cleft Palate-Craniofacial Journal. 2018;55(3):405–422. doi:10.1177/1055665617735102
6.
BettensKWuytsFLVan LierdeKM. Instrumental assessment of velopharyngeal function and resonance: A review. Journal of Communication Disorders. 2014;52:170–183. doi:10.1016/j.jcomdis.2014.05.004
7.
LohmanderAOlssonM. Methodology for perceptual assessment of speech in patients with cleft palate: A critical review of the literature. The Cleft Palate-Craniofacial Journal. 2004;41(1):64–70. doi:10.1597/02-136
8.
HenningssonGIsbergA. Comparison between multiview videofluoroscopy and nasendoscopy of velopharyngeal movements. The Cleft Palate-Craniofacial Journal. 1991;28(4):413–418. doi:10.1597/1545-1569_1991_028_0413_cbmvan_2.3.co_2
9.
WilliamsJLPerryJLSnodgrassTDSinghDJTemkitMSitzmanTJ. Can MRI replace nasopharyngoscopy in the evaluation of velopharyngeal insufficiency?The Cleft Palate Craniofacial Journal. Published online March15, 2024:10556656241239459. doi:10.1177/10556656241239459
10.
PerryJLMasonKSuttonBPKuehnDP. Can dynamic MRI be used to accurately identify velopharyngeal closure patterns?The Cleft palate-craniofacial journal: Official publication of the American Cleft Palate-Craniofacial Association. 2017;55(4):499. doi:10.1177/1055665617735998
11.
D’antonioLLAchauerBMKamVMV. Results of a survey of cleft palate teams concerning the use of nasendoscopy. The Cleft Palate-Craniofacial Journal. 1993;30(1):35–39. doi:10.1597/1545-1569_1993_030_0035_roasoc_2.3.co_2
12.
SellD. Issues in perceptual speech analysis in cleft palate and related disorders: A review. International journal of language & communication disorders. 2005;40(2):103–121.
13.
BicknellSMcFaddenLRCurranJB. Frequency of pharyngoplasty after primary repair of cleft palate. Journal-Canadian Dental Association. 2002;68(11):688–692.
14.
MasonKNBlackJ. Incorporating velopharyngeal MRI into the clinical decision-making process for a patient presenting with velopharyngeal dysfunction following a failed palatoplasty. Cleft Palate Craniofac J. 2024;61(9):1563–1573. doi:10.1177/10556656231173500
15.
RiskiJERuffGLGeorgiadeGSBarwickWJ. Evaluation of failed sphincter pharyngoplasties. AnnPlastSurg. 1992;28(6):545–553.
16.
SullivanSRMarrinanEMMullikenJB. Pharyngeal flap outcomes in nonsyndromic children with repaired cleft palate and velopharyngeal insufficiency. Plastic and Reconstructive Surgery. 2010;125(1):290. doi:10.1097/PRS.0b013e3181c2a6c1
17.
LoskenAWilliamsJKBursteinFDMalickDRiskiJE. An outcome evaluation of sphincter pharyngoplasty for the management of velopharyngeal insufficiency. PlastReconstrSurg. 2003;112(7):1755–1761. doi:10.1097/01.PRS.0000090720.33554.8B
18.
MasonKNPerryJ. The use of magnetic resonance imaging (MRI) for the study of the velopharynx. Perspectives of the ASHA Special Interest Groups. 2017;2(5):35–52.
19.
MasonKNRiskiJEWilliamsJKJonesRAPerryJL. Utilization of 3D MRI for the evaluation of sphincter pharyngoplasty insertion site in patients with velopharyngeal dysfunction. Cleft Palate Craniofac J. 2022;59(12):1469–1476. doi:10.1177/10556656211044656
20.
KotlarekKJSitzmanTJWilliamsJLPerryJL. Nonsedated magnetic resonance imaging for visualization of the velopharynx in the pediatric population. The Cleft Palate-Craniofacial Journal. Published online November17, 2021:10556656211057361. doi:10.1177/10556656211057361
21.
PerryJLSuttonBPKuehnDPGamageJK. Using MRI for assessing velopharyngeal structures and function. The Cleft Palate-Craniofacial Journal. 2014;51(4):476–485.
22.
MasonKN. Magnetic resonance imaging for assessing velopharyngeal function: Current applications, barriers, and potential for future clinical translation in the United States. The Cleft Palate-Craniofacial Journal. Published online August29, 2022:10556656221123916. doi:10.1177/10556656221123916
23.
KollaraLBaylisALKirschnerREBatesDGSmithMFangXPerryJL. Velopharyngeal structural and muscle variations in children with 22q11.2 deletion syndrome: An unsedated MRI study. The Cleft Palate-Craniofacial Journal. 2019;56(9):1139–1148. doi:10.1177/1055665619851660
24.
SchenckGCPerryJLO’GaraMMLindeAMGrasseschiMFWoodRJLaceyMSFangX. Velopharyngeal muscle morphology in children with unrepaired submucous cleft palate: An imaging study. The Cleft Palate-Craniofacial Journal. 2021;58(3):313–323. doi:10.1177/1055665620954749
25.
MasonKNPerryJLRiskiJEFangX. Age-related changes between the level of velopharyngeal closure and the cervical spine. JCraniofacSurg. 2016;27(2):498–503.
26.
MasonKNPerryJL. Relationship between age and diagnosis on volumetric and linear velopharyngeal measures in the cleft and noncleft populations. JCraniofacSurg. 2016;27(5):1340–1345.
27.
KotlarekKJPerryJLFangX. Morphology of the levator veli palatini muscle in adults with repaired cleft palate. JCraniofacSurg. 2017;28(3):833–837. doi:10.1097/SCS.0000000000003373
28.
KotlarekKJPellandCMBlemkerSSJaskolkaMSFangXPerryJL. Asymmetry and positioning of the levator veli palatini muscle in children with repaired cleft palate. Journal of Speech, Language, and Hearing Research. 2020;63(5):1317–1325. doi:10.1044/2020_JSLHR-19-00240
29.
PerryJLKuehnDPSuttonBPGamageJK. Sexual dimorphism of the levator veli palatini muscle: An imaging study. Cleft PalateCraniofacJ. 2014;51(5):544–552. doi:10.1597/12-128
30.
KollaraLPerryJLHudsonS. Racial variations in velopharyngeal and craniometric morphology in children: An imaging study. Journal of Speech, Language, and Hearing Research. 2016;59(1):27–38. doi:10.1044/2015_JSLHR-S-14-0236
31.
PerryJLKuehnDPSuttonBPGamageJKFangX. Anthropometric analysis of the velopharynx and related craniometric dimensions in three adult populations using MRI. The Cleft Palate-Craniofacial Journal. 2016;53(1):e1–e13.
32.
AndersonPFelsSStavnessIPearsonWGGickB. Intravelar and extravelar portions of soft palate muscles in velic constrictions: A three-dimensional modeling study. Journal of Speech, Language, and Hearing Research. 2019;62(4):802–814. doi:10.1044/2018_JSLHR-S-17-0247
33.
TranTPerryJBlemkerSMasonK. Simulation of velopharyngeal biomechanics identifies differences in sphincter pharyngoplasty outcomes: A matched case-control study. Cleft Palate Craniofac J. 2024;61(2):339–349. doi:10.1177/10556656221122634
34.
InouyeJMPerryJLLinKYBlemkerSS. A computational model quantifies the effect of anatomical variability on velopharyngeal function. Journal of Speech, Language, and Hearing Research. 2015;58(4):1119–1133. doi:10.1044/2015_JSLHR-S-15-0013
35.
PerryJLSnodgrassTDGilbertIRWilliamsJLSinghDJSitzmanTJ. The levator veli palatini: Are all segments created equal?The Cleft Palate Craniofacial Journal. Published online August13, 2024:10556656241271666. doi:10.1177/10556656241271666
36.
MasonKNHansonBBlackJS. Measurement matters: MRI analysis of differing anatomic measurement techniques for velar length and the velopharyngeal needs ratio. Plastic and Reconstructive Surgery – Global Open. 2024;12(2):e5617. doi:10.1097/GOX.0000000000005617
37.
SubtelnyJD. A cephalometric study of the growth of the soft palate. PlastReconstrSurg(1946). 1957;19(1):49-62.
38.
LuYShiBZhengQXiaoWLiS. Analysis of velopharyngeal morphology in adults with velopharyngeal incompetence after surgery of a cleft palate. Annals of Plastic Surgery. 2006;57(1):50. doi:10.1097/01.sap.0000208937.05684.38
39.
TianWRedettRJ. New velopharyngeal measurements at rest and during speech: Implications and applications. JCraniofacSurg. 2009;20(2):532–539. doi:10.1097/SCS.0b013e31819b9fbe
40.
RogersCKonofaosPWallaceRD. Superiorly based pharyngeal flap for the surgical treatment of velopharyngeal insufficiency and speech outcomes. Journal of Craniofacial Surgery. 2016;27(7):1746. doi:10.1097/SCS.0000000000003050
41.
MarshJL. Management of velopharyngeal dysfunction: Differential diagnosis for differential management. JCraniofacSurg. 2003;14(5):621–628.
42.
CarlisleMPSykesKJSinghalVK. Outcomes of sphincter pharyngoplasty and palatal lengthening for velopharyngeal insufficiency: A 10-year experience. Archives of Otolaryngology–Head & Neck Surgery. 2011;137(8):763–766.
43.
LentskevichMAYauAFigueroaAETermaniniKMGosainAK. Speech outcomes of buccal myomucosal flap palatal lengthening for treatment of velopharyngeal insufficiency: Systematic literature review and meta-analysis. Cleft Palate Craniofac J. Published online November22, 2023:10556656231216834. doi:10.1177/10556656231216834
44.
PerryJLSnodgrassTDGilbertIRSuttonBPBaylisALWeidlerEMTseRWIshmanSLSitzmanTJ. Establishing a clinical protocol for velopharyngeal mri and interpreting imaging findings. Cleft Palate Craniofac J. 2024;61(5):748–758. doi:10.1177/10556656221141188
45.
ChapmanKLBaylisATrost-CardamoneJCorderoKNDixonADobbelsteynCThurmesAWilsonKHarding-BellASweenyT, et al. The americleft speech project: A training and reliability study. The Cleft Palate Craniofacial Journal. 2016;53(1):93–108. doi:10.1597/14-027
46.
FedorovABeichelRKalpathy-CramerJFinetJFillion-RobinJCPujolSBauerCJenningsDSonkaM, et al. 3D slicer as an image computing platform for the quantitative imaging network. Magn Reson Imaging. 2012;30(9):1323–1341. doi:10.1016/j.mri.2012.05.001
JohnstonRJonesKManleyD. Confounding and collinearity in regression analysis: A cautionary tale and an alternative procedure, illustrated by studies of British voting behaviour. Qual Quant. 2018;52(4):1957–1976. doi:10.1007/s11135-017-0584-6
49.
PerryJLKuehnDPSuttonBPFangX. Velopharyngeal structural and functional assessment of speech in young children using dynamic magnetic resonance imaging. The Cleft Palate-Craniofacial Journal. 2017;54(4):408–422. doi:10.1597/15-120
50.
MasonKNRiskiJEPerryJL. Changes in the height of velopharyngeal closure relative to the cervical spine from infancy through adolescence in patients with cleft palate. The Cleft Palate-Craniofacial Journal. 2018;55(4):508–516.
51.
UrsiWJTrotmanCAJrMcNamara JABehrentsRG. Sexual dimorphism in normal craniofacial growth. Angle Orthod. 1993;63(1):47–56. doi:10.1043/0003-3219(1993)063 < 0047:SDINCG>2.0.CO;2
52.
DiSalvoMDBlemkerSSMasonKN. A computational model reveals how varying muscle activation in the lateral pharyngeal wall and soft palate differentiates velopharyngeal closure patterns. Journal of Speech, Language, and Hearing Research. doi:10.1044/2024_JSLHR-24-00353
53.
SitzmanTJWilliamsJLSinghDJTemkitMSnodgrassTDPerryJL. MRI of the Velopharynx: Clinical findings in patients with velopharyngeal insufficiency. Plastic and Reconstructive Surgery. Published online June6, 2023. doi:10.1097/PRS.0000000000010798
54.
MasonKNGampperTBlackJ. Achieving Clinical Success in Nonsedated velopharyngeal MRI: Insights for optimal data quality & effective patient selection. Plastic and Reconstructive Surgery. Published online2024:10.1097/PRS.0000000000011619. doi:10.1097/PRS.0000000000011619
55.
SakranKAHuangHAl-MoraissiEElayahSAYounisHLiYShiB. Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs. International Journal of Oral and Maxillofacial Surgery. 2024;53(8):677–685. doi:10.1016/j.ijom.2024.01.012
56.
NguyenDCPatelKBSkolnickGBSkladmanRGramesLMStahlMBMarshJLWooAS. Progressive tightening of the levator veli palatini muscle improves velopharyngeal dysfunction in early outcomes of primary palatoplasty. Plastic and Reconstructive Surgery. 2015;136(1):131. doi:10.1097/PRS.0000000000001323
57.
InouyeJMLinKYPerryJLBlemkerSS. Contributions of the musculus uvulae to velopharyngeal closure quantified with a 3D multi-muscle computational model. Ann Plast Surg. 2016;77(Suppl 1):S70–S75. doi:10.1097/SAP.0000000000000777
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
