Accepted Manuscript

Pharyngeal Flap is Effective Treatment for Post Maxillary Advancement

Velopharyngeal Insufficiency in Patients with Repaired Cleft Lip and Palate

Kelley M. Dentino, D.M.D., Eileen M. Marrinan, M.S., M.P.H., Katherine Brustowicz,

John B. Mulliken, M.D., Bonnie L. Padwa, D.M.D., M.D.

PII: S0278-2391(16)00008-2
DOI: 10.1016/j.joms.2015.12.016
Reference: YJOMS 57076

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 6 July 2015

Revised Date: 6 December 2015
Accepted Date: 12 December 2015

Please cite this article as: Dentino KM, Marrinan EM, Brustowicz K, Mulliken JB, Padwa BL, Pharyngeal
Flap is Effective Treatment for Post Maxillary Advancement Velopharyngeal Insufficiency in Patients
with Repaired Cleft Lip and Palate, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/
j.joms.2015.12.016.

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 ACCEPTED MANUSCRIPT

Pharyngeal Flap is Effective Treatment for Post Maxillary Advancement Velopharyngeal

Insufficiency in Patients with Repaired Cleft Lip and Palate

Kelley M. Dentino, D.M.D.;1 Eileen M. Marrinan, M.S., M.P.H.;2 Katherine Brustowicz;3 John

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B. Mulliken, M.D.;4 Bonnie L. Padwa, D.M.D., M.D. 5

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Address correspondence and reprint requests:

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Dr. Bonnie L. Padwa, DMD, MD
Department of Plastic and Oral Surgery
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Boston Children’s Hospital
300 Longwood Avenue, Boston, MA 02115
Phone: 617-355-6259
Fax: 617-738-1657
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E-mail: Bonnie.Padwa@childrens.harvard.edu
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1
Clinical Research Fellow, Harvard Medical School, Department of Plastic and Oral Surgery,
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Boston Children’s Hospital, Boston, MA

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Research Instructor, Department of Otolaryngology, SUNY Upstate Medical University,
Syracuse, NY
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Research Coordinator, Department of Plastic and Oral Surgery, Boston Children’s Hospital,
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Boston, MA
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Professor of Surgery, Harvard Medical School; Department of Plastic & Oral Surgery, Boston
Children’s Hospital, Boston, MA
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Associate Professor, Harvard School of Dental Medicine; Oral-Surgeon-in-Chief, Department

of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA
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Pharyngeal Flap is Effective Treatment for Post Maxillary Advancement Velopharyngeal

Insufficiency in Patients with Repaired Cleft Lip and Palate

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ABSTRACT

Purpose: Patients with repaired cleft lip and/or palate (CL/P) can develop velopharyngeal

insufficiency after Le Fort I maxillary advancement. The aim of this study was to evaluate

speech outcomes in patients who required a pharyngeal flap after Le Fort I maxillary

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advancement.

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Patients and Methods: Retrospective cohort study of all patients with repaired CL/P who

underwent a Le Fort I osteotomy and subsequently required a pharyngeal flap to correct

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velopharyngeal insufficiency (VPI). Subjects were included if they had outcome measures

documented at three time points: 1) pre-Le Fort I (baseline), 2) post-Le Fort I, and 3) post-

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pharyngeal flap. Outcome measures including speech characteristics (resonance, nasal emission,
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intra-oral pressure) and velopharyngeal function were evaluated on perceptual assessment by a

speech pathologist specializing in cleft care. Velopharyngeal closure was assessed with multi-
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view videofluoroscopy and/or nasopharyngoscopy. Patient characteristics and descriptive

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statistics were summarized and continuous data expressed as mean ± standard deviation.
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Repeated measures ANOVA and paired samples t-test were used to measure changes in speech

outcome variables between time-points. All p-values were two-tailed and considered significant
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for values of p<0.05.

Results: There were 23 patients for analysis: 13 females (56.5%) and 10 males (43.5%). Two
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patients (9%) with cleft palate (CP) only; 9 (39%) with unilateral cleft lip and palate (CLP); and
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12 (52%) with bilateral CLP. Follow-up evaluations performed on average 12 months post-

operatively demonstrated a statistically significant improvement for all variables, including

decreased hypernasality, reduced nasal emission, and increased intra-oral pressure for consonant

production. Patients with repaired CL/P who had VPI after Le Fort I maxillary advancement

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demonstrated significant improvement in all outcome measures following pharyngeal flap

surgery (p<0.001).

Conclusions: The superiorly-based pharyngeal flap is highly successful in correcting VPI after

Le Fort I maxillary advancement in patients with repaired CL/P.

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Introduction

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Children with cleft lip and/or palate (CL/P) can exhibit restricted maxillary growth

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following repair; either as an unwanted consequence of surgical intervention or part of an
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intrinsic abnormality of skeletal growth.1 Regardless of etiology, approximately 25-40% of

patients2 with repaired CL/P will require Le Fort I osteotomy and maxillary advancement after
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completion of facial growth.3 Although this procedure corrects skeletal malocclusion and
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improves nasolabial appearance, it also alters palatal position, increases pharyngeal volume, and
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thus can effect velopharyngeal closure.2,4-7

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Functional adaptation of the velopharyngeal sphincter is possible following maxillary

advancement. However, patients who have had a palatoplasty are at a disadvantage because the
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short, scarred velum may be unable to accommodate to an increase in pharyngeal size.8,9 The
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reported incidence of velopharyngeal insufficiency (VPI) in patients with CL/P after maxillary

advancement varies widely, ranging from 0-84%.2,4,5,7 McComb and colleagues reported an

incidence of 23% in our unit and showed that patients with a short soft palate or increased

pharyngeal depth are at greatest risk for developing VPI after Le Fort I osteotomy, regardless of

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the extent of sagittal maxillary advancement.2 Several other studies have documented that there

is no correlation between the magnitude of advancement and speech outcomes.10-15

Surgical correction of VPI can be achieved through a number of techniques including pharyngeal

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flap, sphincter pharyngoplasty, double-opposing Z-palatoplasty, and palatal muscular

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retropositioning.16 We favor a superiorly-based “tailored” pharyngeal flap.9 Pre-operative

nasopharyngoscopy and/or videofluoroscopy allow the surgeon to adjust the dimensions of the

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flap according to the valve closure pattern and width of the pharynx. Success rates in these

patients have been reported between 78-98% with a very low incidence of complications.6,9,17,18

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No studies have evaluated whether the superiorly-based flap is similarly effective for correcting

VPI in patients with CL/P who required maxillary advancement. The aim of this study is to
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investigate speech outcomes in patients with repaired CL/P who had a pharyngeal flap for VPI
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after Le Fort I osteotomy and maxillary advancement.

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The purpose of this study was to evaluate speech outcomes in patients who required a pharyngeal
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flap after Le Fort I maxillary advancement. The investigators hypothesize that a superiorly based

pharyngeal flap is effective treatment for post maxillary advancement velopharyngeal

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insufficiency in patients with repaired CL/P. The specific aims of the study were: 1) measure
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speech and velopharyngeal function before and after maxillary advancement and 2) compare to

outcomes after pharyngeal flap.

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Methods

Study design

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To address the research purpose, the investigators designed and implemented a retrospective

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cohort study of patients with repaired CL/P who had VPI following Le Fort I maxillary

advancement and were treated with a pharyngeal flap. This study was approved by the

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Institutional Review Board of the Committee on Clinical Investigation at Boston Children’s

Hospital and all research activities were conducted in accordance with the Declaration of

Helsinki.
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Subjects
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The study population was composed of all patients with repaired CL/P who had VPI after
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maxillary advancement and required a pharyngeal flap between 2008 and 2013. To be included
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in the study patients had to have speech evaluations at three time points: 1) prior to Le Fort I

(baseline), 2) post-Le Fort I, and 3) post-pharyngeal flap. Patients were excluded if they had
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insufficient records.
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Descriptive data were collected from the medical record including date of birth, gender, cleft side
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and severity, syndromic diagnosis, surgical history, and post-operative course. Speech

evaluations, multi-view videofluoroscopic studies, and nasopharyngoscopy reports were

reviewed to document outcome measures, including speech characteristics and velopharyngeal

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closure, at three time points: 1) prior to Le Fort I (baseline), 2) post-Le Fort I, and 3) post-

pharyngeal flap.

Procedures

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All patients underwent a tailored, superiorly-based pharyngeal flap. Two patients with VPI

required post-Le Fort I osteotomy take-down of an existing flap that had previously been

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performed at another institution and a new flap. One surgeon (JBM) performed the pharyngeal

flap in all patients. The width of the flap (narrow, medium, wide, very wide) was tailored based

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the amount of lateral pharyngeal wall motion at the level of closure observed on pre-operative
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multi-view videofluoroscopy and the width of the nasopharynx. If the tonsils or adenoids were

enlarged on pre-operative nasopharyngoscopy, tonsillectomy and/or adenoidectomy were

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performed at least 8 weeks prior to the pharyngeal flap. There were 2 patients who had an
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adenotonsillectomy prior to the procedure and 4 patients who had adenoidectomy.

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Speech Characteristics and Velopharyngeal Closure

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Speech pathologists specializing in cleft care performed perceptual evaluations of speech and
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velopharyngeal function. Speech was scored using the Pittsburgh Weighted Values for Speech
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Symptoms Associated with Velopharyngeal Incompetence19 and graded on three structurally

correctable variables (Table 1): resonance (0-6, normal to severely hypernasal), visible and

audible nasal emission (0-4, absent to turbulent), and intraoral pressure for the production of

consonants (0-3, adequate to reduced). Patients were also asked whether their resonance posed a

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personal or social problem.20 Articulation errors and voice quality were assessed, but not

calculated in the final weighted score of speech outcomes, as they are not corrected by an

operation. The speech pathologist provided an overall diagnosis of velopharyngeal function as:

1) normal, 2) borderline sufficient, 3) borderline insufficient or 4) insufficient (Table 2).

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Velopharyngeal function and valve closure patterns were further assessed by nasopharyngoscopy

and/or multi-view videofluoroscopy. Pre-operative nasopharyngoscopy was performed by a

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single otolaryngologist specializing in cleft care. The results of multi-view videofluoroscopy

were reviewed by a speech pathologist and the plastic surgeon (JBM). The data were recorded

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for velopharyngeal touch closure (consistent, intermittent, none), gap size (pinhole, small,
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moderate, large) and defect pattern (coronal, sagittal, circular). The presence of a Passavant ridge

or large adenoids contributing to closure was noted and the size and position of the tonsils was
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also documented. Lateral pharyngeal wall motion was recorded as the percentage of closure by
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medial movement toward the midline as determined by the vomer21,22 Palatal length was judged
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to be short, normal, or long relative to pharyngeal depth during full velar elevation by the speech

pathologist based on lateral view videofluoroscopy.21

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Normal or borderline sufficient velopharyngeal function was categorized as a success, whereas

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borderline insufficient or insufficient velopharyngeal function was categorized as a failure and a

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second operation was recommended. Time to most recent follow-up was documented and

complications were recorded, including flap dehiscence, hyponasal speech, obstructive

symptoms, and need for secondary operation or revision (tonsillectomy, adenoidectomy, flap

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division, or dilation of pharyngeal ports).

Variables

The primary predictor variables were classified as demographic variables, anatomic variables,

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and surgical variables. Demographic predictor variables included: age, gender, cleft type, and

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syndromic diagnosis. Anatomic predictor variables were evaluated prior to pharyngeal flap and

included: presence of a Passavant ridge, large adenoids or tonsils contributing to closure

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(yes/no), velopharyngeal touch closure (consistent, intermittent, none), gap size (pinhole, small,

moderate, large), defect pattern (coronal, sagittal, circular), and lateral pharyngeal wall

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movement (poor, fair, good, excellent). Surgical predictor variables included presence of
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velopharyngeal insufficiency prior to maxillary advancement (yes/no) and pharyngeal flap width

(small, medium, wide, very wide).

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The primary outcome variable was velopharyngeal function following maxillary advancement,
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as determined by the speech pathologist (Table 2). Secondary outcome variables included

Pittsburgh Scale scores and speech characteristics of resonance, nasal emission, and intraoral
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pressure for consonant production (Table 1).

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Statistical Analysis
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De-identified data were collected in Excel (Microsoft, Redmond, WA) and analyzed using SPSS

PC Version 19.0 (IBM SPSS Inc., Chicago, IL). Patient characteristics and descriptive statistics

were summarized and continuous data were expressed as a mean ± standard deviation. A paired t

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test compared pre and post-operative speech scores and we used a non-parametric Wilcoxon

signed rank test to compare pre- and post-operative Pittsburgh Scale scores. Bivariate non-

parametric analyses were used to identify relationships between predictor and outcome variables;

those with significance of p<0.15 were selected for inclusion in the regression analysis. A

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repeated measures ANOVA was used to measure changes in each speech outcome variable

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between all time-points while controlling for effect modifiers and covariates. All p-values were

two-tailed and considered significant for values of p<0.05.

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Results

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Subjects
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There were 64 patients with repaired CL/P who had a Le Fort I maxillary advancement (mean
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advancement 8mm + 2.2 mm [range 5-12 mm]) between 2008 and 2013, all by the senior author
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(BLP). Twenty-six patients (40.6%) had VPI after Le Fort I, including 20 patients who were

known to have borderline VPI prior to maxillary advancement and 2 patients who had a
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pharyngeal flap in place at the time of the procedure. Three subjects were excluded because of

insufficient records, leaving 23 patients for analysis: 13 females (56.5%) and 10 males (43.5%).
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Two patients (9%) had CP only; 9 (39%) had unilateral CLP; and 12 (52%) had bilateral CLP.
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Three of the subjects (13%) had a syndromic diagnosis: popliteal pterygium (n=1), Opitz G/BBB

(n=1), and Marshall (n=1). The mean age at Le Fort I osteotomy and maxillary advancement was

17.9 + 0.48 years and the mean age at pharyngeal flap was 19.2 + 0.56 years. The mean time

between Le Fort I and pharyngeal flap was 1.3 + .52 years (range 6 – 52 months).

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Baseline Speech and Velopharyngeal Function

The mean scored speech variables and velopharyngeal function prior to Le Fort I osteotomy are

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shown in Tables 3 and 4. At baseline, Pittsburgh Scale scores varied from 0-11 (median=2). A

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majority of patients (n=17, 74%) were diagnosed as borderline sufficient/insufficient at baseline,

the others had normal velopharyngeal function (n=3) or gross VPI (n=3). Speech was typically

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characterized by intermittent-to-mild hypernasality (n=10, 45%) and/or visible nasal emission

(n=17, 77%). There were no patients with moderate to severe hypernasality or audible nasal

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emission and only 1 patient (5%) reported a social concern related to speech. Of 21 patients
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demonstrating articulatory errors, only 2 patients exhibited compensatory patterns related to VPI;

the other 19 patients had errors related to dental malocclusion.

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Pre-operative nasopharyngoscopy documented a persistent central gap with incomplete closure

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in 5 patients; all others demonstrated at least touch closure, often with intermittent leakage or

mild bubbling of secretions through a pinhole size defect (n=14). Average lateral wall movement
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towards the midline was 51+ 20%. Of note, most patients had a short palate (n=15), and 3

patients had a moderate to large adenoidal pad contributing to closure: 1 with no VPI (Pittsburgh
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Scale score=0) and 2 with borderline sufficiency (Pittsburgh scale scores=1,2). Six patients had a
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large Passavant ridge contributing to closure, 3 with borderline sufficiency (Pittsburgh Scale

scores 1-2) and 3 with borderline insufficiency (Pittsburgh Scale scores 3-6).

Post- Le Fort I Speech and Velopharyngeal Insufficiency

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Following maxillary advancement, all 23 patients were diagnosed with borderline to gross VPI

demonstrating a significant deterioration from baseline (p<0.001) (Table 4). Patients had speech

evaluation an average of 5.8 months following Le Fort I advancement. The increase in VPI and

associated speech characteristics were evidenced by statistically significant trends toward

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hypernasal resonance, increased nasal emission, weak intraoral pressure for consonants, and

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higher Pittsburgh Scale scores (median 6, range: 2-14) (Table 3).

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The speech characteristics that became worse following Le Fort I osteotomy included hypernasal

resonance (83%), nasal emission (73%), and inadequate pressure for oral consonants (57%). Six

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patients demonstrated compensatory articulation errors related to VPI.
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Nasopharyngoscopy and/or videofluoroscopy were performed to estimate lateral pharyngeal wall
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movement and level of velopharyngeal closure. Only 1 patient had consistent touch closure
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centrally, but still had air escape through a bilateral defect due to inadequate pharyngeal wall
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motion. Two patients had intermittent closure, with inconsistent air escape through a small or

moderate circular gap; 18 patients (78%) had obvious VPI, including 15 who had a small-to-
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large persistent central gap, 2 who had a widely open valve, and 1 patient with an existing

pharyngeal flap had open lateral ports with minimal pharyngeal wall movement. There were 11
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patients who were noted to have a prominent Passavant ridge near the level of closure. The mean
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lateral pharyngeal wall motion toward midline was 46.2 + 20%.

Outcomes following Pharyngeal Flap

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Following the pharyngeal flap, the median time to post-operative assessment of speech and

velopharyngeal function was 5 months (range: 2-58). All patients had sufficient or borderline

sufficient velopharyngeal closure following pharyngeal flap (Table 4), representing a statistically

significant improvement (p<0.001) that was unchanged when controlling for effect modifiers

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and covariates (Table 5). Follow-up evaluations performed on average 12 months post-

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operatively also demonstrated a statistically significant improvement for all variables (Table 6),

including decreased hypernasality, reduced nasal emission, and increased intra-oral pressure for

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consonant production (Table 3), that was unchanged when controlling for covariates (Table 5).

The average Pittsburgh Scale score was also effectively corrected, with scores ranging from 0-3.

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Two patients had clinically insignificant findings: 1 had inconsistent mild hypernasality and 1
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had inconsistent visible nasal emission. There were 2 patients who had inconsistent hyponasal

resonance, however, they did not report any social concerns or difficulty with speech and were
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pleased with the outcome.

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The mean time to most recent follow up was 2.1 years (range: 3 mo-10 years). There were no

patients who required a flap augmentation for persistent or relapsing VPI and none of the
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patients required a flap revision or take-down. Five patients reported sleep disordered breathing

postoperatively, but overnight attended polysomnography failed to demonstrate obstructive sleep

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apnea.
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Discussion

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The purpose of this study was to evaluate speech outcomes in patients who required a pharyngeal

flap after Le Fort I maxillary advancement. The investigators hypothesize that a superiorly based

pharyngeal flap is effective treatment for post maxillary advancement velopharyngeal

insufficiency in patients with repaired CL/P. The specific aims of the study were to: 1) measure

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speech and velopharyngeal function before and after maxillary advancement and 2) compare to

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outcomes after pharyngeal flap.

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This study documents a superiorly-based pharyngeal flap to be effective treatment for patients

with CL/P who have VPI after Le Fort I maxillary advancement. Hyponasal speech indicates

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some degree of obstruction after pharyngeal flap;23 this was documented in 13% of our cohort,
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although in all cases it was minor and not bothersome to the patients. Overall, there were no

major complications requiring a second intervention, and 100% of the patients reported a
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satisfactory speech outcome - a measure that is arguably the most critical gauge of success.20
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We selected for a sample of patients who had persistent changes in velopharyngeal function

following Le Fort I osteotomy, and in whom we were able to quantify and objectively measure
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VPI using visualization studies. Many patients had borderline-to-insufficient velopharyngeal

closure at baseline, with elements of mild hypernasal resonance, visible nasal emission, and
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inconsistently decreased intraoral pressure. Alterations in speech following Le Fort I osteotomy

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and maxillary advancement are common, variable, and often they are transient.24,25 Among

individuals with CL/P, the implications of a change in speech are not trivial: Broder and Strauss

showed that patients with CL/P and speech difficulties are more vulnerable to psychosocial

adjustment issues than patients without speech concerns.26,27

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Previous studies have mentioned the benefits of pharyngeal flap following maxillary

advancement,5,7,28 but without quantifying outcomes. Similar successful outcomes have been

documented for non-syndromic CL/P patients who require pharyngeal flap for VPI after

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palatoplasty in childhood. Sullivan et al9 reported a 97% success rate and significant

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improvements (p<0.0001) in all outcome measures using the same technique.

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There are important anatomic and physiological differences between young patients who develop

VPI after primary palatal closure and adult patients who develop VPI as a consequence of

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sagittal advancement of the velar musculature.8,21,29-37 In childhood, deficient palatal length or
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insufficient palatal elevation may be masked by large adenoids.36-39 With growth, adenoidal

involution is accompanied by a three-dimensional increase in airway dimensions, and the plane

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of the velopharyngeal port rotates to a more vertical position.21,34-37,40,41 A repaired palate is less
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able to accommodate these changes because of inadequate velar stretch42 and poorly formed
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velar eminence.43 As a result, contact with the pharyngeal wall occurs at a more posterior part of

the uvula compared to normal.8,29,36,44,45 While many adults with repaired CL/P can achieve
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functional borderline or touch closure, there may be subclinical defects such as a pinhole gap,

seen on videofluoroscopy or endoscopy.46

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It has been suggested that adult patients may be predisposed to forming a prominent Passavant

ridge following Le Fort I advancement.47-50 There is speculation that this occurs because of

stretched muscle fibers that insert on the posterior pharyngeal wall.51,52 The function of a

Passavant ridge remains controversial. It is unclear whether the ridge develops following Le Fort

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I osteotomy or is only more obvious having previously been hidden below the level of closure

when viewed on nasopharyngoscopy. In our sample, the number of patients with a Passavant

ridge nearly doubled after Le Fort I (n=6 at baseline, and n=11 post-Le Fort I). Whatever the

anatomic basis of the ridge, it may be possible to take advantage of its position when locating the

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flap.16,47,53,54

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The strengths of this study include a single protocol with one surgeon performing the primary

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cleft repair and pharyngeal flap and a second surgeon doing the Le Fort I osteotomy. However,

there was more than one speech pathologist that evaluated these patients at all time points. The

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perceptual evaluations of speech and velopharyngeal function are objective measures that have
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some inherent subjectivity and it is possible that this introduced some bias into the data. This

study has several other weaknesses including its retrospective nature and relatively small sample
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size.
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In conclusion, a pharyngeal flap, tailored to lateral pharyngeal wall movement and pharyngeal

width, is an effective treatment for post-Le Fort I osteotomy VPI in patients with repaired CL/P.
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The risks are minimal and velopharyngeal gap defects can be corrected in patients with variable

velopharyngeal anatomy.
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Table 1. Structurally correctable speech variables, graded by severity

Resonance
0 = Normal

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1 = Mildly hyponasal
2 = Mixed hyponasal/hypernasal
3 = Inconsistent mildly hypernasal

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4 = Consistent mildly hypernasal
5 = Moderately hypernasal
6 = Severely hypernasal

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Nasal emission
0 = Absent
1 = Visible by mirror exam

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2 = Audible
3 = Turbulent
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Intraoral pressure for consonant production
0= Adequate
1 = Inconsistently reduced
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2= Consistently reduced
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Table 2. Perceptual Assessment of Velopharyngeal Function with Corresponding Pittsburgh

Scale Scores

1) Sufficient
• normal-hyponasal resonance, absence of visible nasal emission, adequate intraoral pressure, no
personal/social problems

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• Pittsburgh Scale score = 0 (Sufficient)
2) Borderline sufficient
• inconsistent mildly hypernasal resonanace, visible nasal emission, adequate intraoral pressure,

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no personal/social problems
• Pittsburgh Scale score = 1-2 (Borderline sufficient)
3) Borderline insufficient

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• consistent hypernasal resonance, audible or turbulent nasal emission, inconsistent reduced
intraoral pressure, personal or social problem
• Pittsburgh Scale score = 3-6 (Borderline insufficient)

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4) Insufficient
• moderate or severely hypernasal resonance, audible or turbulent nasal emission, reduced
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intraoral pressure, personal/social problem
• Pittsburgh Scale score <7 = Insufficient
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Table 3. Scored Speech Variables for All Time Points. Expressed as mean + SD.

Pre-Le Fort I Post-Le Fort I

Score Score Post-PF Score

Resonance 1.25 ± 1.50 4.00 ± 1.30 0.46 ± 0.89

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Nasal Emission 0.98 ± 0.75 2.56 ± 1.21 0.77 ± 0.56

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Intraoral 0.16 ± 0.37 0.80 ± 0.41 0.00 ± 0.00
Pressure
Pittsburgh Scale 2.77 ± 2.84 7.13 ± 3.42 1.82 ± 1.17

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score
VPI 1.27 ± 0.94 2.83 ± 0.39 0.25 ± 0.27

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Table 4. Pre- and Post-Operative Velopharyngeal Diagnosis. Expressed as % of total cohort.

Pre-Le Fort I Post- Le Fort I Post- Flap

Normal 13% 0% 31%

Borderline sufficient 44% 0% 69%

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Borderline insufficient 30% 30% 0%

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Insufficient 13% 70% 0%

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Table 5. Bivariate correlations between predictor and outcome variables. Data given as p
values with significant values starred.

Outcome Variables

Pittsburgh Nasal Intraoral

VPI Scale Score Resonance Emission Pressure

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Age 0.157 0.150 0.034* 0.014* 0.064
Predictor Variables

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Demographic

Gender 0.05* 0.087 0.212 0.999 0.027*

Cleft Type 0.134 0.442 0.377 0.420 0.669

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Syndromic
Diagnosis 0.584 0.999 0.716 0.097 0.211

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Passavant
Ridge 0.199 0.221 0.375 0.835 0.409
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Touch
Anatomic Predictor Variables

Closure 0.238 0.599 0.999 0.999 0.375

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Gap Size 0.221 0.264 0.617 0.221 0.114

Defect
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Pattern 0.739 0.999 0.221 0.739 0.114

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Lateral Wall
Movement 0.041* 0.683 0.599 0.685 0.515
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Palatal
Length 0.418 0.999 0.510 0.548 0.157

Pre-Op VPI 0.227 0.725 0.999 0.265 0.873

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Surgical Predictor

Sagittal
Variables

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Advancement 0.767 0.420 0.717 0.767 0.546

Pharyngeal
Flap Width 0.022* 0.488 0.383 0.936 0.721

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Table 6. Improvement in All Outcome Variables after Pharyngeal Flap. Data given as p
values.

Outcome Variable p value*

VPI <0.001

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Pittsburgh Scale Scores 0.001

Resonance 0.008

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Nasal Emission 0.003

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Intraoral Pressure <0.001

*Repeated measures ANOVA, adjusted for covariates age, gender, cleft type, pharyngeal flap width and

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lateral pharyngeal wall movement.
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References

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