CME

Velopharyngeal Incompetence: A Guide for

Clinical Evaluation
Donnell 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 speech
production. 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 speech
production analysis. 4. Understand the advantages and disadvantages of various types of instrumental modalities and their
specific indications in diagnosing speech abnormalities.
Various causes of velopharyngeal disorders and the
myriad of diagnostic methods used by speech-language
pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal
walls fail to separate the oral cavity from the nasal cavity
during speech and deglutination. The functional goals of
cleft palate operations are to facilitate normal speech and
hearing without interfering with the facial growth of a
child. Basic and helpful techniques are presented to help
the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will
enable any member of the multidisciplinary cleft palate
team to better assist in the differential diagnosis and management of patients with speech disorders. (Plast. Reconstr. Surg. 112: 1890, 2003.)

pose of this article is to describe the various

causes of velopharyngeal disorders and the
myriad of diagnostic methods used by speechlanguage pathologists and plastic surgeons for
assessment. This will enable any member of the
multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.
Velopharyngeal closure refers to the normal
apposition of the soft palate, or velum, with the
posterior and lateral pharyngeal walls.1218 It is
primarily a sphincteric mechanism consisting
of a velar component and a pharyngeal component. Movement of the velar component is
produced principally by the action of the levator veli palatini muscle. Movement of the pharyngeal component is more dependent on the
contraction of the superior constrictor muscle
and the palatopharyngeal muscles. The upward and backward movement of the velum,
coupled with the mesial movement of the lateral pharyngeal walls and the slight anterior
movement of the posterior pharyngeal walls (at
the level of the first cervical vertebra), separates the oral cavity from the nasal cavity during deglutination and speech. Velopharyngeal
incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination.

The functional goals of cleft palate surgery

are to facilitate normal speech and hearing
without interfering with the facial growth of a
child. Unfortunately, after primary palatoplasty, up to 20 percent of patients have unsatisfactory speech results and require secondary
management because of insufficient velopharyngeal closure.111 The speech-language pathologist plays a vital role in identifying this
group of patients. With early recognition and
intervention, the chances for development of
normal speech and hearing are increased. Further, the specific treatment plan and surgical
procedure will be based on the causes of the
inadequate velopharyngeal closure. The pur-

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication April 24, 2003; revised
May 30, 2003.
DOI: 10.1097/01.PRS.0000091245.32905.D5

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EVALUATING VELOPHARYNGEAL INCOMPETENCE

ETIOLOGY

Different nomenclature exists that attempts

to describe subgroups of velopharyngeal disorders based on etiology. We prefer the use of a
single generic term, velopharyngeal incompetence, to denote any type of abnormal velopharyngeal function in which the velum and lateral and posterior pharyngeal walls fail to
separate the oral cavity from the nasal cavity.
The etiology of velopharyngeal incompetence
includes structural deficits, neurogenic impairment, and mechanical interference to velopharyngeal closure.19 30
Of particular concern to the craniofacial surgeon is velopharyngeal incompetence occurring in patients with cleft palate secondary to a
structural deficit of the velum or pharyngeal
walls at the level of the nasopharynx with insufficient tissue to accomplish closure. Structural congenital defects include gross tissue
deficiency, submucous or overt unoperated
clefts, a short or immobile soft palate, a large
and deep nasopharynx, or a palatal fistula.
Velopharyngeal incompetence may also be acquired due to anatomic pathology as a result of
cancer treatment or maxillofacial trauma.
Similarly, neurogenic impairment can result
in partial or total immobility of the soft palate
and/or pharyngeal walls and lead to velopharyngeal incompetence. This neurogenic, impaired velopharyngeal valve closure will produce dysarthric speech. Protective and
reflexive acts such as gagging and swallowing
may be impaired depending on the nature and
the level of the lesion. Velopharyngeal incompetence secondary to a neurogenic deficit may
be congenital, although it is most often acquired after trauma. The disturbance in
speech production is caused by a weakness,
paralysis, or a lack of coordination of speech
musculature. The injury may be localized to
cranial nerves IX, X, or XI, lower motor nerves,
upper motor nerves, and/or the cerebellum.
The localization and severity of the impairment will dictate whether speech intelligibility
will improve with velopharyngeal valve
remediation.
Velopharyngeal incompetence may also be
present secondary to mechanical interference
with the velopharyngeal valve closure. For example, severely hypertrophied tonsils can
cause a mechanical interference resulting in
incomplete valve closure. Similarly, an exces-

sively wide pharyngeal flap may inhibit apposition of the velum with the pharyngeal walls.
Misarticulations may present in a manner
similar to that seen in velopharyngeal incompetence.3133 Phoneme-specific misarticulations
refer to the occurrence of nasal emission on
certain (but not all) pressure consonants in the
absence of any hypernasal resonance. Fricatives (s, z) and affricates (ts, dz) are most vulnerable to this type of misarticulation. Recognizing this selective phoneme emission is
crucial in identifying the cause of articular impairment in patients with inconsistent nasal
emission, since a resonance disorder does not
exist.
VELOPHARYNGEAL FUNCTION

The ability to achieve properly articulated

speech pivots on the dynamic interaction of
the palatal and pharyngeal wall musculature,
which is driven by neural pathways to constrict
the velopharyngeal portal. Because the entire
vocal tract is a resonating cavity, coupling and
uncoupling of the nasal and oral cavity are
necessary to produce various sounds and intelligible speech. The velum and pharynx act as a
valve that selectively channels airflow and
acoustic energy under different pressures into
the oral and nasal cavities. To produce nasal
sounds (m, n, ng), the velopharyngeal valve
channels airflow to the nasal cavity. Similarly,
for the oral sounds (all vowels and remaining
consonants), the valve closes off the nasal cavity and selectively transmits airflow and energy
through the oral cavity. Thus, for normal
speech, one must have rapid and competent
velopharyngeal function in addition to being
able to produce appropriate airflow and adequate pressure. With competent velopharyngeal valving, a pressure column of exhaled air
is shared with the oral cavity, where interrelating tongue, palatine shelves, dentition, and lips
fashion the various sound waves. Combined
intermittently with nasal resonance, these
sound waves characterize human speech.
Abnormal resonance can result from previously described structural, neurogenic, physiologic, or mechanical impairment. When the
normal space relationship or coupling between
the velum and nasopharynx is disturbed, velopharyngeal incompetence results. This produces three common speech characteristics
secondary to increased transmission through
the nasal cavity: hypernasality, nasal emission,
and reduced aspiration and frication. Hyper-

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PLASTIC AND RECONSTRUCTIVE SURGERY,

nasality is secondary to excess nasal resonance

(particularly with vowel production) just as turbulent airflow through the nasal cavity is responsible for nasal emission. On the other
hand, stop plosives and fricatives are secondary
to a leak, which prohibits the accumulation of
sufficient oral pressures.
EVALUATION

OF

VELOPHARYNGEAL ACTIVITY

Two types of evaluation are used to obtain a

thorough assessment of velopharyngeal function: a clinical evaluation and an instrumental
evaluation. An understanding of the various
subjective and objective techniques of each
type of evaluation that are available to assess
velopharyngeal function will enable the practitioner to identify the exact cause and determine the specific management of any velopharyngeal disorder. As no single modality is
adequate for complete appraisal of velopharyngeal function, a variety of techniques should be
used for evaluation. Utilizing different modalities will reveal the presence, size, location, and
contour of an opening between the oral and
nasal cavities during speech and delineate the
nature of the velar and pharyngeal wall movements and interactions. The following is a description of the methods available, with particular focus on the approaches used most often
at our institution in the diagnosis and treatment of velopharyngeal incompetence.
Clinical Assessment of Velopharyngeal Activity

The clinicians eyes and ears are used as the

first and primary diagnostic tools. As the most
valid measure of adequate velopharyngeal
function is sound produced during normal
speech, by simply listening, one can judge
whether further investigation is warranted.
When a patients speech deviates from normal,
a complete clinical evaluation is performed.
After a thorough history is obtained, the clinical examination proceeds with an intraoral examination to assess structural integrity, reflexive behavior, and voluntary phonetic behavior.
The speech production characteristics are then
assessed. Particular focus is paid to resonance
quality, airflow, air pressure, and whether compensatory articulatory productions exist.
Intraoral Examination

The first step in the intraoral examination is

the direct visual assessment of structural integrity. The lips, teeth, tongue, tonsils, hard and
soft palate, uvula, and pharyngeal walls should

December 2003

be carefully inspected. The symmetry of the

velum, tonsils, and nasopharynx is noted. Submucous clefts are revealed through palpation
of a notch in the hard palate, identification of
a zona pellucida in the soft palate, or a bifid
uvula. The presence of an oral nasal fistula
should be sought. A rhinoscopic examination
should be included to check for hypertrophied
turbinates, septal deviation, and nasal
obstruction.
The second step in the intraoral examination is to assess reflexive and voluntary behavior. Reflexive behavior assists in determining
the overall dysarthric status. This assessment is
performed by repetitive stimulation of a gag
reflex at different loci. Delay, fatigue, asymmetry, or lack of response is noted. The presence
or absence of nasal regurgitation during swallowing of liquids should also be determined.
Unlike reflexive behavior, a voluntary behavioral assessment is limited to competent, cooperative patients. Visual intraoral assessment
during sustained phonation of a assists in
determining velar motion (elevation, length,
asymmetry, amplitude, fatigue, and speed).
Speech Production Characteristics

Upon completion of a thorough intraoral

examination, the clinical examination proceeds with an assessment of speech production
characteristics. Four specific characteristics are
assessed: resonance quality, airflow, air pressure, and compensatory articulation. Deviations in the normal movement of a pressurized
airstream through the resonating vocal tract
will cause specific alterations in these four
characteristics. The recognition of these alterations will assist in obtaining the correct
diagnosis.
The first characteristic, resonance quality, is
assessed by checking for the presence of nasal
vibration during vowel production (i, u, and e).
With an incomplete velopharyngeal seal, the
nasal cavity becomes coupled with the oral cavity and the airstream escapes through the open
velopharyngeal port, causing hypernasal resonance. This resonance can be detected clinically by comparing occluded and unoccluded
nares for the presence of a nasal vibration during vowel production.
The presence or absence of nasal emission of
the airstream is the second speech production
characteristic to assess. Nasal emission may be
audible or inaudible. In addition to the noise
that may be produced, the occurrence of nasal

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EVALUATING VELOPHARYNGEAL INCOMPETENCE

flaring assists in identification. Other methods

helpful in diagnosing inaudible nasal emission
include a mirror that fogs when placed under
the nares during vowel production and the
deflection of tissue paper.
The third characteristic is the adequacy of
intraoral air pressure build-up. The average
adult requires 5 to 7 cm of water pressure
build-up in the oral cavity behind the site of
constriction to produce most oral consonants,
particularly plosives (p) and fricatives (f).
When velopharyngeal insufficiency is present,
an inadequate amount of pressure is accrued
in the oral cavity secondary to incomplete closure of the velopharyngeal valve. The phrase
used frequently at our institution to test air
pressure is I pet puppies.
To complete the speech production assessment, the presence or absence of compensatory articulation productions should be sought.
Patients with cleft palate will derive compensatory articulation in a different anatomic area
that will compensate for a poor or absent velopharyngeal valve. Specific types of compensatory articulations used by these patients include glottal stops, pharyngeal fricatives,
pharyngeal stops, velar fricatives, posterior nasal fricatives, and middorsal palatal stops (Table I). In other words, the patient substitutes a
functioning glottis or pharynx or uses the mid
dorsum and the back of the tongue to valve the
airflow. The neurogenic patient, however, will
have compensatory productions occurring at
the same anatomic level but deviating in the
manner of speech production. Thus, glottal
and pharyngeal productions are absent.
Rather, labial substitution is performed for
tongue inadequacy. Regardless of the derivation of compensatory productions, they are all
learned behaviors, which frequently persist
even after adequate surgical or prosthetic
management.
Instrumental Assessment of Velopharyngeal Activity

The subjective yet invaluable information

gathered from the clinical examination should

be used to complement objective structural

data obtained from an instrumental assessment. The goal of the instrumental assessment
is to obtain anatomic data regarding the adequacy of velar length, palatal elevation, velopharyngeal gap, excursion of the lateral and
posterior pharyngeal walls, nasopharyngeal
depth, pattern, and level of attempted closure.
Two subgroups of techniques are used in the
diagnostic process: direct and indirect. Direct
instrumental techniques are those that enable
the investigator to observe activity at the velopharyngeal port. Examples of direct techniques include lateral cephalogram, cineradiography, multiview videofluoroscopy, oralnasal panendoscopy, and magnetic resonance
imaging. Indirect instrumental techniques provide information about vocal tract behavior,
and gathered data are used to make relative
inferences. Phototransduction, electromyography, and movement transduction are a few
examples of indirect instrumental techniques.
Direct Instrumental Techniques

Lateral cephalometric radiography. The lateral

cephalometric radiograph continues to be a
mainstay of the evaluation process at our institution as well as many others. It is the primary
direct method of assessing structures of the
velopharynx and the surrounding tissues. Obtained at a constant magnification factor both at
rest and during a sustained -ee production,
lateral cephalogram views permit visualization
of soft palate elevation and its contact with the
posterior pharyngeal wall. The addition of barium allows for enhanced visualization of the
margins of the velum and pharyngeal wall. Using this technique, we have had a greater than
90 percent rate of accurate prediction of the
need for a pharyngeal flap based solely on this
radiographic study.
Obvious advantages include the ability to assess structural features and velopharyngeal relationships in a simple, reliable, and quantifiable method. The length of a pharyngeal flap is

TABLE I
The Phonetic Alphabet: Consonants

Bilabial

Nasals
Plosives
Fricatives
Sibilants
Affricates

Labiodental

m
p-b (pat-bat)
f-v (fat-vat)

Dentoalveolar

n
t-d (tot-dot)
th-th (thank-than)
s-z (sue-zoo)
ts-dz (cheap-jeep)

Palatoalveolar

Velar

ng (sing)
k-g (coat-goat)
sh-zh (ash-azure)
sh-z (ash-azure)
ts-dz (cheap-jeep)

1894

determined by assessing the relationships provided.34,35 Because the velopharyngeal mechanism is three-dimensional and dynamic, the
disadvantages of a lateral still radiograph are
obvious: it is a two-dimensional study representative of structural features only in the sagittal
plane. Hence, the width of a pharyngeal flap
cannot be determined by this method. Further,
because it is a static study, the events occurring
between the two extremes of movement (between the resting state and the -ee production) are not visualized. Despite its limitations,
it continues to be a vital part of the diagnostic
battery at multidisciplinary cleft palate centers.
Multiview videofluoroscopy. In response to the
limitations of the lateral still radiograph, lateral
view motion picture radiography was introduced to study velopharyngeal function in motion. With advances in technology, this evolved
from cine (motion picture films) to multiview
videofluoroscopy. Multiview videofluoroscopy
has distinct advantages, such as less radiation
exposure (10 times less than cinefluoroscopy),
the ability to record and replay immediately,
assessment of velopharyngeal function in three
planes (sagittal, coronal, and transverse), and a
dynamic view during connected speech from
beginning to end.36 42 The lateral views depict
movements of the velum and posterior pharyngeal walls. The frontal view of the oropharynx
demonstrates gradations of mesial motion of
the lateral pharyngeal walls, which ultimately
determines the width of a proposed pharyngeal
flap. Although its primary limitation is the inability to provide an absolute measurement of
structural relationships, the width of a proposed
pharyngeal flap is easily determined by a relative scale. The degree of lateral pharyngeal wall
motion ranges from zero (no motion during
quiet respiration) to five (maximal motion to
the midline; Fig. 1). This ability to obtain an
accurate preoperative assessment of lateral pharyngeal wall motion appears to be a prime determinant of postoperative success after a pharyngeal flap operation. In addition to being
excellent in depicting necessary information on
velopharyngeal function and dictating surgical
management, compared with other techniques,
it has the least variability and is most reflective
of actual speech pattern.
Nasopharyngoscopy. The limitations of nasopharyngoscopy are similar to those of videofluoroscopy. The information obtained to assess gap size is in the form of a ratio than an
absolute number. Although nasopharyngos-

PLASTIC AND RECONSTRUCTIVE SURGERY,

December 2003

FIG. 1. Diagrammatic frontal view of the oropharynx

demonstrates gradations of mesial motion of the lateral pharyngeal walls. Zero represents no motion during quiet respiration, and 5 depicts maximal motion of each lateral pharyngeal wall to the midline. Reprinted from Johns, D. F.,
Cannito, M. P., Rohrich, R. J., and Tebbetts, J. B. The selflined superiorly based pull-through velopharyngoplasty: Plastic surgery-speech pathology interaction in the management
of velopharyngeal insufficiency. Plast. Reconstr. Surg. 94: 436,
1994.

copy provides a substantial amount of information through visualization of the velum and
pharyngeal walls, it is difficult to obtain standardized views or infer relative dimensions.
Other limitations include the inability to identify small velopharyngeal gaps or pinpoint the
exact anatomical location of the gap. Patient
cooperation becomes a critical factor that further limits the use of nasopharyngoscopy in the
pediatric population unless the patient is anesthetized. DAntonio et al.43,44 have described the
criteria, indications, and impact of nasal endoscopy on tailoring pharyngeal flaps, flap revisions, and the fitting of palatal prostheses. Similarly, Pigott finds the 70-degree endoscope to
be indispensable and complementary to multiview videofluoroscopy in the evaluation of the
velopharyngeal sphincter.45,46
Magnetic resonance imaging. Magnetic resonance imaging uses the resonant absorption and
remission of radio waves by hydrogen nuclei to

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EVALUATING VELOPHARYNGEAL INCOMPETENCE

obtain images. It has a number of advantages over

the methodologies currently used to study the
vocal tract and velopharyngeal mechanism.47,48
Magnetic resonance imaging technology allows
noninvasive visualization of the vocal tract without
exposure to radiation or any known biohazards
and provides better soft-tissue resolution. Functional images at any chosen level can be obtained
in the sagittal, frontal, and transaxial views without changing the position of the patient. The
current limitations of this method for imaging
include the potential distortion of the velopharyngeal mechanism by gravitational forces in the
supine position, the need for patient cooperation,
and cost. It is hoped that further technological
developments will result in nearreal-time functional imaging that will soon reach its full potential and provide unique full-range vocal tract configuration data.
Indirect Instrumental Techniques

Indirect techniques used to study the velopharyngeal mechanism are those that provide
inferences through data about the structure
and kinematics of the velopharyngeal mechanism. Examples include phototransduction,
electromyography, and movement transduction. Other types of indirect measures study
the effects of velopharyngeal function on other
physiologic parameters. Aerodynamics, acoustics, sound pressure, and spectrography fall under this category. Although indirect measures
provide objective information, they do not necessarily dictate the decision-making process.
Phototransduction. Photoelectric technology
uses light transmission to obtain relative information on the velopharyngeal port. A fiberoptic
device couples a light source to an electronic
detector. The two fibers are introduced
through the nasal cavity until the light source is
below the velopharyngeal port and the detector
fiber is above the velopharyngeal port. Quantifiable data are produced that provide information regarding the opening and closing
movements of the velopharyngeal port.
Electromyography. Electromyography studies
the electrical activity produced by muscle contraction using hooked wire electrodes. The limitations of electromyography are intuitive, such
as discomfort from placement of needle electrodes, small and malpositioned muscles in cleft
patients, and multiple passive and active forces
acting on the velopharynx.
Movement transduction. Movement transduction combines the use of mechanical and elec-

trical devices to transduce velopharyngeal

movement. The second maxillary molar acts as
an anchor, with placement of a bar/spring attachment along the oral midline. With velar
motion, the spring sensor converts motion into
an electrical output along the strain gauge resistor. Although this technique is not currently
used as an evaluation tool, it has been helpful
as a biofeedback device.
Aerodynamics. The study of pressure and
flow provides significant information that allows a distinction to be made between velopharyngeal insufficiency and dysfunction secondary to other anatomic valve abnormalities. In
addition, it helps determine the presence and
magnitude of velopharyngeal incompetence
and obstruction (nasal or pharyngeal). Specific
information details the relative contributions of
velopharyngeal components and nasal components to total airway resistance. In a complex
case, this technique may be useful before surgical intervention to isolate and determine various contributions to insufficiency. Similarly, it
is helpful after surgical intervention to determine whether a pharyngeal flap is the cause of
a patients difficulty with nasal respiration.
Acoustics. Quantitative changes in nasal resonance that occur with different degrees of coupling (the nasal and oral cavities) provide information about the presence and degree of
velopharyngeal incompetence. In these patients, excessive acoustic energy in the nasal
cavity is observed during reading from passages
with oral sounds. In children with velopharyngeal obstruction, lack of acoustic energy in the
nasal cavity is observed during reading from
passages containing many nasal sounds. In addition to deciphering the location and degree
of abnormal resonance, the information is provided instantaneously. Therefore, the acoustic
assessment is a helpful method used for
biofeedback during treatment sessions. Further, acoustic analyses with a sound spectrograph will identify subtle changes in the acoustic signal and can be used to monitor speech
characteristics objectively. These acoustic findings should validate the more subjective perceptual ratings.
DISCUSSION

The multidisciplinary cleft palate team is indispensable in coordinating evaluation, diagnosis, and management of velopharyngeal insufficiency, as is the speech pathologist. The
focus of this article is to present basic and

1896

PLASTIC AND RECONSTRUCTIVE SURGERY,

helpful techniques to improve the capabilities

of any member of the cleft palate team in
identifying preoperative or postoperative velopharyngeal incompetence. Through improvements in preoperative diagnostic techniques,
improvements in outcomes are sure to follow.
Similarly, the ability to critique a speech outcome after surgical intervention and to identify
factors in patients with poor outcomes that
may be avoided or modified in the future will
lead to an improvement in outcomes. A thorough understanding of the mechanism of velopharyngeal function and the instrumental
techniques used for evaluation may inspire
new treatment modalities or improve those
that currently exist. It is hoped that the multidisciplinary team will use the thorough clinical
assessment and data obtained from instrumental techniques discussed in this article to determine the most appropriate intervention for a
given patient. Clearly, without an armamentarium of several surgical techniques, the surgeon
will be limited to applying a single treatment
modality to a problem with varied physiological
and structural causes.
Rod J. Rohrich, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard, E7.212
Dallas, Texas 75390-9132
rod.rohrich@utsouthwestern.edu
ACKNOWLEDGMENT
This is the last paper written by Dr. Donnell F. Johns before
his untimely death. He left it on his desk, almost completed.
The last time I spoke with him, he reminded me that he
needed to finish it. His dedication to the correction of neurogenic velopharyngeal insufficiency, particularly in underprivileged children, demonstrated his humanity. His dedication exemplified who he was as an individual. He was a
tremendous asset to us and to our profession. We miss him.
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Self-Assessment Examination follows on

the next page.

Self Assessment Examination

Velopharyngeal Incompetence: A Guide for Clinical Evaluation
by 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 palate
B) Short or immobile palate following primary cleft repair
C) Mechanical obstruction
D) Neurologic deficit
E) Palatal fistula
2. DURING VELOPHARYNGEAL CLOSURE, MOVEMENT OF SOFT PALATE IS PRINCIPALLY DUE TO ACTION
OF WHICH MUSCLE?
A) Tensor veli palatini
B) Levator veli palatini
C) Pharyngopalatinus
D) Palatoglossus
E) Superior constrictor
3. SINCE THE ENTIRE VOCAL TRACT IS A RESONATING CAVITY, NORMAL SPEECH PRODUCTION REQUIRES
THE VELOPHARYNGEAL PORT COUPLING AND UNCOUPLING OF THE NASAL AND ORAL CAVITIES.
A) True
B) False
4. SURGICAL CORRECTION OF VELOPHARYNGEAL INCOMPETENCE WILL IMPROVE EACH OF THE
FOLLOWING EXCEPT:
A) Resonance quality
B) Nasal airflow
C) Intraoral air pressure
D) Articulation errors
E) Nasal regurgitation
5. ACCORDING TO THE AUTHORS, THE BEST METHOD TO ASSESS SOFT-PALATE ELEVATION AND
CONTACT WITH THE POSTERIOR PHARYNGEAL WALL IS:
A) Lateral cephalometric radiography
B) Magnetic resonance imaging
C) Multiview videofluoroscopy
D) Nasopharyngoscopy
E) Aerodynamics
6. ACCORDING TO THE AUTHORS, THE DEGREE OF LATERAL WALL MOTION USED TO DETERMINE THE
WIDTH OF A PLANNED PHARYNGEAL FLAP IS BEST DETERMINED USING:
A) Lateral cephalometric radiography
B) Magnetic resonance imaging
C) Multiview videofluoroscopy
D) Nasopharyngoscopy
E) Movement transduction

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