It is interesting to note that 256 patients (59 %) were referred by speech-language pathologists (Table 40.3), indicating that velopharyngeal incompetency is not recognized at an early age and that the diagnosis is frequently made when the patient starts school. The number of physician referrals was 96 (22 %). The remaining referrals (19 %) came from rehabilitation counselors, dentists, rehabilitation centers, and families.

Please note that 104 patients (25 %) had had their tonsils and adenoids removed in order to eliminate or remedy the velopharyngeal incompetency (Table 40.4). This, of course, causes an increase in hypernasality for the VPI patient.

In addition to oral examination, nasal endoscopy, and individual judgment, all patients had two cephalometric radiographs taken, one with the soft palate at rest and the second during prolonged phonation of the vowel “E.” Twenty-five percent of the subjects had cineradiographic ­studies of the velopharyngeal region to observe continuous phonation.

According to nasal endoscopic evaluation, radiographic analysis, and listener judgments, 126 (29 %) of the patients demonstrated inconsistent or borderline velopharyngeal dysfunction (Table 40.5). The team decided that each subject was to be referred to a speech-language pathologist with instructions to have a review by the team in 1 year if the condition persisted. Further evaluation of these patients after 1 year revealed that the hypernasality or nasal emission had subsided, and none required further treatment.

It was recommended that 177 patients (41 %) have pharyngeal flap surgery. In 122 patients (mean age, 10 years), the surgical procedure consisted of a superiorly based flap performed by our staff plastic surgeon. The remaining 55 subjects were referred to the plastic surgeon of their choice for a pharyngeal flap with instructions to return to the clinic after insertion of the flap for further evaluation.