الفهرس 
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Abstract
Velopharyngeal closure refers to the normal opposition of the soft palate, or velum, with the posterior and lateral pharyngeal walls. It is primarily a sphincteric mechanism consisting of a velar component and a pharyngeal component. Velopharyngeal insufficiency represents an inadequate closure of the VPV due to anatomical or structural abnormalities. It can develop secondary to surgical intervention, congenital malformations, or trauma. The most common congenital causes of VPI include cleft palate and velopharyngeal disproportion. Surgical procedures such as palatoplasty, tumor resection, and adenotonsillectomy can also result in velopharyngeal insufficiency.
The aim of this study is to evaluate the efficiency of a new operation (mere myomucosal resection and direct closure of the posterior pharyngeal wall) in patients with velopharyngeal insufficiency (VPI) and or incompetence The current study is a prospective one that had been conducted on patients had velopharyngeal insufficiency. selected 30 children came to the Phoniatrics unit Minia university hospital, complaining from symptoms of open nasality and /or nasal regurge of fluids and solids and well diagnosed as having velopharyngeal insufficiency (24 cases) and or incompetence (6 cases) .They were admitted in the plastic surgery department for surgical correction by mere myomucosal resection and direct closure of posterior pharyngeal wall.They were 13 males (43.3 %) and 17 females (56.7%), their age ranged between (3&10) years and mean age was 6.5years.
Methods:-
A-First step
All the 30 children were subjected to the following protocol of assessment preoperatively in the Phoniatric unit, Minia university hospital
1-Auditory perceptual assessment (APA) of speech: The speech of each case were assessed by expert phoniatricians. The evaluation included type and degree of open nasality, consonant precision, the compensatory articulatory mechanisms (glottal articulation and pharyngealization of fricatives), facial grimace, audible nasal air escape and overall intelligibility of speech. All these elements were graded along a 5-point scale in which (0 normal, 1 slight, 2 mild, 3 moderate, 4 severe). (Kotby et al, 1997).
2- (ENT) Examination: The lips, teeth, tongue, hard and soft palate, uvula, tonsillar pillars, tonsils, lateral and posterior pharyngeal walls were examined with a tongue blade and a good light.
3- Video nasoendoscopic assessment::
This was done using nasopharyngeal video-fibroscopy Henke-Sass-Wolf, type 10, connected to a Lemke video camera (mc 204) and Panasonic video cassette recorder 357. The nasofibroscope was introduced through the nasal cavity to a position superior to the soft palate for evaluation of the velopharyngeal area (velar mobility, lateral pharyngeal wall mobility, presence of adenoid , type of VP port closure , presence or absence of passavent’s ridge) and width of velopharyngeal port . The velopharyngeal valve movement was recorded and graded from grade 0 to grade 4 while the patient was repeating the speech samples that have been recommended by an International Working group (Golding-Kushner, 1990; Abde Elfatah et al., 2014; El-Anwar et al., 2016) as follows:
Movement of the velum, lateral and posterior pharyngeal wall are traced on monitior, the movement of each component is given score from 0to 4 as follow : 0 is the resting (breathing) position or no movement; 2 is half the distance to the corresponding wall; 4 is the maximum movement reaching and touching the opposite wall.
4- Assessment of nasal tone of speech:
The nasalance (acoustic correlates of nasality) was determined by using Kay nasometer model 6200-2 with a software version 1.5. Every patient was asked to repeat (with a normal conversational loudness, while sitting comfortably on a chair) (mama betnajem manal) as a nasal loaded sentence and (ali rah jelab korah) as an oral sentence devoid of nasal sounds The main nasalance score of each of the sentences was automatically calculated. The main nasalance score is the percentage of nasal acoustic energy of the total energy (nasal plus oral; Abou-Elsaad et al., 2012; Kummer et al., 2014). El-Anwar et al., 2016).
B. The second step included:
(operative details of MAHROUS(the surgical author) technique for surgical correction of velopharyngeal insufficiency)
ANAESTHESIA:
General endotracheal anesthesia with an orotracheal tube pluged inside a channel made inside the dingman retractor.
Patient position : Supine with the head hyperextended, the shoulder supported by a pillow and the head supported by a ring.
TECHNIQUE
1- Access midline palatotomy done if the patient had submucous cleft, soft palatal fistula or if the soft palate is long and hindered the view of the velopharyngeal port otherwise, the soft palate was retracted posteriorly to have access to the velopharyngeal port.
2- The two lateral soft palatal flaps were retracted by vicryl sutures hanged over the transverse arm of the dingman retractor
3- The surface area of the myomucosal part to be resected from the posterior wall of the velopharyngeal port was judjed preoperatively from the videonasoendoscopy proportionate to the width of the gap (marked by methylene blue).
4- The posterior pharyngeal mucosa was palpated to exclude velocardiofacial syndrome
5- Submucosal injection of 1/100000 adrenaline.
6- The planed myomucosal area was resected down to the prevertebral fascia (like the pharyngeal flap but the margins were completely excised).
7- The cut ends of the superior constrictor muscles in the posterior pharyngeal wall were approximated.
8- The cut ends of the mucosa were undermined and sutured.
9- The sutures used for retraction was removed and the soft palate was closed in layers (nasal mucosa, muscles and oral mucosa). Either the submucous cleft or the soft palatal fistula were closed during closure.
C- The third step included:
I- postoperative follow up of the patients in the plastic surgery department for the surgical care to deal with any possible complications.
II- All the patients in the study group have received speech therapy sessions three weeks after surgery, 3 times per week (30 min. / session) for 6 months regularly in our phonatric unit . The aim of speech therapy was to establish appropriate placement for each speech sound and establish normal oral air pressure and airflow
III- Follow up of the patients postoperatively, 3 months and 6 months after the surgical repair of VPI by
5. APA of speech.
6. ENT examination
7. nasopharyngeal video-fibroscopy
8. Kay nasometer model 6200-2
Results: thirty patients were included in this study. Statistical analysis of the results documented a significant reduction in the degree of open nasality, glottal articulation and pharyngalization of fricatives following myomucosal resection and direct closure of the posterior pharyngeal wall . A significant improvement of the overall intelligibility of speech and audible nasal air emission postoperatively was delineated regardless of the pattern of velopharyngeal closure. Postoperatively, significant reduction in the velopharyngeal gap dimenstions in the majority of patients as detected by flexible fiberoptic nasopharyngeal endoscope.