A Qualitative Exploration of Current Approaches to Evaluation and Treatment Decision-Making for Velopharyngeal Insufficiency Following Cleft Palate Repair

ObjectiveTo explore current approaches to evaluation and treatment decision-making for velopharyngeal insufficiency (VPI) following cleft palate repair.DesignCross-sectional, qualitative study.Setting/participantsParticipants included 28 surgeons and 17 speech-language pathologists (SLPs) from 12 cleft teams in the United States and Canada.InterventionsSemi-structured, qualitative interviews were conducted exploring participants' current approaches to VPI evaluation and treatment decision-making. Data were analyzed using thematic analysis.ResultsParticipants viewed VPI evaluation as a joint effort of surgeons and SLPs. SLPs were entrusted to conduct formal speech evaluations. All teams completed a perceptual evaluation of speech resonance that included spontaneous speech and phrase repetition. Teams varied in their use of patient questionnaires and nasometry. Most teams performed nasoendoscopy as part of their evaluation, although providers noted limited cooperation in younger children and those with developmental delay. Treatment decision-making occurred either as a joint effort between the evaluating surgeon and SLP or exclusively by the surgeon. Most surgeons employed a personalized approach to treatment decision-making, with 19 distinct approaches described. Elements frequently considered in surgical procedure selection included velopharyngeal gap size and closure pattern as seen on nasoendoscopy. Providers were satisfied with their current approach, although most identified opportunities for improvement.ConclusionsCleft teams have individualized approaches to VPI evaluation and treatment decision-making, with the only common element being completion of a perceptual speech evaluation by an SLP. These findings suggest that efforts to implement new approaches will need to be customized to each team's current process.