الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
V
elopharyngeal insufficiency (VPI) is the inability to completely close the velopharyngeal port during speech and the resultant air leakage from the nasal cavity can lead to hypernasal vocal resonance a common condition that can result in altered speech patterns also VPI can have a significant functional impact on breathing, eating,, especially in patients with cleft palate. Surgical treatment is the most important approach to restore the functional seal between the nasopharynx and the oropharynx. Pharyngeal flap and sphincter pharyngoplasty are the two most common surgical techniques used to correct VPI. The findings of this study could contribute to the development of guidelines for the management of VPI and help improve the quality of life for patients with this condition (Rashed et al., 2014).
Velopharyngeal closure is attained by movement of the velum toward the closing pharyngeal walls to close the lumen of the velopharynx. Velopharyngeal insufficiency (VPI) is the inability to completely close the velopharyngeal port during speech, the resultant air leakage from the nasal cavity can lead to hypernasal vocal resonance (Visser et al., 2012).
Velopharyngeal insufficiency has many causes, including congenital anomalies, abnormalities of the lymphoid tissue (tonsils and adenoids), and acquired defects. The commonest cause of VPI is a history of an overt or submucous cleft palate. In addition, 20e30% of children with cleft palate either with, or without cleft lip, will experience VPI after their palatal repair due to inadequate velar length, Palatal fistulas, neuromuscular dysfunction and genetic anomalies such as velocardiofacial syndrome (Hodgins et al., 2014).
Etiologies of velopharyngeal insufficiency include cleft palate, trauma, and sequelae after surgery. Velopharyngeal insufficiency is characterized by altered speech patterns (eg, hypernasal resonance, increased nasal emission) which lead to impaired speech development, especially in cleft palate patients. Untreated, VPI can have a significant functional impact on breathing, eating, and speech. Speech in VPI is characterized by decreased intraoral pressure for pressure consonants (Dailey et al., 2016).
The best diagnostic approach for the analysis of the velopharyngeal sphincter is the combination of videonasopharyngoscopy (VNP) and multi-view videofluoroscopy (MMVF) also Diagnosis can be made clinically¬ (Johns et al., 2013).
Management of velopharyngeal dysfunction is dependent on specific cause and subsequent customization of treatment to optimize speech outcomes. Treatment may be nonsurgical (speech therapy or prosthetic devices), surgical, or a combination of the two (Reisberg et al., 2015).
Treatment Prosthetic options may be used as a temporary or permanent solution for nonsurgical candidates.There are several surgical techniques used to treat VPI, and the two most common methods are pharyngeal flap and sphincter pharyngoplasty. Velopharyngeal closure is attained by movement of the velum toward the closing pharyngeal walls to close the lumen of the velopharynx (Grames et al., 2015).
Selected papers for the present meta-analysis included those that provided data from January 2010 to January 2022 on comparison for better surgical technique in treatment of velopharyngeal insufficiency for cleft palate patients, either pharyngeal flaps or sphincter pharyngoplasty. When institutions have published duplicate trials, only the most updated reports were included for qualitative appraisal. All publications as randomized controlled trials, cohort and case- control series, and reviews were limited to patient subjects ranged 2–5 years old and English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded.
Meta-analyses of relevant studies showed that patients underwent sphincter pharyngoplasty have significant double risk ratio than who underwent pharyngeal flap in treatment of velopharyngeal insufficiency in cleft palate 2–5 years old patients [Risk ratio (RR) = 2.092, 95% CI (1.266–3.457), p-value=0.004] Figure (22). Fixed model was used due to absence of heterogeneity with I^2=19.69 and P-value=0.291.
We underwent this systematic review and meta-analysis to detect which of the two is a most common surgical procedures for the resolution of velopharyngeal insufficiency is more efficacious: pharyngeal flap or sphincter pharyngoplasty. After a systematic literature review, we proceeded by articles exclusion according to our criteria, with the removal of potentially duplicated results, the data from four articles -259 patients (Abyholm et al., 2004; Abdel-Aziz et al., 2011; Luo et al., 2020; Ysunza et al., 2004) comparing these two procedures were pooled and analyzed. The analysis was performed using a fixed effect model because of data homogeneity, even small number of studies were used.
Conclusion
O
ur conclusion is that the pharyngeal flap procedure had statistically significant efficacy than the sphincter pharyngoplasty procedure in the resolution of velopharyngeal insufficiency in patients with cleft palate. As well, hyper nasality and resonance decreased more statistically significantly in the group of a pharyngeal flap than in sphincter pharyngoplasty. Nasal obstruction was found to be less in the pharyngeal flap procedure than in sphincter pharyngoplasty but with no significant result. Snoring incidence was found to be less in the sphincter pharyngoplasty procedure than pharyngeal flap, but with no significant result. Nasal emission and consonant accuracy were found with low rates in pharyngeal flap procedures in treating velopharyngeal insufficiency (12% and 13.6%).
Recommendations
Pharyngeal flaps is a more adequate technique for treating velopharyngeal insufficiency after repair of cleft palate than sphincter pharyngoplasty, with no postoperative complications.
To select surgical method on an individual basis for sphincter pharyngoplasty as for its cost reduction then pharyngeal flap.Even the pharyngeal flap was found to be a better procedure in velopharyngeal insufficiency treatment in patients with cleft palate.
As there is currently a lack of further high-level evidence to reinforce the declarations that one of these surgical techniques is foremost to the other, additional randomized controlled trials with longer follow-ups are required to raise the evidence base on velopharyngeal insufficiency treatment.