Pharyngoplasty in patients with cleft lip and palate after maxillary advancement

The development of velopharyngeal incompetence and increased hypernasality after maxillary advancement has been described previously by several authors. If speech and velopharyngeal function deteriorate after maxillary advancement, pharyngoplasty is frequently the treatment procedure of choice because of the natural cause of the deficit. Of 91 cleft lip and palate patients who have undergone maxillary advancement at the Australian Cranio-Facial Unit, 23 patients received a pharyngoplasty after surgery. Thirteen of these patients who had pre- and postoperative speech evaluations were included in this study. Of the 13 patients, six patients received a superiorly based pharyngeal flap, two patients underwent an orticocheal pharyngoplasty, and five patients received either a revision or augmentation of the previous flap based on results of preoperative examinations. Serial nasendoscopic evaluations were available for 11 of these 13 patients, and they demonstrated that velopharyngeal function improved after pharyngoplasty in six patients and was unchanged in five patients. Of the 13 patients, 10 improved and three patients were unchanged on an intelligibility rating. Nine of the 13 patients demonstrated decreased hypernasality and four patients were unchanged. Hyponasality decreased in two patients increased in one patient, and was unchanged in one patient. Because the results obtained are considered acceptable, the authors conclude that pharyngoplasty can be used effectively to treat velopharyngeal dysfunction subsequent to Le Fort I maxillary advancement.     

Limited value of preoperative cervical vascular imaging in patients with velocardiofacial syndrome

The purpose of this two-part study was to evaluate the safety of surgical management of speech production disorders in patients with velocardiofacial syndrome without preoperative cervical vascular imaging studies. Anomalous internal carotid arteries have been shown to be a frequent feature of velocardiofacial syndrome. These vessels pose a potential risk for hemorrhage during velopharyngeal narrowing procedures. Magnetic resonance angiography, and other forms of cervical vascular imaging studies such as computerized tomography, have been advocated as aids to surgery by defining the preoperative vascular anatomy. However, it remains unclear whether these studies alter either the conduct or outcome of operations on the velopharynx. In the first part of this study, we reviewed the charts and videonasendoscopic evaluations of 39 consecutive patients with confirmed or suspected velocardiofacial syndrome who underwent sphincter pharyngoplasty or pharyngeal flap from 1978 to 1996. The charts were reviewed to determine (1) the frequency of identification of abnormal pharyngeal pulsations; (2) whether such pulsations affected the conduct of the operative procedure; and (3) whether the presence of pulsations affected surgical morbidity and/or surgical outcome. None of the patients underwent any type of cervical vascular imaging study. In the second part of this study, we surveyed plastic surgeons with numerous years of experience participating on cleft-craniofacial teams, to ascertain practice patterns relating to the management of patients with velocardiofacial syndrome. The questions related specifically to the surgeons' behavior in relation to angiography and their awareness of any cases of surgical morbidity related to the cervical vascular system in patients with velocardiofacial syndrome. We were interested in discerning both how commonly this situation arises clinically and the distribution of the various types of operative procedures in common use. Of our 39 patients, 10 patients (26 percent) had detectable pulsations on preoperative nasendoscopy. Of these, five patients underwent sphincter pharyngoplasty and five underwent pharyngeal flap procedures. Preoperative instrumental and intraoperative clinical assessment of pulsatile vessels allowed velopharyngeal reconstruction in all patients without surgical morbidity. Results of the questionnaire indicated that most cleft surgeons do not routinely order cervical vascular imaging studies for all of their patients with velocardiofacial syndrome. About half of the respondents indicated that their operative approach was influenced by information obtained from angiographic studies. None of the surgeons queried were aware of any cases of surgical morbidity related to the cervical vascular system in patients with velocardiofacial syndrome. Nearly 50 percent of surgeons use pharyngeal flap procedures most frequently, whereas 22 percent of surgeons use sphincter pharyngoplasty most frequently. Results of this study support the safety of sphincter pharyngoplasty or pharyngeal flap procedures in patients with velocardiofacial syndrome without preparatory angiography. These procedures can be performed safely, even in patients having aberrant velopharyngeal pulsations. Given the market cost of magnetic resonance angiography ($1600), one must question the cost-efficacy of magnetic resonance angiography for routine use in the velocardiofacial syndrome population.     

Sequence analysis of a 33.2 kb segment from the left arm of yeast chromosome XV reveals eight known genes and ten new open reading frames including homologues of ABC transporters, inositol phosphatases and human expressed sequence tags

This retrospective study was undertaken to determine the revision rate for dynamic sphincter pharyngoplasty (DSP) at the University of Michigan Medical Center to analyze the determinants contributing to the need for revision pharyngoplasties, and ultimately to improve primary pharyngoplasty to avoid the need for revision. The records of 30 children with repaired palatal clefts who presented with velopharyngeal insufficiency and hypernasal speech, and who underwent DSP from January 1988 through July 1994 were reviewed. Clinical follow-up ranged from 6 to 48 months (mean, 20.2 months). Seven of the original 30 patients (23%) had persistent, moderate-to-severe hypernasality that required reoperation, while 1 patient (3%) demonstrated hyponasality requiring revision. Seven of 8 patients who underwent revision pharyngoplasty had acceptable speech after revision. Dehiscences, low-lying pharyngoplasty flaps, and end-to-end suturing of the flaps were the main determinants resulting in the need for revision. In our study, female gender and older age was associated with a higher success of primary operation.     

Complete eradication of Aspergillus fumigatus from the lung in an immunocompromised patient by oral itraconazole

Fifty-three deaf subjects with a history of prelingual profound bilateral sensorineural hearing loss, similar language habilitation with hearing aids, and normal velopharyngeal structures underwent a study protocol including speech evaluation, behavioral pure-tone audiometry, videonasopharyngoscopy, multiview videofluoroscopy, and electromyography of the velopharyngeal muscles. Subjects were divided into two groups: the first group included 13 subjects with normal nasal resonance or mild hypernasality (four normals and nine with mild hypernasality); the second group had subjects with severe hypernasality and severe articulation deficits. Pure-tone thresholds, velopharyngeal closure patterns, and electromyographic activity of velopharyngeal muscles were similar for both groups of subjects. However, in subjects with severe hypernasality, despite normal muscle activity as observed by electromyography, velopharyngeal valving activity lacked rhythm and strength during speech. It is concluded that deaf subjects may present a functional disorder of the velopharyngeal sphincter related to absence of auditory regulation during phonation. Visual biofeedback using videonasopharyngoscopy may be useful for treating this disorder.     

Simultaneous evaluation of articulatory velopharyngeal function under different dynamic conditions with EMA and videoendoscopy

Objective examination of velopharyngeal (VP) sphincter function has been described based on multiple methods. Videofluoroscopy and videoendoscopy represent today's clinical standard. A new concept of analysis of VP functioning is described using electromagnetic articulography (EMA) for midsagittal measurement of velar movement and videoendoscopy in a setting for simultaneous recording. Multidimensional analysis of VP functions using this setting is demonstrated for a normal subject. Timing aspects of VP closure and a transverse-sagittal ratio of VP port diameter are reported under different conditions of speech dynamics.     

Robin sequence: obstructive sleep apnea following pharyngeal flap

OBJECTIVE: We reviewed 24 children with Robin sequence who underwent cleft palate repair. METHOD: All patients were 5 years of age or older at the time of review, allowing for accurate assessment of speech in relation to velopharyngeal function. All infants had palatal closure between 9 and 14 months of age, either V-Y repair (n = 16) or von Langenbeck repair (n = 8). RESULTS: Only 1 of 16 children who had V-Y repair had borderline velopharyngeal dysfunction (VPD). For reasons that are unclear, in the von Langenbeck repair group, six of eight children had VPD, and four of six underwent pharyngeal flap. Three additional patients with nonsyndromic Robin sequence had palatoplasty and subsequent pharyngeal flap. Six of the combined total of seven children with nonsyndromic Robin sequence developed obstructive sleep apnea and require flap take-down. CONCLUSION: Since conventional pharyngeal flap for VPD in nonsyndromic Robin sequence children resulted in a high incidence of obstructive sleep apnea, alternative management should be considered: modification of the standard pharyngeal flap, palatal lengthening (V-Y or double-opposing Z-plasty), or construction of a speech bulb.     

Relationship between velopharyngeal dimensions and palatal EMG during progressive hypercapnia

To examine the contribution of specific palatal muscles to velopharyngeal dimensions, we recorded electromyographic (EMG) activity in the levator veli palatini, the tensor veli palatini, and the palatoglossus while examining the velopharynx (VP) with videoendoscopy in eight awake normal adults. Simultaneous display of VP images and airflow provided precise timing of events. Video images and EMG signals were recorded during progressive hypercapnia. Every tenth breath was analyzed. For each selected breath, VP area, anteroposterior and lateral diameters, and EMG activity were determined at five points: beginning, middle, and end of inspiration and middle and end of expiration. VP measurements changed significantly during the respiratory cycle. Although maximum area was measured at end inspiration or middle expiration and minimum area at the beginning or end of the breath, respiratory-related changes in VP measurements and EMG activity were characterized by substantial inter- and intrasubject variability. This variability is similar to velopharyngeal behavior during nonrespiratory tasks and suggests that upper airway patency is determined by multiple factors.     

Excess mortality and its relation to hypertension and proteinuria in diabetic patients. The world health organization multinational study of vascular disease in diabetes

The speech problem in patients born with cleft lip and palate is mainly due to the insufficiency of the velopharyngeal (VP) valving mechanism, manifested as in visually seen nasal emission, and auditorily perceived hypernasality and articulation disorders. Evaluations of resonance and VP function can be conducted by: (1) perceptual rating scale based on speech pathologist's subjective judgement and (2) objective instrumental assessment, by the use of specific instrument. Nasopharyngoscopy has been commonly used clinically to diagnose VP function. The purpose of this study is: using nasopharyngoscopy to investigate the differences in VP mechanism between those with VP competence and VP incompetence in the dimension of velar displacement, lateral pharyngeal wall (LPW) displacement, degree of VP closure and pattern of VP closure. Ninty-eight subjects were studied from June 1990 to August 1991. They were divided into 4 groups: (1) group 1: normals with normal speech; (2) group 2: cleft of lip only, with normal speech; (3) group 3: cleft palate without nasal emission, but normal articulation; (4) group 4: cleft palate with nasal emission, with or without articulation error. Age range was from 6-47 years old with equal sex distribution. Ten Chinese sentences were used for standard test sentences, and were grouped according to Mandarin phonological distinctive features into 5 categories: (1) nasals; (2) vowels; (3) plosives; (4) fricatives/affricates; (5) connected number counting. The result indicates that the insufficient velar displacement to contact posterior pharyngeal wall is a determining factor causing velopharyngeal insufficiency in group 4; however, the lateral pharyngeal wall movement is not significantly different among 4 groups. Coronal pattern of velopharyngeal closure is the most common pattern among 4 groups of speakers.     

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery—an audit of 148 children born between 1985 and 1997

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications.Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed.We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery.Outcome of surgery was determined by a ‘Cleft Audit Protocol for Speech’ (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality.Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.     

Generalizability of the limits of stability test in the evaluation of dynamic balance among older adults

OBJECTIVE: Reliability of platform posturography tests is essential for the identification and treatment of balance-related disorders. The purposes of this study were to establish the reliability of the limits of stability (LOS) test and to determine the relative variance contributions from identified sources of measurement error. DESIGN: Generalizability theory was used to calculate (1) variance estimates and percentage of variation for the sources of measurement error, and (2) generalizability coefficients. Random effects repeated measures analysis of variance (RM ANOVA) was used to assess consistency of measurements across both days and targets. PARTICIPANTS: Thirty-eight community-dwelling older adults with no recent history of falls. MAIN OUTCOME MEASURES: Outcome measures derived from the LOS tests included movement velocity (MV), maximum center of gravity (COG) excursion (ME), end point COG excursion (EE), and directional control (DC). RESULTS: Estimated generalizability coefficients for 2 and 3 days of testing ranged from .69 to .91. Relative contributions of the day facet were minimal. The RM ANOVA results indicated that for three of the movement variables, no significant differences in scores were observed across days. CONCLUSIONS: The 75% and 100% LOS tests are reliable tests of dynamic balance when administered to healthy older adults with no recent history of falls. Dynamic balance measures were generally consistent across multiple evaluations.     

Anatomic basis of cleft palate and velopharyngeal surgery: implications from a fresh cadaveric study

The aim of this investigation was to examine the blood supply of the normal velopharyngeal musculature and its clinical implications. Detailed dissections were performed on each side of five fresh human adult cadaveric head and neck specimens (n = 10) following carotid artery injection with liquid neoprene latex stained with green pigment. The vascular network of the soft palate was situated within its glandular layer. The velopharyngeal muscles were supplied by the following four branches of the external carotid artery: (1) ascending palatine branch of the facial artery, which supplied the palatoglossus, palatopharyngeus, musculus uvulae, and the intravelar part of the levator veli palatini; (2) ascending pharyngeal artery, which supplied the superior constrictor; (3) the previously undescribed recurrent pharyngeal artery, which supplied the extravelar part of the levator veli palatini; and (4) maxillary artery, which supplied the tensor veli palatini. All muscles except the musculus uvulae had at least a dual blood supply. Analysis of this vascular anatomy suggests that (1) the overall generous blood supply of the velum allows it to tolerate the dissection performed during intravelar veloplasty and the Furlow double opposing Z-plasty; (2) dissection around the hamulus, along the medial pterygoid plate, and in the space of Ernst should be performed carefully to avoid damage to the ascending palatine artery, ascending pharyngeal, and recurrent pharyngeal arteries; (3) vertical pharyngeal flaps are random pattern in nature; and (4) the posterior tonsilar pillar flaps of the sphincter pharyngoplasty are adequately supplied by the hamular branch of the ascending palatine artery.     

Comparison of CapiFlow and frame by frame analysis for the assessment of capillary red blood cell velocity

The aim of this study was to describe the aerodynamics related to velopharyngeal function during speech in bilabial, dental, and velar articulatory positions in Swedish speakers. Repeated syllables including voiceless stop consonants and sentences including combinations of voiceless stops and nasal consonants were uttered by 11 normal adults. Oropharyngeal pressure was assessed with a miniature pressure transducer positioned transnasally, in combination with measurement of nasal pressure and nasal airflow. The corresponding velopharyngeal opening area was estimated. The results suggest that the velopharyngeal function during stop consonants is similar in different articulatory positions. Differences in oropharyngeal pressure and nasal airflow between bilabial versus dental and velar positions were found, presumably due to differences in volume and compliance of the vocal tract.     

Adult age differences in semantic and episodic memory

Cleft lip and palate occurs in approximately 1 in every 750 live human births, making it one of the most common congenital malformations. Surgical closure of the palatal cleft does not always result in a velopharyngeal port capable of supporting normal speech. The University of Florida (UF), in collaboration with the University of S?o Paulo (USP), is engaging in a 5-year prospective, randomized controlled study to compare velopharyngeal function for speech outcomes between patients undergoing palatoplasty for complete unilateral cleft lip and palate performed using the von Langenbeck procedure with intravelar velarplasty and those receiving the Furlow double-reversing Z-plasty palatoplasty. The von Langenbeck procedure was selected as the time-tested standard against which the Furlow procedure could be judged. The Furlow procedure, a relatively new operation, has been reported to yield substantially higher rates of velopharyngeal competency for speech than have most other reported series and theoretically should result in less disturbance to midfacial growth. A total of 608 patients will be entered into one of two age categories. Inclusion of two age groups will allow a comparison of results between patients having surgery before 1 year of age (9-12 months) and patients undergoing surgery at approximately 1.5 years of age (15-18 months). Speech data will be collected and will be available for definitive analysis throughout the last 3 years of the study. Collection of preliminary growth data will require more than 5 years; growth analysis is anticipated to continue until all patients have reached maturity. The Hospital for Research and Rehabilitation of Patients with Cleft Lip and Palate at the University of S?o Paulo (USP-HPRLLP) in Bauru, Brazil, is uniquely situated for conducting this study. The well-equipped and modern facilities are staffed by well-trained specialists representing all disciplines in cleft-palate management. In addition, an already existing social services network throughout Brazil will ensure excellent follow-up of study cases. The clinical caseload at this institution currently exceeds 22,000, and more than 1200 new cases are added annually. This project represents a unique opportunity to obtain prospective data from a large number of subjects while controlling the variables that have traditionally plagued cleft-palate studies. This study is designed to determine which of the two proposed surgical procedures is superior in constructing a velum capable of affecting velopharyngeal competency for the development of normal speech.     

Speech outcome and maxillary growth in patients with unilateral complete cleft lip/palate operated on at 6 versus 12 months of age

A prospective study of speech outcome and maxillofacial growth was carried out in cleft palate patients. Seventy-six cleft palate patients were randomly selected for the study group; 41 patients were operated on at 12 months of age, and 35 patients were operated on at 6 months of age. All patients were followed until they were 4 years of age. All patients underwent a complete speech evaluation, videonasopharyngoscopy, videofluoroscopy, and maxillofacial assessment. The rate of velopharyngeal insufficiency did not differ between the two groups (17 to 19 percent; p > 0.05). However, phonologic development was significantly better (p < 0.05) in the patients operated on at 6 months of age. Furthermore, none of the patients operated on at 6 months of age showed compensatory articulation disorder. In contrast, 62 percent of the patients with postoperative velopharyngeal insufficiency operated on at 12 months of age showed compensatory articulation disorder (p < 0.05). Maxillofacial assessment showed that there were non-significant differences (p > 0.05) in maxillofacial growth in both groups of patients. All patients showed similar degrees of maxillary collapse (p > 0.05). The results of this study suggest that cleft palate repair performed at 6 months of age significantly enhances speech outcome and prevents compensatory articulation disorder.     

Occurrence and trends in ski injuries in Norway

OBJECTIVE: The objective of this study was to determine the influence of velopharyngeal (VP) inadequacy on respiratory speech compensations. DESIGN: The pressure-flow technique was used to measure pressure, airflow, and timing variables associated with VP closure during the production of the initial plosive consonant /p/ in a series of the utterance "papa." SETTING: The study was conducted in the speech and breathing laboratory of the UNC Craniofacial Center. PARTICIPANTS: Eighty-two subjects with cleft lip and/or palate were assessed. The subjects were divided into two groups, those with adequate VP closure (VP size <.010 cm2) and those with inadequate VP closure (VP size >0.10 cm2). The adequate group was comprised of 62 subjects, and 20 subjects were categorized as inadequate. RESULTS: Peak intraoral pressure decreased in the inadequate group, but the difference was not significant. Nasal airflow increased (p < .01), but duration of the pressure pulse was the same for both groups. The area under the pressure curve decreased for the inadequate group (p = .04). CONCLUSION: These data contrast with previously reported published data using /p/ in the utterance "hamper." This suggests that phonetic context influences the compensatory response to velopharyngeal inadequacy. Additionally, while the findings are somewhat similar to studies that involved noncleft subjects whose oral airway was suddenly vented during the production of /p/, there is enough difference to suggest that learning also affects the compensatory outcome.     

Variability in urinary flow rate and prostate volume: an investigation using the placebo arm of a drug trial

PURPOSE: We analyzed a large data set to study reproducibility of peak urinary flow rates and prostate volumes in benign prostatic hyperplasia patients. MATERIALS AND METHODS: Longitudinal data were analyzed from 284 placebo treated patients in a double-blind, placebo controlled benign prostatic hyperplasia drug trial. RESULTS: A statistically significant increase in mean maximum flow rate was seen in the initial 3 measurements, as well as after adjusting for voided volume and time between uroflows. The mean maximum flow rate increased from 8.61 to 9.36 ml. per second at measurement 4 (8.7%). Of the patients 43% had 2 consecutive prostate volume determinations within +/- 10%. Within patient variability accounted for 7% of total prostate volume variability. CONCLUSIONS: With subsequent voidings maximum flow rate increases in a large group of patients. At least 4 uroflows must be performed to reach a plateau for maximum flow rate. Explanations for this finding may be the increasing experience of the patient and regression to the mean. These findings may impact on comparison of large trials of treatment efficacy. Within patient variability of prostate volume is substantial and, in addition to measurement method and lack of reader blinding to time and patient identity, may be caused by other yet unknown factors.     

Incidence of velopharyngoplasty following various techniques of palatoplasty

A total of 474 patients with cleft palates were treated at the Department for Maxillofacial Surgery of Rostock University from 1971 to 1991. In 145 cases velopharyngoplasty was indicated. Primary velopharyngoplasty was performed on 36 and secondary velopharyngoplasty on 109 patients. In our opinion today primary velopharyngoplasty should be the exception. Intravelar veloplasty according to Kriens (1970) created particularly favorable conditions for good velar function so that secondary pharyngoplasty was only rarely indicated. Secondary pharyngoplasty should be performed and timed only in agreement with the speech therapist.     

A cineradiographic study of articulation in two talkers with temporarily induced oral sensory deprivation

Cineradiography was used to study the behavior of the lips, tongue, and mandible in two subjects talking normally and under the influence of trigeminal nerve-block anesthesia. The speech sample consisted of isolated words and sentences. The nerve block was administered to eliminate somesthetic sensation in all of the oral articulators except the jaw. Frame-by-frame measurements of lip protrusion, tongue position, and jaw placement were taken from the film data for selected stops, glides, fricatives, and vowels in the speech sample. Comparison of these measurements from the normal and nerve-block condition revealed the following changes in the nerve-block data: (1) reduction in context-appropriate lip protrusion and loss of precision in lip closure activity, which was more noticeable for the upper than the lower lip; (2) a reduction in the precision of tongue articulations particularly on contacts for lingua-alveolar and lingua-velar consonants, apical retroflexion on glides, and steady state postures for lingua-palatal fricatives and vowels; and (3) noticeable alterations in inferior/superior jaw position which was systematically closer to the maxilla for bilabial consonant closures and often reduced or extended in excursion for vowels and other consonants. The data are discussed in terms of the relative effects of an oral somesthetic feedback deficit on speech production, and also with respect to compensation within the articulatory system under conditions of sensory deprivation.     

Pharyngo-esophageal dysphagia in Parkinson's disease

The radiologic characteristics of pharyngoesophageal (PE) dysfunction in Parkinson's disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.     

The double-reversing Z-plasty in primary palatoplasty: operative experience and early results

The double-reversing Z-plasty of Furlow for closure of the soft palate was used in 34 children with various types of cleft palate. Mean age at repair was 12.8 months. Intraoperative experience was favorable, with acceptable operating time and blood loss. Length of hospitalization averaged 1.9 days. Postoperatively, two children experienced temporary stridor, which resolved within 24 to 48 hours. One child had dehiscence of the hard palate (Von Lagenbeck repair) 4 weeks postoperatively, and three children developed small oronasal fistulae. Early speech evaluation demonstrated adequate soft palate mobility in 33 of 34 patients, with observable velopharyngeal function. Twelve children had mild velar compromise, with eight exhibiting slight nasal air escape.