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Purpose: Need of secondary surgery for velopharyngeal dysfunction (VPD) after cleft palate repair is determined by clinically significant hypernasality. Our institution utilizes the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence to standardize speech evaluations. This system accurately identifies patients with significant VPD; however, it can falsely inflate the severity of VPD in some patients due to compensatory errors such as facial grimacing, hoarseness, and poor articulation, making it a suboptimal tool for surgical decision-making. Our purpose was to create an abbreviated and surgically relevant scoring system to assist the plastic surgeon in identifying patients who are surgical candidates for VPD surgery.
Methods: The CHOP VPD Surgical Decision Scale was created by isolating the key features used in surgical decision-making, namely hypernasal resonance and audible nasal air emission . To test the utility of this scale, a retrospective chart review was performed of all nonsyndromic patients who underwent primary cleft palate repair utilizing the Furlow technique from 1996-2006. Patients were excluded for hearing loss, age<5 at speech evaluation, and unrepaired oronasal fistula. The most recent Pittsburgh speech scores were recorded and converted to the CHOP VPD Scale, and patients requiring secondary pharyngeal surgery for VPD were identified. The two scales were then compared.
Results: 285 nonsyndromic patients included in the study. The average length of follow up was 7.5 years. In 66.7% of patients diagnosed with an incompetent velopharyngeal mechanism by Pittsburgh score, secondary surgery was performed or recommended, compared to 100% of those in the Physical Management group on the CHOP VPD scale. Of all patients in which secondary surgery was performed or recommended, 84.21% were scored as incompetent on the Pittsburgh score, and 73.7% were recognized as needing Physical Management on the CHOP VPD scale. When comparing the two scales, 22.8% of patients were placed into different categories, and of these 98.5% had an improved velopharyngeal mechanism on the CHOP VPD Scale compared to the Pittsburgh Scale. The most common finding on the Pittsburgh Scale contributing to worse score was visible emission (76.6%).
Conclusion: The CHOP VPD Surgical Decision Scale is a useful tool for surgeons in assessing need for secondary pharyngeal surgery for VPD after cleft palate repair due to its high positive predictive value and low false negative rate. A prospective study utilizing this scaling system will better solidify its place in surgical decision making for patients with velopharyngeal incompetence, and will be the focus of our future endeavors.

CHOP VPD Surgical Grading Scale
Hypernasality
normal resonance	0
mild	1
moderate	2
severe	3
Audible Emission/ Nasal Turbulence
inconsistent	0
consistent	1

CHOP VPD Surgical Decision Scale
VP MECHANISM	COMPETENT	BORDERLINE	INCOMPETENT
SCORE	0 - 1	2	3 - 4
MANAGEMENT	none	observe +/- study	physical management