surgery, however, pharyngeal flaps are considered to be more valuable in correcting velopharyngeal function than other treatment options, especially in severe cases of VPI (Sloan, 2000). It has also been reported that large tonsils have been found in a high percentage of OSA cases. Large tonsils may be shifted posteriorly, under the ports of the flap. In superiorly-based pharyngeal flaps, tonsils are a likely contributor to OSA. Surgical procedures such as uvulopalatopharyngoplasties and tonsillectomies may be required to resolve the OSA. Consequently, tonsillar tissue is an important area of pre-operative assessment (Ysunza et al., 1993). Outcomes Pharyngeal flap surgery may be able to improve speech performance in children or adults with a cleft palate who have velopharyngeal insufficiency. In fact, there is a high success rate for improvement of speech following pharyngeal flap surgery. However, surgery does not guarantee perfect or 100% intelligible speech. In addition to speech improvements, pharyngeal flap surgery may help eliminate hypernasality, nasal turbulence, and facial grimacing (Tonz et al., 2002). Often, speech improvements are not obvious immediately following the surgery. Speech improvements are more prevalent after one year post surgery and usually continue for several years. The outcomes of pharyngeal flap surgery vary among each individual in regards to improvements in hyponasality, hypernasality, nasal turbulence, voice quality, articulation, and intelligibility (Tonz et al., 2002; Liedman-Boshki et al., 2005). Patients who undergo pharyngeal flap surgery encounter the risk of never breathing through their nose again, which could create abnormal speech (i.e., denasal resonance) (Witt et al., 1998). It is estimated that around 20-30% of patients with clefts develop hypernasal speech after pharyngeal flap surgery (Heliovaara et al., 2003). The percentage reported for individuals developing hypernasal speech is debated by researchers. It is possible that hypernasality can be a side effect of pharyngeal flap surgery, however hyponasal speech occurs more frequently after a successful surgery (Liedman-Boshki et al., 2005). It is also possible that pharyngeal flap surgery will be unsuccessful. Some patients may even require secondary surgery for velopharyngeal insufficiency. It is common that individuals who have to undergo a second surgery could develop secondary speech problems, more specifically compensatory articulation and resonance disorders. Problems occurring post secondary surgery are often more difficult to extinguish (Tonz et al., 2002). As previously mentioned, one problem that may occur after surgery is hypernasality. This is caused when a narrow flap and inadequate lateral pharyngeal wall movement prohibit lateral port