Modified Project Summary/Abstract Section Velopharyngeal insufficiency (VPI) is a common finding after primary cleft palate repair characterized by hypernasal sounding speech that can impact speech intelligibility. VPI requires surgical intervention to correct secondary to underlying anatomical differences. Nasopharyngoscopy is a widely used imaging modality for assessment of velopharyngeal variables in patients presenting for management of VPI. Imaging obtained on nasopharyngoscopy is used to develop a treatment plan and for surgical selection. However, there are inherent drawbacks to nasopharyngoscopy that limit interpretation of findings. Nasopharyngoscopy is invasive and uncomfortable. Proportion distortion exists depending on the size of the endoscope used and placement of the camera. There can be instances when the entire velopharyngeal port is not visible secondary to the angle of the scope. Other factors that interfere with assessment include the patient crying or screaming, not obtaining an adequate speech sample to accurately assess movement, and patients using speech sound errors that invalidate the assessment. Compliance in obtaining a ratable nasopharyngoscopy exam is not well documented or defined in the literature. The lack of documented compliance with this procedure in the pediatric population is alarming given that 59% of team in the United States currently use nasopharyngoscopy for surgical decision making. Even when a patient is compliant and imaging can be interpreted, there is wide variation in interpretation practices. Some surgeons will use velar notching as the criteria to repair the underlying levator veli palatini (LVP) muscles, even though the LVP cannot be directly visualized from the scope. Other surgeons use closure pattern to determine a surgical intervention, while gap size is another driver. There is also no way on nasopharyngoscopy to directly measure anatomical structures that may be causing VPI such as a short velum. The purpose of this supplement is to examine the utility of nasopharyngoscopy in surgical selection to treat VPI. Reliability for rating velopharyngeal variables among clinicians will be established. Once reliability is established, interpretation of findings to form a surgical plan will be assessed amongst surgeons across cleft teams. Finally, findings from nasopharyngoscopy will be compared to the imaging modality of MRI that is well documented to have high patient compliance and provides additional information not available from nasopharyngoscopy.