Velopharyngeal insufficiency

Presented by - Dr Parag S. Deshmukh

Contents :

• Introduction

• Causes

• Normal anatomy

• Different closure patterns of velopharynx

• Diagnostic tools

• Treatment

• Related article

• Conclusion

Introduction:

• The terms velopharyngeal "incompetence", "inadequacy" and "insufficiency" historically have been used interchangeably

• Velopharyngeal insufficiency includes any structural defect of the velum or pharyngeal walls at the level of the nasopharynx with insufficient tissue to accomplish closure, or there is some kind of mechanical interference with closure.

oVelopharyngeal insufficiency (VPI) :

• It is known as a failure of the separation between nose andmouth, because of an anatomical dysfunction of the softpalate, the lateral or posterior wall of the pharynx.

oVelopharyngeal inadequacy :

• (VPI) is a malfunction of a velopharyngeal mechanism.

• The velopharyngeal mechanism is responsible for directing thetransmission of sound energy and air pressure in both the oralcavity and the nasal cavity.

• When this mechanism is impaired in some way, the valve doesnot fully close, and a condition known as 'velopharyngealinadequacy' can develop.

Definition :

• VP incompetence: Due to neurological etiologies such as motor disorders (e.g dysarthria)

• VP incorrect learning: The result of sensory deficits (e.g.hearing impairment), or congenital disorders (existing at birth)

• Velopharyngeal insufficiency (VPI) is a disorder

resulting in the improper closing of the velopharyngeal

sphincter (soft palate muscle in the mouth) during

speech, allowing air to escape through the nose instead

of the mouth.

• During speech, the velopharyngeal sphincter must

close off the nose to properly pronounce strong

consonants such as "p," "b," "g," "t" and "d.“

• To close off the nose from the mouth during speech,

several structures come together to achieve

velopharyngeal closure.

• These include the velum (soft palate or roof of the mouth), the lateral pharyngeal walls (side walls of the throat) and the posterior pharyngeal wall (the back wall of the throat).

• If the velopharynx is not closed, snort sounds may be produced through the nose or you may hear air coming out of the nose during speech.

• Improper function of this structure also produces a nasal tone in the voice.

Symptoms:

• The two main speech symptoms of velopharyngeal insufficiency (VPI) are hypernasality and nasal air emission.

• Hypernasality is sometimes called nasal speech. In English the sounds "m," "n" and "ng" are the only sounds that should resonate nasally.

• Hypernasality occurs when sounds other than these resonate through the nose, and it varies from mild to severe.

• Some other consonants can be produced without velopharyngeal closure, including "h," "w," "y," "l" and "r."

• The rest of the consonants are referred to as pressure consonants because they require buildup of air pressure in the mouth to produce normal sounds.

• Nasal air emission occurs when air escapes through the nose on pressure consonants, and it can sound like puffs, squeaks or snorts, or it might make speech sound muffled.

• Children sometimes develop unusual speech sounds to compensate for their VPI. A common one is a glottal stop, produced by stopping air with the vocal cords (as one would do when saying "uh oh").

• Some other sounds are made by awkward stopping or restricting air with the tongue in the throat or mouth in unusual ways.

Causes :

• Any child with cleft palate is at risk for VPI.

• The most common cause of VPI is a history of cleft palate

or submucous cleft (cleft covered by the lining or mucous

membrane of the roof of the mouth).

• About 20% to 30% of children who have cleft palate with

or without cleft lip will have persisting VPI after their

palate repair.

• A small percentage of children with submucous cleft

palate will also have VPI.

• Sometimes VPI develops after an adenoidectomy (a

surgical procedure to remove adenoids or lymphoid

tissue in the back of the nose).

• Children who are born with weak throat muscles or

who suffer a traumatic brain injury that results in weak

throat muscles may have VPI.

• Sometimes children have VPI from an unknown cause.

• Velopharyngeal insufficiency (VPI) can be caused by a variety of disorders : Structural Genetic Functional Acquired

Terms used in the study of VP

function/dysfunction :

Nasalization: significant communication of the nasal cavity with the rest of the vocal tract during speech.

Nasality: perceptual quality of nasal resonance. Hypernasality: excessive nasally escaping air reverberating in

the nasal cavity. Hyponasality: blocked nasal resonance caused by

nasal obstruction. Nasal emission: increased nasal instead of oral airflow

during the production of pressure consonants (not necessarily acoustic).

Nasal turbulence: fricative sounds caused by nasal airflow

Normal anatomy :

• The muscles that control its movement can be grouped based on their

respective actions on the soft palate. They include elevators, depressors, and

tensors.

Elevators Depressors Tensor

Levator veli palatini palatopharyngeus Tensar veli palatini

Musculus uvulae palatoglossus

• In addition to the five soft palate muscles, there are two other pharyngealmuscles that also arise in pairs and assist in the functional mechanism ofvelopharyngeal closure: pulling the soft palate to the sides and thereby openingthe pharyngotympanic tube during swallowing and yawning

Levator Veli Palatini :

• Bilaterally, the muscle is superiorly attached to the cartilage of the pharyngotympanic tube and the temporal bone and inferiorly attached to the palatine aponeurosis.

• Since 1953, it has been acknowledged that the principal function of the LVP is to elevate the soft palate. (Bosma J: A correlated study of the anatomy and motor activity of theupper pharynx and by

cinematic study of patients after maxillo-facial surgery. Ann Otol Rhinol Laryngol 1953; 62:51-72.)

The action of the LVP is the principal velar component to velopharyngeal closure and is important in maintaining closure, particularly for expiration at high intraoral pressures.

The LVP is the primary muscle involved in velopharyngeal closure, which is important for normal speech and in the production of oral sounds, and is also active in non-speech activities, such as blowing or sucking.

Palatopharyngeus :

• palatopharyngeus has two components: the

velar component consisting of two heads that clasp round and insert into the levator,

and the pharyngeal component which inserts into the superior constrictor in the lateral and posterior pharyngeal walls.

• The function of the palatopharyngeus is primarily to lower the palate, which assists the swallowing of food.

• It may elevate the larynx, which assists in the phonation of high pitched sounds.

• palatopharyngeus is active in the production of oral sounds as well as nasal speech sounds.

Palatoglossus :• The palatoglossus is attached superiorly to the palatine aponeurosis and

inferiorly to the sides of the tongue.

• The function of this muscle is to elevate the posterior part of the tongue and assist in depressing the soft palate onto the tongue.

• The palatoglossus coordinates with the TVP to lower the soft palate to produce nasal sounds.

• The palatoglossus raises the tongue against the soft palate to pronounce the consonant k or g.

Musculus Uvulae :

This muscle is found bilaterally, attaching to the posterior nasal spine and the palatine aponeurosis superiorly and inserting into the mucosa of the uvula inferiorly.

The main action of this muscle is to shorten the uvula and add bulk to the soft palate, thereby assisting the levator veli palatini in velopharyngeal closure.

There have been differing opinions as to whether the musculus uvulae is single or paired and whether or not the muscle has a passive or active role in contributing to velopharyngeal closure during normal speech.

Superior Constrictor : • The superior pharyngeal constrictor is superiorly attached to the

pterygoid hamulus, the pterygomandibular raphe, the posterior end of the mylohyoid, and the side of the tongue.

The muscle on either side sweeps around superiorly and medially to form the lateral and posterior walls of the pharynx and inserts at the midline into the pharyngeal ligament, thus encircling the nasopharynx and upper oropharynx.

The action of the superior constrictor is to elevate the pharyngeal wall and draw the pharyngeal walls inward, assisting the action of palatopharyngeus in the pharyngeal component of velopharyngeal closure by reducing the pharyngeal diameter.

• The uppermost fibres of this muscle originate from the medial pterygoid plate, it is known as Passavant’s pad, named after Gustav Passavant (1860s) who first observed a ridge on the posterior pharyngeal wall in cleft palate patients.

• Prominence on posterior wall of nasopharynx formed by contraction of superior constrictor muscle of pharynx during swallowing Also called Passavant bar, cushion, pad, and ridge.

• When present, this pad may assist in effecting a seal with the soft palate as it moves anteriorly with contraction of the superior constrictor muscle.

• Passavant’s pad has been reported to be more marked in individuals with palatal insufficiency, suggesting that this ridge may develop further when acting to compensate for ineffective velopharyngeal closure

Salpingopharyngeus :

• Attached superiorly to the cartilaginous part of the pharyngotympanic tube and inferiorly to the palatopharyngeal muscle.

• It was first believed that the muscle elevates the larynx and shortens the pharynx during swallowing and speaking.

• Some of the fibres of the salpingopharyngeus blend with the fibres of the superior constrictor, which may indicate that the salpingopharyngeus assists the superior constrictor in elevating the pharyngeal wall

VELOPHARYNGEAL CLOSURE :

• The soft palate (or velum) separates the nasopharynx from the oropharynx.

• During quiet breathing the soft palate suspends between the nasal and oral cavities, allowing air to freely move through the mouth or through the nose.

• During active breathing in and out through only the mouth, the soft palate will elevate to touch the posterior pharyngeal wall, thus closing the opening between the oropharynx and nasopharynx.

• This velar closure is known as velopharyngeal or palatopharyngeal closure and is important for swallowing, speech, and blowing.

Functional Anatomy of the Soft Palate Applied to Wind PlayingAlison Evans, MMus, Bronwen Ackermann, PhD, Medical Problems of Performing Artists, December 2010.

Velopharyngeal mechanism :

Sphincteric mechanism:

• Firstly, the velar component involves the elevation and posterior movement of the velum.

• Secondly, the pharyngeal component involves the movement of the pharyngeal walls encompassing the oropharynx and nasopharynx.

• Croft et al. (1981) observed four main types of closure patterns

4. Circular

closure with

Passavant’s

pad is a

combination

of the circular

closure with

the anterior

movement

of the

posterior

pharyngeal wall.

3. Circular

closure

requires an

equal

movement

from both

the velum

and the

lateral

pharyngeal walls.

Sagittal closure involves the medial movement of the lateralpharyngeal walls to meet the velum

Coronal closure is achieved by the elevation of the velum to touch the posterior pharyngeal wall;

Variations in VP Closure

• Non-Pneumatic Closure - swallowing, gagging, and

vomiting

• Closure is high in the nasopharynx and is exaggerated.

• Pneumatic Closure - sucking, whistling, blowing, speech

• Closure may be complete for non-pneumatic activities, but may be insufficient for speech and other pneumatic activities.

Evaluation of Velopharyngeal Function :

• Modulation of the pressurized air stream that emerges from the lungs during expiration produces an auditory phenomenon that is called “speech”.

• The tissues comprising the velopharyngeal sphincter are one of several articulators capable of modification of the air stream.

• Dysfunction of that sphincter impairs the normalcy of speech to varying degrees.

• There is a lack of consensus on the preferred terminology to describe such dysfunction: velopharyngeal incompetency, velopharyngeal insufficiency, and velopharyngeal inadequacy have all been abbreviated as VPI.

• It is a physiological impairment without attempting to denote etiology.

Diagnostic evaluation :

• It can be divided into two broad categories:

perceptual Instrumental.

• “instrumental” includes all evaluations that use some type of instrumentation.

Perceptual :

• “Perceptual” connotes the use of the evaluator’s unaided senses.

• Listening for the production of specific phonemes (i.e., auditory perceptual velopharyngeal evaluation) is the major form of perceptual evaluation.

Observing the face for grimacing

watching for fogging of a mirror below the nares

feeling for airflow through the nares with attempted pronunciation of phonemes that require velopharyngeal function.

Instrumental : [Krakow & Huffman, Baken & Orlikoff ]

Muscle activities:

Electromyography (EMG)

• Surface electrodes

• Intramuscular electrodes

VP study usually needs

the intramuscular one.

Imaging :

• Fiberoptic endoscope

• Xray / MRI / Ultrasound

Videofluoroscopy :

• It is a radiographic technique, mostly used to demonstrate the lateral and posterior wall of the pharynx.

• This is a questionable technique considering these children undergo radiographic examinations frequently.

• Most of the time barium is used in multiviewvideofluoroscopy.

• Besides the fact that videofluoroscopy provides an overview of the lateral and posterior walls of the pharynx, this technique also provides information about the length and movement of the soft palate, the posterior and the lateral walls

Speech analysation :

• To come to the right diagnosis this is the gold standard in VPI evaluation.

• The speech scientist listens to the voice, articulation, motor speech and the velopharyngeal function of the patient.

• The main symptom is hypernasality of the voice.

• The patient is unable to create normal resonance because of nasal air emission.

Nasometry :

• Nasometry is a test which calculates a ratio between the nasal and oral sound emissions.

• The ratios of the patient will be compared with a normal ratio and standard deviation.

• These ratios will help determine whether the operation was a success.

• Preoperative ratios will be compared with postoperative ratios.

Airflow:

• Pneumotachograph:

split mask with airflow sensors

Sound pressure:

• Microphones (eg. Probemic, Nasometer)

• Accelerometers or contact microphones for tissue vibrations

• The scientist also examines the patient

for Obstructive Sleep Apnea Syndrome (OSAS),

when this is positive the patient will be treated

for OSAS first.

• When there is no sign of oral sleep apnea the

patient will conduct a speech analyzation.

• If is proven that the patient has an indication for

surgical treatment, the next step will be

visualization of the mouth and pharyngeal cavity.

• Often the visualization is combined with

audiometry or speech analyzation.

Nasoendoscopy :

• Nasoendoscopy is a non radiographic technique in which the physician uses a scope to enter the mouth of the patient.

• Usually the examiner uses a flexible scope, but in certain situations a rigid scope is used.

• Nasoendoscopy provides an overview of the anatomy of the velopharynx during phonation.

• With nasoendoscopy the vocal tract but especially the soft palate and the lateral wall of the pharynx can be visualized.

• Not only the location but also the movement can be visualized with nasoendoscopy.

Limitations :

• It is hard to get an overview with nasoendoscopywith a rigid scope in small kids.

• Especially when there are abnormalities or obstructions in the nasal cavity, which are frequently found in children with a history of cleft palate.

• The nasoendoscope can cause irritations of the mucosa when the child does not cooperate.

• A third grouping can be based on whether the

technique provides “visualization” of the

functioning velopharyngeal port or more indirect

assessment by recording changes in airflow, air

pressures, or sound or light transmission across

the velopharyngeal port, usually by means of oronasal discrimination.

Differential Diagnosis of Velopharyngeal Dysfunction

1. Anatomical deficiency

2. Myoneural deficiency

3. Anatomical and myoneural deficiency

4. Neither anatomical nor myoneural deficiency

Anatomical deficiency means a structural problem such as an unrepaired cleft palate, a palatal fistula, a short velum, a deep velopharynx, or ablated velopharyngeal tissue.

Myoneural deficiency means adequate palatal and velopharyngeal structural anatomy but inadequate or absent function of one or more components of the velopharyngeal port.

Combined anatomical and myoneural deficiency may occur with repaired cleft palate, unoperated submucous cleft palate, or postablative surgery and/or radiotherapy for oronasopharyngeal malignancy.

Velopharyngeal insufficiency in patients with cleft palate:

Patients born with cleft palate have, by definition, a malformation that involves critical anatomic components of the velopharyngeal mechanism.

Normally, the soft palate, or velum, is part of the complex coupling and decoupling of the oral and nasal cavities to produce orally based or nasally based speech sounds.

When a cleft of the soft palate is present, abnormal muscle insertions are located at the posterior edge of the hard palate.

Surgery must not be aimed simply at closing the physical palatal defect, but rather at the release of abnormal muscle insertions, establishment of muscle continuity, and correct orientation so that the velum may serve as a dynamic sling-like structure.

Despite successful closure of the soft and hard palate, the velopharyngeal valving mechanism may not work adequately to allow for appropriate closure of the nasopharynx from the oropharynx.

Most commonly, this insufficiency of the velopharyngeal valving mechanism results in hypernasality, the audible nasal emission of air, which also may be associated with abnormal compensatory articulation problems.

Most children who have cleft palate repairs performed at the appropriate time in a successful manner have speech that is normal or speech that displays minor abnormalities that can be treated successfully with speech therapy.

Approximately 20% of children with palates repaired appropriately develop VPI, that may require additional surgical treatment using one of several surgical options

A second clinical situation in which cleft palate patients may develop VPI is after orthognathic surgical procedures.

Depending on the degree of skeletal movement, the soft palate structures may be advanced to the point at which adequate velopharyngeal closure is no longer possible.

VPI in cleft palate patients after Le Fort I midfacial advancement usually resolves within 6 months of the procedure, but there is a small subgroup of patients who benefit from an additional surgical procedure to help with adequate closure of the velopharyngeal mechanism.

Speech abnormalities in the cleft patient :

One of the complexities of the cleft palate malformation is the function of the velopharyngeal sphincter.

In patients with a repaired cleft palate, the apparatus is altered and the patient has learned to overcome a short or scarred palate that does not move well by recruiting extra efforts from the adjacent structures.

Activation of Passavant’s ridge (hypertrophy of tissue in the posterior pharyngeal wall) is an example of a compensatory effort that many cleft patients have developed to overcome the insufficiency of velar movement and stretch.

Warren’s aerodynamic demands theory :

severe velopharyngeal closure impairments cause the patient to attempt to articulate pressure consonants at the larynx or pharynx level instead of within the oral cavity.

This attempt causes abnormal compensatory articulation sounds.

Nasal air emission :

During the production of consonants, the creation of relatively high oral pressure is critical to produce the appropriate sound.

If nasal escape occurs because of incomplete velopharyngeal closure or fistula presence, consonants do not sound as they should because of excessive nasal air emission.

It occurs with hypernasality, which is a resonance problem associated with vowel production, not consonant production.

Resonance :

Hypernasal perturbations occur during the production of vowel sounds that require the appropriate closure of the nasal spacefrom the oral space.

Of the 20% of patients who have speech disturbances related to cleft palate, most speech issues present as hypernasality. (Hall C, Golding-Kushner KJ. Long-term follow-up of 500 patients after palate repair performed prior to 18 months of age. Presented at the Sixth International Congress on Cleft Palate and Related Craniofacial Anomalies. Jerusalem)

Hyponasality is a reduction in nasal resonance that occurs because of abnormal obstruction (a pharyngeal flap that is too wide).

Articulation :

Articulation problems may be related to difficulties with creating the adequate amount of oral pressure necessary to create fricative, affricative, oral stop, lateral, and glide sounds (/f/,/th/, /v/, /s/, /z/, /sh/, /zh/, /ch/, /j/, /p/, /b/, /d/, /k/, /g/, /t/, /l/, /r/, /y/, and /w/,).

When the velopharyngeal mechanism does function appropriately to close off the nasal cavity, airstream escape makes it challenging to produce these sounds.

Compensatory articulation occurs when the patient tries to pathologically shape the airstream more posteriorly in the vocal tract rather than at the normal locations of the anterior palate, teeth, and tongue.

Speech evaluations :

VPI is only one element of speech problems that can be seen in patients with cleft palate.

A standardized speech assessment should be used at each center that evaluates these patients

The same clinical evaluation and measurements should be obtained for each visit and ideally should be performed by the same speech pathologist.

Specialized testing such as nasometry, videofluoroscopy, and nasopharyngoscopy usually is warranted in addition to standard screening and evaluation tools.

Management of cleft-related velopharyngeal insufficiency :

Once the diagnosis of VPI has been made, treatment may consist of nonsurgical speech therapy, obturation with a speech bulb, placement of a palatal lift, or reconstructive surgery of the airway.

Surgical treatment of VPI is indicated when the problem is related to anatomic factors and documented to be consistent.

By surgically recruiting additional local tissue to decrease the aperture, complete or improved closure of the velopharyngeal sphincter can occur.

Once the diagnosis is confirmed, the timing of surgical intervention should be early to prevent long-term speech difficulties and abnormal articulatory compensations that are difficult to correct later in life.

A firm diagnosis of VPI may not be possible before age 3 because appropriate testing is difficult in such young children.

For most children, reliable testing can be performed somewhere between 3 and 5 years of age.

The surgeon and speech pathologist must work together to select the procedure that might offer the best outcome based on the specific clinical situation.

• When the pharyngeal flap is used, a flap of the posterior wall is attached to the

posterior border of the soft palate.

• The flap consists of mucosa and the superior pharyngeal constrictor muscle.

• The muscle stays attached to the pharyngeal wall at the upper side (superior

flap) or at the lower side (inferior flap).

• The function of the muscle is to obstruct the pharyngeal port at the moment that

the pharyngeal lateral walls move towards each other.]

• It is important that the width and the level of insertion of the flap are properly

constructed, because if the flap is too wide, the patient can have problems with

breathing through the nose what can result in sleep apnea.

• Or a postoperative situation can be created with the same symptoms as before

surgery. Although there are complications such as the flaps width can change

because of contraction of the flap.

• This results in a situation with the same symptoms of hypernasality after a few weeks of surgery.

superiorly based pharyngeal flap:

Inferior based pharyngeal flap :

When the sphincter pharyngoplasty is used, both sides of the superior-based palatopharyngeal mucosa and muscle flaps are elevated.

Because the distal parts (posterior tonsillar pillars, which the palatopharyngeal muscles are attached to) are sutured to the other side of the posterior wall the pharyngeal port will become smaller.

As a result the tissue flaps cross each other, leading to a smaller port in the middle and a shorter distance between the palate and posterior pharyngeal wall.

The procedure is relatively easy to execute. This makes the operation cheaper, also because of a reduced anesthesia time.

The dynamic sphincter can be moved as result of a remaining neuromuscular innervation, what gives a better function of the velopharyngeal port.

At last there is a lower complication rate, although obstructive sleep apnoea syndrome(OSAS) is associated.

Sphinctoroplasty:

Posterior wall Augmentation :

• This technique can only be used for small gaps.

• When this operation is performed there are a several advantages.

• It is possible to narrow down the velopharyngeal port without modifying the function of the velum or lateral walls.

• Furthermore the chance of obstructing the airway is less, because the port can be closed more precisely.

• Many materials have been used for this closure: petroleum jelly, paraffin, cartilage, adjacent soft tissue, silastic, fat, Teflon and proplast.

Complications of surgery for velopharyngeal insufficiency :

Long-term postoperative complications are frequently seen as part of a continuum of pathologic resistance in the airway that may result after pharyngeal flap surgery.

Patients who have undergone pharyngeal surgery to decrease the aperture of the sphincter to allow for closure during the formation of certain speech sounds may present with problems related to snoring, upper airway resistance sequence, or obstructive sleep apnea.

These pathologic conditions are each a progressive form of increased resistance within the upper airway.

• Snoring is the audible sound produced when airflow is inefficient through the upper airway.

• This may not be significant pathophysiologically but may be bothersome to the significant other if the snoring prevents the other’s normal and restful sleep.

• Upper airway resistance syndrome develops when more significant resistance occurs without clear obstruction and a decrease in effective oxygenation.

• Obstructive sleep apnea is the clear cessation of breathing during sleep that causes an arousal from the normal sleep cycle.

• This condition contributes to daytime hypersomnolence and is associatedwith increased risks for hypertension, cardiovascular disease, and stroke.

Non operation techniques :

• Prosthesis :• Prosthesis are used for nonsurgical closure

in a situation of velopharyngeal dysfunction.

• There are two types of prostheses. One called the speech bulb and the other one the palatal lift prosthesis.

• The speech bulb is an acrylic body that can be placed in the velopharyngeal port and can achieve obstruction.

• The palatal lift prosthesis is comparable with the speech bulb, but with a metal skeleton attached to the acrylic body.

• This will also obstruct the velopharyngeal port.

• It is a good option for patients that have enough tissue but a poor control of the coordination and timing of velopharyngeal movement.

• It is also used in patients with contraindications for surgery.

• It has also been used as a reversible test to confirm if a surgical intervention would help.

Related article:

• Association between velopharyngeal function and dental-consonant misarticulations in children with cleft lip/palateJ. Pulkkinen, M.-L. Haapanen, J. Laitinen, M. Paaso and R. Ranta

(British Journal of Plastic Surgery (2001), 54, 290–293)

Introduction :

• The prevalence of dental-consonant articulatory errors is higher in cleft patients than in non-cleft patients.

• earlier studies have shown that, at the age of 6 years, 44% of cleft patients misarticulate at least one of the sounds /r/, /s/ and /l/; 41% distorted and 5% substituted (2% both distorted and substituted) at least one sound.

• Speech aerodynamics and breathing may be distorted in cleft patients.

• Dentoalveolar dysmorphology, in terms of the severity of the cleft, results in atypical cephalometric dimensions.

• This is associated with abnormalities in vocal-tract anatomy and may cause abnormal functioning and physiology during breathing and phonation.

• Alveolar fistulae, and the presence or absence of incisors, may also interfere with the ability to articulate.

• Aim of this study was to examine the relationship between velopharyngeal function and articulation of the Finnish dental consonants /r/, /s/ and /l/, normally produced by linguoalveolar contact.

• To control for possible misleading variables, the effects of sex, cleft type, method and timing of primary palatoplasty, palatal fistulae, earlier velopharyngoplasty and speech therapy were also studied.

Patients and methods :

They assessed 278 6-year-old Finnish-speaking non-syndromic children (115 girls, 163 boys) with isolated cleft palate, cleft lip/alveolus or unilateral or bilateral cleft lip and palate.

Auditory analysis of speech and velopharyngeal function, the presence of fistulae, previous velopharyngoplasty and speech therapy, as well as surgical technique and timing of primary palatal surgery were obtained from the hospital records.

The misarticulations of the sounds /r/, /s/ and /l/ were evaluated in spontaneous speech by two experienced speech pathologists from the cleft team.

Velopharyngeal function was categorised, on the basis of the effect on speech, into competent, marginal incompetent and obvious incompetent.

Nasal grimace and distortions due to palatal fistulae were registered.

• Number of patients with each type of cleft by sex, misarticulations of /r/,

/s/, /l/ or their combinations, obvious or marginal velopharyngeal

incompetence (VPI), previous velopharyngoplasty, previous speech

therapy and fistulae

• Specific signs of velopharyngeal incompetence (VPI) were not

included in the misarticulations studied.

• Speech characteristics associated with VPI were registered for all of

the sounds. Those were:

• 1:nasal air emissions;

• 2: hypernasality;

• 3: weakness of pressure consonants; and

• 4: compensatory articulations (glottal, lingual, pharyngealstops and nasal and laryngeal fricatives).

• The inter-judge agreement in the assessment of speech characteristics of velopharyngeal function and psychomotor development ranged from 91.3% to 94.2%.

• The data for each patient’s /r/, /s/ and /l/ sounds were evaluated simultaneously by the two speech pathologists; the categorizing of distortions and substitutions was based on a 100% consensus between them.

Results :

• The occurrences of misarticulation of /r/, /s/ or /l/ or their combinations were statistically compared to velopharyngeal competence, marginal velopharyngeal competence and obvious VPI.

• No significant differences were observed.

• There was no significant difference in velopharyngeal function between boys

and girls in any cleft group.

• Thus, boys and girls were combined in later comparisons

• only significant difference was observed in the bilateral-cleft-lipand- palate group, where all /s/ disorders were in the velopharyngeal competence group.

Conclusion:

• Dental-consonant errors in cleft patients are a separate error category.

• The treatment of dental-consonant errors could be planned independently of the treatment of VPI.

• Some features specific to VPI may, of course, also occur in association with dental-consonant misarticulations, but according to our results dental-consonant misarticulations are not significantly related to velopharyngeal function, whether competent or not.

Conclusion :

• The factors that may prevent VPI are not well understood and further research is therefore needed.

• The function of the soft palate is essential for maintaining upper respiratory tract structure and function under pressure and hence for allowing optimal airflow.

• It is crucial for patients with cleft palate, some repaired cleft patients, wind and brass players to be able to maintain firm velopharyngeal closure for optimum performance.

• It is important to increase understanding of the functional anatomy of the soft palate to help better manage injuries that may arise from overuse or misuse of the soft palate muscles.

References:

• Cleft Palate & Craniofacial Anomalies Effects on Speech and Resonance - Ann Kummer.

• Functional Anatomy of the Soft Palate Applied to Wind Playing (Alison Evans, MM us, Bronwen Ackermann, PhD, and Tim Driscoll, PhD)

• Management of Velopharyngeal Dysfunction: Differential Diagnosis for Differential Management (Jeffrey L. Marsh, MD St. Louis,

Missouri)

• Resonance Disorders and Velopharyngeal Dysfunction: Part I. Types, Causes and Characteristics. Ann W. Kummer, PhD, CCC-SLP

• Wikipedia, the free encyclopedia

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