Cleft Palate Speech & Management of Velopharyngeal Dysfunction
Normal Physiology: Levator veli palatini – Sling – Elevates and posteriorly displaces palate for velopharyngeal closure and competence Assisting musculature – Superior constrictor – Palatoglossus – Palatopharyngeus – Tensor veli palatini – Uvula Velopharynx: Physiology
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Velum § Extends from posterior hard palate to uvula. Velopharyngeal Mechanism § Muscular valve extending from posterior hard palate to posterior pharyngeal wall. § Provides separation between oral and nasal cavities during speech and swallowing. Velopharyngeal Closure At rest, velum suspended with tip of uvula resting on dorsum of tongue. § Velopharyngeal port open during rest breathing to allow unencumbered air flow Normal VP Closure
During closure, velum elevates to make complete contact with posterior pharyngeal wall to prevent escape of air through nose Lateral pharyngeal wall movement toward midline and anterior movement of posterior wall movement Passavant’s ridge: Prominent bulging of posterior pharyngeal wall in patients with inadequate velar elevation §
Compensatory hypertrophy of superior pharyngeal constrictor
Soft Palate (Vellum) Muscular complex § Levator veli palatine § Tensor veli palatine § Palatoglossus § Palatopharyngeus § Muscularis uvulae Oral mucosa Nasal mucosa
Swallowing: 1. Bolus of food pushed back by elevating tongue (styloglossus) into fauces 2. Palatoglossus & palatopharyngeus m contract to squeeze the bolus backward into oropharynx. Tensor veli palatini & levator veli palatini eleavate soft palate & uvula to close entrance into nasopharynx 3. Wall of pharynx raised by palatopharyngeus & stylopharyngeus to receive food, Suprahyoid m elevate hyoid bone & laynx to close opening into larynx, passing over the epiglottis, prevent food from entering respiratory pathway 4. Action of sup,mid,inf constrictor move food through oropharynx and laryngopharynx –> esophagus, where propelled by peristalsis Cleft Palate and Velophayrngeal Dysfunction Velopharyngeal Insufficiency: § §
Satisfactory speech occurs in ~ 85% after palatoplasty with therapy after palatoplasty 15% need secondary surgical correction of VPI
Anatomic Causes of VPI and Hypernasality in Cleft Palate § § § § § § §
LVP not oriented transversely to form normal sling Instead LVP inserts anteriorly on HP Oronasal fistula Abnormal LVP cannot elevate velum Submucous cleft palate Adenoidal involution (puberty in CP pts) Orthognathic surgery in CP pts (controversial)
Speech Pathology: §
Patients with clefts are at risk for: – Severe speech impairment – Language skill in the low-‐average range – Reading difficulties • 30% vs. 10% general population
Velopharyngeal Inadequacy § General term used for all types of VP dysfunction Velopharyngeal Insufficiency §
Anatomical or structural defect that precludes adequate velopharyngeal closure Velopharyngeal Incompetence §
A neuromotor physiological disorder that results in poor movement of structures
Potential Causes of VPI: § § § § §
Hx of Submucous cleft Short velum or deep pharynx Removal of adenoids /adeniod atrophy o Pharyngeal wall atropy Maxillary advancement Hypertrophic tonsils
VPI and Speech Pathology: §
Pathophysiology – All phonemes (except m,n,ng) require oral airflow – VP valve needs to be closed – Oral resonance is important to articulate speech – Disordered articulation affects plosives, fricatives, affricates not glides
Phonetic errors: Errors in articulation or formation of sounds Phonologic errors: Difficulty in child’s organization, learning, representation Hypernasality Nasal air emission Weak or omitted consonants Short utterance length Dysphonia Compensatory articulation productions Compensatory Misarticulations § §
Inability to generate oral pressure against closed velum Sacrifice place while maintaining manner of production o Push air into other areas of the pharynx Obligatory errors o Nasalization of oral phonemes o Hypernasal Allows tongue to function
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Glottal stop Pharyngeal stop Pharyngeal fricative Pharyngeal affricative Mid-‐dorsum palatal stop Velar fricative Posterior nasal fricative
Diagnosis of VPI: § §
Simply listen to patient speak – Articulation is hypernasal – Difficulty forming sounds, particularly the consonants To optimize treatment, establish: – Amount of excursion of velum – Lateral pharyngeal wall motion – Pattern of attempted closure of VP – Level at which VP closure achieved, if any
Screening of VP Function: §
Assess VP closure with oral sounds – Pressure consonants -‐ P,B,S,D – Assess VP opening with nasal sounds – Nasal sounds (open VP port) -‐ m,n,ng – Sound like -‐ b,d,g
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Spontaneous speech sample
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CV Syllable repetition
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Sentence repetition
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Sentence repetition o Pick up the puppy. o Buy Bobby a book. o Go get a bigger egg. o Katie cut the cake. o Daddy eats doughnuts. o Take it to Ted. o I like lollipops o My name is not Mickey Mouse o Mama made lemonade
Diagnosis of VPI:
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Voice and Resonance Evaluation
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Videofluoroscopy o Barium swallow o Duplicate sounds with fluorosocpic imaging o Lateral, frontal, submentovertx views o Quantitative data
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CV syllables o Pa o Ba o Ma o Wa o To o da
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Nasal Endoscopy o Complimentary to videofluoroscopy for direct visualization of VP mechanism o Qualitative information on closure mechanism
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CT and MRI – Less common methods – Mitnick and associates used to r/o VCF syndrome – Abnormal position of IC arteries • Can be almost directly under mucous membrane of pharynx
Treatment Options for VPI § § § § §
Speech Therapy / Articulation Therapy Visual Feedback Nasal continuous positive airway pressure Prosthetics Conservative measures will not overcome large gaps in the VP closure mechanism
Non-‐surgical Therapy: §
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Palatal training procedures – Articulation therapy – Sucking blowing exercises – Electrical and tactile stimulation – Speech appliances – Biofeedback techniques Palatal Lift Device Articulation disorders should be corrected before surgery for VPI
Surgical Options: § § § § §
Pharyngeal flap o Superiorly based o Inferiorly based Sphincter pharyngoplasty Intravelar veloplasty Furlow palatoplasty Posterior pharyngeal wall augmentation o Autogenous and alloplastic
Pharyngeal Flaps: § § § §
Flap from posterior pharyngeal wall brought to velum Reduces hypernasality Normal resonance in 75% Indications – Poor velar elevation – Good lateral pharyngeal wall motion – Large central defects
Pharyngeal Flap: Inferior Based §
May have advantage in terms of vascularity but has limitations in regards to length, ability to inset the flap secondary to incorporated adenoid tissue at the tip, and the low position at the base of the pharynx.
Pharyngeal Flap: Superior Based §
May be lengthened and inset at the level of the soft p alate b ut may be lacking in a robust vasculature. Inclusive evidence on outcomes superior vs. inferior flaps.
Double-Opposing Z-Plasty § Double opposing Z-plasty from the oral and nasal surfaces § Levator included in each posteriorly based mucosal flap § Reorients levator muscles § Palatal lengthening
Sphincter Pharyngoplasty §
Specifically indicated in treatment of patients whose velopharyngeal dysfunction is secondary to markedly impaired or absent lateral pharyngeal wall function, who would otherwise require a wide obstructive pharyngeal flap.
Retropharyngeal Implants:
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Augmentation of the posterior pharynx o Autogenous o Allogenic o Synthetic o Not well tolerated Risk of extrusion Rarely used
Obstructive Sleep Apnea: • •
Take-‐down flap Revise flaps and stent lateral ports – Nasal trumpets • Poorly tolerated for long periods • Cosmetically unacceptable – Internal stents • Removed in OR • Can be left in place for months
Velocardiofacial Syndrome (22q11 Deletion): § Medial d isplacement of internal carotid arteries.
Suggested Reading: Kuehn D, Perry J. (2009) Anatomy and Physiology of the Velopharynx. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 557-568). McGraw-Hill Companies. Kummer A. (2009) Assessment of Velopharyngeal Function. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 589-608). McGraw-Hill Companies. Hinton V. (2009) Instrumental measurements of Velopharyngeal Function. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 607-618). McGraw-Hill Companies. Witt P. (2009) Velopharyngeal Dysfunction. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 627-640). McGraw-Hill Companies. Furlow L. (2009) Correction of Velopharyngeal Insufficiency by Double-Opposing ZPlasty. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 641-648). McGraw-Hill Companies. Forrest C, Klaiman P, Mason A. (2009) Posterior Pharyngeal Flaps. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 649-664). McGraw-Hill Companies. Marsh J. (2009) Sphincter Pharyngoplasty. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 665-672). McGraw-Hill Companies. Mazaheri M, Brecht L. (2009) Prosthetic Management of Velopharyngeal Insufficiency. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 673-678). McGraw-Hill Companies.