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PubMed1999

Velopharyngeal anthropometric analysis with MRI in normal subjects.

Magnetic resonance imaging (MRI) is a new method of evaluating velopharyngeal dysfunction. The anatomy of the palate and velopharyngeal closure can be visualized with MRI. Also, fast scanning with turboflash sequences allows surgeons to evaluate the speech mechanism during phonation. The dimensions of the velopharynx are another important factor in velopharyngeal closure, together with the functional performance of the soft palate during phonation. During this study, velopharyngeal anthropometric analyses were performed in cerebral MR images of 136 male and 141 female normal speakers who underwent cerebral MRI for reasons other than speech problems. Age-dependent changes in velopharyngeal dimensions were evaluated. Although the growth of the soft palate was continuous throughout life, hard palate growth ceased by age 15. By using anthropometric data available from MR images taken on normal subjects for other reasons, a large database of age-, gender-, and race-specific data on palatal and pharyngeal morphology was acquired. Comparative data of noncleft subjects in multiple age groups were obtained with MRI.

Adolescent↗
PubMed2001

[A clinical application and study of analysis system of sound spectrography].

OBJECTIVE: The phonetic features were studied for non-velopharyngeal dysfunction in postoperative patients with cleft plate. METHODS: The feature of velopharyngeal competency of 32 postoperative patients with cleft palate were analyzed with KAY-7800 sound spectrograph, compared with characteristic of 30 subjects with normal phonogram. RESULTS: There were three types of abnormal phonogram for the postoperative patients of cleft palate with velopharyngeal competence. The heavy noise was a common sight. CONCLUSION: An analytic system of sound spectrography has certain value for evaluation of phonic function in cleft palate patients.

English Abstract↗
PubMed1988

Screening of velopharyngeal closure based on nasal airflow rate measurements.

Although sophisticated techniques for estimating velopharyngeal port area during speech are available, clinicians continue to seek approaches for screening patients with suspected velar inadequacy. The aim of the present study is to determine the sensitivity and specificity of predicting velopharyngeal dysfunction based on nasal airflow measurements. The pressure-flow technique was used to measure velopharyngeal orifice area and nasal airflow rate in 211 subjects with cleft palate or velar dysfunction, or both. The data demonstrate that nasal airflow rates above 125 cc/sec are almost always associated with velar dysfunction. Sensitivity and specificity of this index were high (0.85 and 0.96, respectively). A correct diagnosis was made in 93% of the cases. As expected, errors in judgment occurred most frequently in subjects with borderline velopharyngeal inadequacy.

Adolescent↗
PubMed2006

Velopharyngeal anatomy in 22q11.2 deletion syndrome: a three-dimensional cephalometric analysis.

OBJECTIVE: 22q11.2 deletion syndrome is the most common genetic cause of velopharyngeal dysfunction (VPD). Magnetic resonance imaging (MRI) is a promising method for noninvasive, three-dimensional (3D) assessment of velopharyngeal (VP) anatomy. The purpose of this study was to assess VP structure in patients with 22q11.2 deletion syndrome by using 3D MRI analysis. DESIGN: This was a retrospective analysis of magnetic resonance images obtained in patients with VPD associated with a 22q11.2 deletion compared with a normal control group. SETTING: This study was conducted at The Children's Hospital of Philadelphia, a pediatric tertiary care center. PATIENTS, PARTICIPANTS: The study group consisted of 5 children between the ages of 2.9 and 7.9 years, with 22q11.2 deletion syndrome confirmed by fluorescence in situ hybridization analysis. All had VPD confirmed by nasendoscopy or videofluoroscopy. The control population consisted of 123 unaffected patients who underwent MRI for reasons other than VP assessment. INTERVENTIONS: Axial and sagittal T1- and T2-weighted magnetic resonance images with 3-mm slice thickness were obtained from the orbit to the larynx in all patients by using a 1.5T Siemens Visions system. OUTCOME MEASURES: Linear, angular, and volumetric measurements of VP structures were obtained from the magnetic resonance images with VIDA image-processing software. RESULTS: The study group demonstrated greater anterior and posterior cranial base and atlanto-dental angles. They also demonstrated greater pharyngeal cavity volume and width and lesser tonsillar and adenoid volumes. CONCLUSION: Patients with a 22q11.2 deletion demonstrate significant alterations in VP anatomy that may contribute to VPD.

Adenoids↗
PubMed2003

The relationship between the characteristics of speech and velopharyngeal gap size.

OBJECTIVE: The purpose of this study was to examine the relationship between perceptual characteristics of hypernasality, nasal emission and nasal rustle, and size of the velopharyngeal gap. DESIGN: A retrospective medical chart review. SETTING: Cincinnati Children's Hospital Medical Center. SUBJECTS: Subjects were patients of the Craniofacial Anomaly Team. All were between ages 3 and 12 years and diagnosed with velopharyngeal dysfunction secondary to cleft palate +/- cleft lip. A total of 173 charts were reviewed. OUTCOME MEASURES: Speech characteristics were assessed perceptually by an experienced speech-language pathologist. Following that assessment, velopharyngeal closure was evaluated using videofluoroscopy, nasopharyngoscopy, or both. RESULTS: Based on the perceptual ratings alone, 21 subjects were diagnosed with nasal rustle only, 27 had hypernasality with nasal rustle, 89 had hypernasality with nasal emission without nasal rustle, and 36 had hypernasality with no audible nasal emission. An ordinal logit regression was conducted and showed that moderate and severe hypernasality contributed significantly to the prediction of a large gap size; nasal rustle contributed significantly to prediction of a small gap size. Perceptual characteristics of speech correctly predicted gap size for 121 of the 173 subjects (70%). CONCLUSIONS: This investigation revealed that some information regarding velopharyngeal gap size may be predicted from the speech assessment alone. Confidence in the prediction is strongest if the patient has nasal rustle, suggesting a small gap, or if the patient has moderate to severe hypernasality, which is more commonly associated with a large opening.

Child↗
PubMed2004

Air pressure responses to sudden vocal tract pressure bleeds during production of stop consonants: new evidence of aeromechanical regulation.

Two studies were conducted to evaluate short-latency vocal tract air pressure responses to sudden pressure bleeds during production of voiceless bilabial stop consonants. It was hypothesized that the occurrence of respiratory reflexes would be indicated by distinct patterns of responses as a function of bleed magnitude. In Study 1, 19 adults produced syllable trains of "puh" using a mouthpiece coupled to a computer-controlled perturbator. The device randomly created bleed apertures that ranged from 0 to 40 mm2 during production of the 2nd or 4th syllable of an utterance. Although peak oral air pressure dropped in a linear manner across bleed apertures, it averaged 2 to 3 cm H2O at the largest bleed. While slope of oral pressure also decreased in a linear trend, duration of the oral pressure pulse remained relatively constant. The patterns suggest that respiratory reflexes, if present, have little effect on oral air pressure levels. In Study 2, both oral and subglottal air pressure responses were monitored in 2 adults while bleed apertures of 20 and 40 mm2 were randomly created. For 1 participant, peak oral air pressure dropped across bleed apertures, as in Study 1. Subglottal air pressure and slope, however, remained relatively stable. These patterns provide some support for the occurrence of respiratory reflexes to regulate subglottal air pressure. Overall, the studies indicate that the inherent physiologic processes of the respiratory system, which may involve reflexes, and passive aeromechanical resistance of the upper airway are capable of developing oral air pressure in the face of substantial pressure bleeds. Implications for understanding speech production and the characteristics of individuals with velopharyngeal dysfunction are discussed.

Adolescent↗
PubMed2001

Management of velopharyngeal competence.

Velopharyngeal dysfunction is common in patients with a repaired cleft palate or unrepaired submucous cleft palates. The optimal time of surgical repair is 4 to 6 years of age after a thorough speech evaluation and speech therapy. Assessment of the velopharyngeal defect during speech allows the surgeon to customize the surgery to the patient. Patients require careful monitoring postoperatively for obstructive sleep apnea.

Child↗
PubMed1995

Management of the hypodynamic velopharynx.

Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.

Adolescent↗
PubMed2002

Temporal characteristics of aerodynamic segments in the speech of children and adults.

OBJECTIVES: The primary purpose of this study was to determine the temporal characteristics of aerodynamic segments in the normal speech of children and adults without cleft palate. A secondary objective was to determine the within-speaker variability of the segments. METHOD: Speakers consisted of 46 children aged 6 to 8 years, 41 older children aged 11 to 12 years, and 41 adults aged 18 to 37 years (total n = 128) who repeated the word "hamper" during continuous utterances. The pressure-flow method was used to determine the duration of six segments of the oral air pressure and nasal airflow pulses associated with the /mp/ sequence. Descriptive statistics, including coefficients of variation (COV), were computed for each segment as a function of age and sex of the speakers. Analysis of variance (ANOVA) procedures were used to determine the effects of age, sex, or both on the temporal variables. RESULTS: ANOVAs indicated statistically significant main effects (p <.008) for age on five of the six temporal measures and for sex on three of the six measures. Five of the six COVs were also statistically significant for age. There were no statistically significant interactions between speaker age and sex for any measure. CONCLUSIONS: The results indicate distinct patterns of timing for aerodynamic segments of speech produced by children and adults. Overall, adults exhibited less temporal variability than children. The generally longer and more variable segments produced by children suggest diagnostic and treatment implications relative to speakers with velopharyngeal dysfunction.

Adolescent↗
PubMed2004

Evaluation of fatigability of the levator veli palatini muscle during continuous blowing using power spectra analysis.

OBJECTIVE: The purpose of this study was to compare the fatigability of the levator veli palatini (LVP) muscle during blowing in speakers who exhibit velopharyngeal incompetence with that from normal speakers by means of power spectra analysis. DESIGN: All subjects were instructed to blow into a tube for more than 10 seconds at maximum possible effort. The LVP muscle activity (electromyography) was sampled at 2 kHz for 10 seconds from the time when the oral air pressure during blowing was stabilized. These samples were subjected to Fast Fourier Transfer analysis with analytic windows of 0.5-second width. The electromyography mean power frequency slope with respect to time for each subject was estimated. PARTICIPANTS: Three speakers with repaired cleft palate and three normal speakers were selected as subjects. RESULTS: The slopes of the regression lines for all three subjects with repaired cleft palate were negatively signed with statistical significance (t test, p <.01). The slopes for all of the normal speakers were negatively signed, but these were not statistically significant. CONCLUSION: These results suggest that the LVP muscle of speakers with repaired cleft palate who exhibit varying degrees of velopharyngeal dysfunction may deteriorate more easily in comparison with the LVP muscle of normal speakers.

Adult↗
PubMed1998

Pharyngoplasty in patients with cleft lip and palate after maxillary advancement.

The development of velopharyngeal incompetence and increased hypernasality after maxillary advancement has been described previously by several authors. If speech and velopharyngeal function deteriorate after maxillary advancement, pharyngoplasty is frequently the treatment procedure of choice because of the natural cause of the deficit. Of 91 cleft lip and palate patients who have undergone maxillary advancement at the Australian Cranio-Facial Unit, 23 patients received a pharyngoplasty after surgery. Thirteen of these patients who had pre- and postoperative speech evaluations were included in this study. Of the 13 patients, six patients received a superiorly based pharyngeal flap, two patients underwent an orticocheal pharyngoplasty, and five patients received either a revision or augmentation of the previous flap based on results of preoperative examinations. Serial nasendoscopic evaluations were available for 11 of these 13 patients, and they demonstrated that velopharyngeal function improved after pharyngoplasty in six patients and was unchanged in five patients. Of the 13 patients, 10 improved and three patients were unchanged on an intelligibility rating. Nine of the 13 patients demonstrated decreased hypernasality and four patients were unchanged. Hyponasality decreased in two patients increased in one patient, and was unchanged in one patient. Because the results obtained are considered acceptable, the authors conclude that pharyngoplasty can be used effectively to treat velopharyngeal dysfunction subsequent to Le Fort I maxillary advancement.

Adolescent↗
PubMed1998

Articulation and nasality changes resulting from sustained palatal fistula obturation.

OBJECTIVE: The purpose of the study was to determine differences in articulation and nasality with obturation over time in children with a palatal fistula. DESIGN: Articulation and nasality were measured with the fistula open, immediately after obturation, and 4 to 7 weeks postobturation. SETTING, PATIENTS, PARTICIPANTS: Subjects were 15 patients with a palatal fistula secondary to a repaired cleft palate who were seen through the Orofacial Program, Utah Department of Health, ranging in age from 4 years 6 months to 13 years 1 month. INTERVENTIONS: Acrylic palatal obturators were designed to provide coverage specific to the unique shape and location of each child's fistula. Obturators were cemented to molar teeth using wire clasps for control of usage. MAIN OUTCOME MEASURES: Measurements consisted of listener judgments of hypernasality, hyponasality, and nasal emissions; instrumental ratings of nasalance using the Nasometer 6200-2; and performance on a standardized articulation test. RESULTS: Significant improvement occurred only on nasal emission measures from the preobturation condition to immediate postobturation. However, significant improvement was found in articulation, listener judgments of hypernasality, nasal emissions, and Nasometric Nasal Sentence mean scores from the preobturation condition to 4 to 7 weeks postobturation and from the immediate postobturation condition to 4 to 7 weeks postobturation. No significant differences were found between conditions for listener judgments of hyponasality and Nasometric Zoo and Rainbow Passage scores. Obturation of the palatal fistula over a 4- to 7-week period resulted in no adverse effect on articulation ability, perceptual ratings of nasality, or instrumental ratings of nasalance. CONCLUSIONS: Clinical management of patients with a palatal fistula can be enhanced with treatment using obturation over time. For subjects who continue to exhibit hypernasality immediately postobturation, sustained obturation is advocated prior to consideration of surgical intervention for treatment of a palatal fistula and/or velopharyngeal dysfunction.

Acrylic Resins↗
PubMed2003

[Clinical analysis of velopharyngeal incompetence in patients with folded pharyngeal flap].

Subjects were 51 patients undergoing folded pharyngeal flap surgery for velopharyngeal incompetence at the Department of Otolaryngology of Kagawa Medical University between August 1985 and July 2001. Causal diseases were cleft palate in 27 (53%), submucous cleft palate in 8 (16%), and congenital velopharyngeal incompetence in 16 (31%). In history, 31% with congenital velopharyngeal incompetence, 25% with submucous cleft palate, and 11% with cleft palate had congenital abnormalities. In addition, 56% with congenital velopharyngeal incompetence, 38% with submucous cleft palate, and 15% with cleft palate had mental retardation, indicating that it occurred with high frequency in patients with congenital velopharyngeal incompetence. The postoperative improvement of nasality was investigated in 48 patients whose progress could be observed for more than 1 year. Of 39 preoperatively diagnosed with advanced velopharyngeal dysfunction, 34 (87%) showed improved nasality. Of 9 with preoperatively slight deficiency, 8 (89%) improved nasality. The blowing test showed no difference in results between patients who had advanced and slight deficiency. Articulation on speech level improved to be normal in 78% of patients with slight deficiency, but only in 46% of those with advanced deficiency. Improvement of articulation on a speech level was high (86%) in patients with submucous cleft palate, but low in patients with congenital velopharyngeal incompetence who had mental retardation. Further study is required to detail postoperative prognosis factors.

Adolescent↗
PubMed1998

The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: is there a learning curve?

There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of "total procedures" and "procedure per year" were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of "total procedures" was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeon's improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high-volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low-volume surgeons. The influence of the surgeon's cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty.

Cleft Palate↗
PubMed2004

Obturation of the partial soft palate defect.

A partially resected soft palate represents a more significant challenge for effective prosthodontic obturation than for complete soft palate resections. In fact, for some patients it may not be possible to prosthetically rehabilitate with partial soft palate resections, resulting in velopharyngeal dysfunction, which could include hypernasal voice quality and nasal regurgitation of food and liquids. This article presents a technique for recording the contours of a partial soft-palate defect for prosthetic obturation.

Denture Bases↗
PubMed1994

Sphincter pharyngoplasty: a preoperative and postoperative analysis of perceptual speech characteristics and endoscopic studies of velopharyngeal function.

Perceptual speech and endoscopic evaluations were videotaped preoperatively and postoperatively for 20 patients who underwent sphincter pharyngoplasty. Randomized videotapes of these evaluations were rated by clinicians experienced in assessment of patients with velopharyngeal dysfunction. Results of perceptual speech ratings showed that nasal resonance following sphincter pharyngoplasty improved in 79 percent of patients (p = 0.006), frequency of nasal emission decreased in 74 percent (p = 0.018), and severity of emission decreased in 79 percent (p = 0.006). Rating of the overall change in speech quality was not statistically greater than chance (p = 0.41). Thirty percent of patients were judged to be hyponasal postoperatively, while none had been preoperatively. Results of endoscopic evaluations showed that 75 percent of patients had a quantitative decrease in orifice size (p = 0.013). Despite improved velopharyngeal function, 65 percent of patients were still considered candidates for additional surgical management postoperatively. While sphincter pharyngoplasty resulted in improved perceptual speech characteristics and velopharyngeal function, only 18 percent of patients showed complete resolution of hypernasality and nasal emission, and only 35 percent demonstrated complete velopharyngeal closure postoperatively.

Adolescent↗
PubMed1998

Does preexisting posterior pharyngeal wall motion drive the dynamism of sphincter pharyngoplasty?

Lateral speech videofluoroscopic evaluations were videotaped preoperatively and postoperatively for 20 patients who underwent sphincter pharyngoplasty. Randomized videotapes were constructed and subsequently evaluated by speech/language pathologists experienced in assessing patients with velopharyngeal dysfunction. Rating forms assessing various motion parameters of the posterior pharyngeal wall were completed and analyzed statistically. Results showed that the posterior pharyngeal wall configuration postoperatively was less likely to be rated as smooth relative to the preoperative configuration (p = 0.019). No other statistically significant data were obtained, although there was a trend for posterior pharyngeal wall movement rated as discrete preoperatively to be described as generalized postoperatively. We conclude that when comparing preoperative and postoperative parameters, sphincter pharyngoplasty does not significantly affect posterior pharyngeal wall motion. Posterior pharyngeal wall configuration is less likely to be categorized as smooth after sphincter pharyngoplasty relative to the preoperative condition. Although sphincter pharyngoplasty has been shown to improve velopharyngeal function, there is little evidence from this study to suggest that preexisting posterior pharyngeal wall motion causes sphincteric movement.

Child↗
PubMed1996

Failed pharyngoplasty and subsequent management.

An investigation of 18 patients who had experienced "surgical failure' following pharyngoplasty for the correction of velopharyngeal dysfunction was undertaken in an attempt to identify the causes. These included poor case selection, poor surgical design and execution. Subsequent management of this group included three modalities of treatment; of the three, a carefully designed and executed surgical procedure produced the most satisfactory results in this particular patient cohort.

Adolescent↗