Proposal for a New Exercise Method for Dysphagia with Velopharyngeal Inadequacy: A Case of Bickerstaff's Brainstem Encephalitis

Bickerstaff's brainstem encephalitis is an autoimmune disease with the primary lesion situated in the brainstem and three cardinal signs: ophthalmoplegia; ataxia; and impaired consciousness. A 68-year-old man was started on rehabilitation exercise 3 months after onset of Bickerstaff's brainstem encephalitis, due to remnant dysarthria and dysphagia (Functional Oral Intake Scale, level 5) after the cardinal signs of Bickerstaff's brainstem encephalitis resolved. Exercise involved using a straw in the anterior midline between the dorsal tongue and hard palate. While the patient was inhaling through the straw, the straw was blocked. After strengthening suction as much as possible, the patient was asked to immediately dry swallow at the same time that suction was stopped. Effects of exercise were examined using videofluorographic swallowing studies before and after 6 weeks of training to compare posterior and superior velar displacements and the presence of nasopharyngeal reflux. No adverse effects of exercise were encountered, and Functional Oral Intake Scale improved to level 7, with significant increases in posterior and superior velar displacement during swallowing compared with before training. In addition, nasopharyngeal reflux that had consistently been seen on swallowing before training was absent after 6 weeks of exercise. This exercise method may prove useful.

Velopharyngeal insufficiency in hemifacial microsomia: Analysis of correlated factors

OBJECTIVE: To investigate the incidence of unilateral hypodynamic palate (UHP) and velopharyngeal insufficiency (VPI) in hemifacial microsomia (HFM), and to determine the dysmorphic manifestations having significant associations with UHP/VPI in HFM.

STUDY DESIGN: This was a nonrandomized study of 48 patients with unilateral HFM without cleft palate. The correlation between each anomaly and UHP/VPI was analyzed statistically. In addition, we observed 4 HFM patients with cleft palate to examine the influence on cleft palate speech.

RESULTS: The incidence of UHP in HFM was 50.0% and that of VPI was 14.6%. All the VPI patients had UHP. Severe micrognathia and soft tissue deficiency, macrostomia, and mental retardation were significant risk factors for developing VPI in HFM. Moreover, UHP exacerbated speech in HFM with cleft lip and palate.

CONCLUSIONS: Significant correlations were detected between VPI and HFM. This finding should be helpful in the overall management of HFM.

© 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Long term speech outcomes following late cleft palate repair using the modified Furlow technique

OBJECTIVES

Published reports and previous studies from our institution have reported worse overall speech results, including significantly higher rates of persistent articulation errors, in patients undergoing palatoplasty at age >18 months. This study further investigates the effects of late repair on long term speech outcomes.

METHODS

A retrospective review was performed of non-syndromic patients undergoing primary palatoplasty at age >18 months between 1980 and 2006 at our institution. Longitudinal speech results were compared based on reason for late repair and age at repair.

RESULTS

Forty-one patients were greater than 18 months of age at the time of palatoplasty, and 24 fit criteria for longitudinal data analysis. There was a statistically significant improvement in nasality scores at Time Point 1 for international adoptees compared to the non-adopted population (p=0.04). Patients with submucosal clefts were found to have significantly less severe nasal emission scores at Time Point 1 compared to those with overt clefts (p=0.04), but not at Time Point 2. There were no significant differences between scores if repair was performed between 18 and 36 months or >36 months, nor any difference in incidence of articulation errors between subgroups of patients with late repair at either Time Point.

CONCLUSION

Our experience demonstrates that cleft palate repair after 18 months of age is associated with a significantly increased incidence of articulation errors associated with VPI, irrespective of reason for late repair, highlighting the persistence of learned compensatory behaviors in speech and the importance of proceeding with early repair.

Management of soft palate agenesis in Nager syndrome with an elongated, superiorly based pharyngeal flap

Nager syndrome, or preaxial acrofacial dysostosis, is associated with aberrant development of the first and second branchial arch structures, as well as abnormal development of the limb buds. It is a rare disorder, and its clinical manifestations have not been completely defined. Absence of the soft palate has been reported in patients with Nager syndrome. In this report we describe the use of an elongated, superiorly based pharyngeal flap for the treatment of severe velopharyngeal insufficiency in a patient with Nager syndrome and absence of the soft palate. We also describe the dysmorphisms associated with Nager syndrome and present a differential diagnosis for the condition.

Management of velopharyngeal disorder with a pharyngeal obturator: a case report

Patients with acquired defects or congenital malformations of the palate reveal disturbances in speech, including hypernasality, nasal emission, and decreased intelligibility of speech. Deglutition is also affected. All of these side effects have a negative impact on the psychological and social status of the patient. Maxillofacial prosthetic treatment can restore the palatopharyngeal integrity and offer the potential for acceptable speech using a pharyngeal obturator, also known as a speech aid prosthesis. This article describes the prosthodontic management of a patient with a palatopharyngeal defect using a pharyngeal obturator.

The influence of the design of removable dentures on patient's voice quality

The main condition for speech intelligibility is the specific anatomical characteristics of the human speech apparatus and harmonious work of all organs in the human vocal apparatus. The voice quality is characterized by speech intelligibility (relationship between the voice pitch, volume, timbre and speech speed). Improper functional quality (related to retention,support, stability), inappropriate design of the prosthetic base and disposition of artificial teeth are the basic reasons for dyslalia - impairment of utterance with abnormality of external speech organs. In the case of dyslalia a patient may suffer from a defective utterance of separate phonemes. When designing removable dental prostheses, it is important to evaluate the disposition of the artifical teeth (taking into account phonetic pronunciation), make a phonetically beneficial construction of the base of the dentures and restore the lost alveolar bone with the basis of removable prostheses. The aim of this study was to review literature on voice quality and the way it can be affected after the insertion of removable dental prostheses and to research the literature describing the ways how voice quality can be improved. The literature reviewed in the paper was retrieved from Science Direct, PubMed, MD Consult, Cochrane Libary databases and dates back to the period from 1990 to 2012.

Autologous fat transplantation to the velopharynx for treating persistent velopharyngeal insufficiency of mild degree secondary to overt or submucous cleft palate

BACKGROUND

Autologous fat transplantation to the velopharynx has been described in a few smaller studies including heterogeneous groups of patients for the treatment of velopharyngeal insufficiency (VPI). The aim of this study was to evaluate speech and to measure velopharyngeal closure with magnetic resonance imaging (MRI) in patients who underwent autologous fat transplantation for the treatment of persistent VPI of mild degree secondary to overt or submucous cleft palate.

METHODS

A prospective study of 16 patients with persistent VPI of mild degree secondary to overt or submucous cleft palate who underwent autologous fat transplantation to the velopharynx. The patients were injected with a median of 5.6 (3.8-7.6) ml autologous fat to the velopharynx. Pre- and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. Hypernasality, hyponasality, nasal turbulence and audible nasal emission were scored on a five-point scale. Pre- and 1-year postoperative MRIs were obtained during vocal rest and during phonation in 12 patients. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane.

RESULTS

Hypernasality improved significantly (p=0.030), but not audible nasal emission (p=0.072) or nasal turbulence (p=0.12). The velopharyngeal distance during phonation decreased significantly (p=0.013), but not the velopharyngeal gap area (p=0.16). There was no significant correlation between speech and MRI results.

CONCLUSION

Autologous fat transplantation to the velopharynx improved hypernasality significantly, but not audible nasal emission or nasal turbulence in patients with persistent VPI of mild degree secondary to overt or submucous cleft palate. Given the low number of patients and the lack of a control group, the value of fat transplantation for the treatment of mild VPI is not proven for sure.

Bassoonists' medical problems-current state of knowledge

Specific musical instruments can be a source of physical problems to their players. Based on reviews of the literature and personal experience, this paper summarizes current knowledge of problems affecting musicians who play instruments in the bassoon family (including the bassoon, contrabassoon, and several other instruments). Prevalence rates are higher in reports of surveys (ranging up to 86%), compared to clinical reports of patients seen and treated. Significant risk factors include young age, small body size, female gender, and use of large instruments. Problems unique to bassoonists are rare; most physical difficulties also are seen in general musculoskeletal clinical practices and in musicians playing all types of instruments. The left upper extremity is more commonly affected by overuse-related conditions in bassoonists. Non-playing-related problems are equally important for consideration (such as degenerative disorders and acute trauma), since they also affect practice and performance. Little experimental data exist to validate current and widely-held principles of treatment, rehabilitation, and prevention.

Velopharyngeal, speech and dental characteristics as diagnostic aids in 22q11.2 deletion syndrome

This study examines velopharyngeal, speech, and dental parameters as possible diagnostic aids in 22q11.2 deletion syndrome. It is a retrospective study on 56 individuals. Twenty-one percent had a submucous cleft palate and 41 percent required palate surgery for speech. Common dental findings included poor oral hygiene, multiple carious lesions, congenitally missing teeth, class II malocclusion, and open bite.There are common findings that can aid the dental practitioner in recognizingthe syndrome and make appropriate referrals.

Subthalamic nucleus deep brain stimulation changes velopharyngeal control in Parkinson's disease

PURPOSE

Adequate velopharyngeal control is essential for speech, but may be impaired in Parkinson's disease (PD). Bilateral subthalamic nucleus deep brain stimulation (STN DBS) improves limb function in PD, but the effects on velopharyngeal control remain unknown. We tested whether STN DBS would change aerodynamic measures of velopharyngeal control, and whether these changes were correlated with limb function and stimulation settings.

METHODS

Seventeen PD participants with bilateral STN DBS were tested within a morning session after a minimum of 12h since their most recent dose of anti-PD medication. Testing occurred when STN DBS was on, and again 1h after STN DBS was turned off, and included aerodynamic measures during syllable production, and standard neurological ratings of limb function.

RESULTS

We found that PD participants exhibited changes with STN DBS, primarily consistent with increased intraoral pressure (n=7) and increased velopharyngeal closure (n=5). These changes were modestly correlated with measures of limb function, and were correlated with stimulation frequency.

CONCLUSION

Our findings suggest that STN DBS may change velopharyngeal control during syllable production in PD, with greater benefit associated with low frequency stimulation. However, DBS demonstrates a more subtle influence on speech-related velopharyngeal control than limb motor control. This distinction and its underlying mechanisms are important to consider when assessing the impact of STN DBS on PD.

LEARNING OUTCOMES

As a result of this activity, the participant will be able to (1) describe the effects of deep brain stimulation on limb and speech function; (2) describe the effects of deep brain stimulation on velopharyngeal control; and (3) discuss the possible reasons for differences in limb outcomes compared with speech function with deep brain stimulation of the subthalamic nucleus.

The submucous cleft palate: diagnosis and therapy

OBJECTIVES

To investigate age of diagnosis, typical symptoms, finding of the palate, therapy options and accompanying diseases.

METHODS

A retrospective analysis of 439 patients with symptomatic submucous cleft palate (SMCP), who received a veloplasty operation (butterfly suture technique developed by Haase) was made.

RESULTS

SMCP was initially diagnosed at the mean age of 4.9 years. Main symptoms were hyper nasal speech (51%) and conductive hearing loss (45%), which resolved after veloplasty (often in combination with adenotomy and insertion of ventilation tubes). Typical findings of the palate were a lack of posterior nasal spine (68%) and bifid uvula (59%). Following surgery 17.1% required speech therapy and 5.5% needed velopharyngoplasty due to continuing hyper nasal speech.

CONCLUSION

SMCP is often diagnosed very late, though symptoms of velopharyngeal insufficiency (hyper nasal speech, Eustachian tube dysfunction) and bifid uvula are present. We therefore recommend that all patients with such findings are examined by an appropriate specialist such as Phoniatrics, Otolaryngologist and Oral-Maxillofacial-Surgeon so that early diagnosis and palatoplasty can be performed. The veloplasty operation (butterfly suture technique) can be recommended as a safe therapy for velopharyngeal insufficiency for patients with symptomatic SMCP.

Functional anatomy of the soft palate applied to wind playing

Wind players must be able to sustain high intraoral pressures in order to play their instruments. Prolonged exposure to these high pressures may lead to the performance-related disorder velopharyngeal insufficiency (VPI). This disorder occurs when the soft palate fails to completely close the air passage between the oral and nasal cavities in the upper respiratory cavity during blowing tasks, this closure being necessary for optimum performance on a wind instrument. VPI is potentially career threatening. Improving music teachers' and students' knowledge of the mechanism of velopharyngeal closure may assist in avoiding potentially catastrophic performance-related disorders arising from dysfunction of the soft palate. In the functional anatomy of the soft palate as applied to wind playing, seven muscles of the soft palate involved in the velopharyngeal closure mechanism are reviewed. These are the tensor veli palatini, levator veli palatini, palatopharyngeus, palatoglossus, musculus uvulae, superior pharyngeal constrictor, and salpingopharyngeus. These muscles contribute to either a palatal or a pharyngeal component of velopharyngeal closure. This information should guide further research into targeted methods of assessment, management, and treatment of VPI in wind musicians.

Effect of a palatal lift prosthesis in individuals with velopharyngeal incompetence

PURPOSE

The aim of this study was to assess the effect of a palatal lift prosthesis (PLP) on the speech intelligibility of cleft palate patients treated with pharyngeal flap surgery, the minimum duration required for improvement in nasality, and the sustenance of speech improvement after removing the appliance.

MATERIALS AND METHODS

Seven patients ranging between 16 and 26 years of age were recruited for this study. These subjects had velopharyngeal dysfunction secondary to a surgically corrected cleft palate, which failed to improve following pharyngeal flap surgery. A PLP was given to these patients and improvements in speech intelligibility were assessed using two speech examinations: perceptual analysis and nasometry. The nasal resonance, nasal air emission, and articulation were measured prior to the insertion of the prosthesis and at the end of every month for the next 3 months, following which the prosthesis was removed and the tests were repeated.

RESULTS

There was a statistically significant decrease in nasalance percentage at the end of the 3 months, and it was found that this improvement in speech persisted even after the removal of the prosthesis.

CONCLUSIONS

A PLP, when used for a minimum duration of 3 months, causes a significant decrease in nasal resonance, thereby improving speech intelligibility in patients who failed to see improvement following pharyngeal flap surgery for velopharyngeal incompetence.

Nasoendoscopy of velopharynx before and during diagnostic therapy

Nasoendoscopy is an important tool for assessing velopharyngeal function. The purpose of this study was to analyze velar and pharyngeal wall movement and velopharyngeal gap during nasoendoscopic evaluation of the velopharynx before and during diagnostic therapy. Nasoendoscopic recordings of 10 children with operated cleft lip and palate were analyzed according to the International Working Group Guidelines. Ratings of movement of velum and pharyngeal walls, and size, location and shape of gaps were analyzed by 3 speech-language pathologists (SLPs). Imaging was obtained during repetitions of the syllable /pa/ during a single nasoendoscopic evaluation: (a) before diagnostic therapy, and (b) after the children were instructed to impound and increase intraoral air pressure (diagnostic therapy). Once the patients impounded and directed air pressure orally, the displacement of the velum, right, left and posterior pharyngeal walls increased 40, 70, 80, and 10%, respectively. Statistical significance for displacement was found only for right and left lateral pharyngeal walls. Reduction in gap size was observed for 30% of the patients and other 40% of the gaps disappeared. Changes in gap size were found to be statistically significant between the two conditions. In nasoendoscopic assessment, the full potential of velopharyngeal displacement may not be completely elicited when the patient is asked only to repeat a speech stimulus. Optimization of information can be done with the use of diagnostic therapy's strategies to manipulate VP function. Assuring the participation of the SLP to conduct diagnostic therapy is essential for management of velopharyngeal dysfunction.

Uvulopalatopharyngoplasty and uvulopalatal flap for the treatment of snoring: technique to avoid complications

OBJECTIVE

To review the outcome of 50 snoring patients treated with uvulopalatopharyngoplasty and uvulopalatal flap, looking for a decrease in the surgical complications rate.

DESIGN

A longitudinal, prospective, self-controlled pilot study.

SETTING

Sleep Disorders Clinic of the National University of Mexico and Angeles Lomas Hospital.

MATERIAL AND METHODS

Fifty consecutive patients underwent surgical treatment for snoring. The Müller manoeuvre was performed in all of them to determine the site of obstruction. In all cases, the bed partner was asked about the presence of snoring before and 6 months after the procedure. Polysomnography was performed before and after the surgery to assess sleep apnea in all patients and to determine the success regarding the snoring index. Every complication was registered.

RESULTS

All patients had only habitual snoring, without sleep apnea. Thirty-eight males and 12 females were included in the study. At the sixth postoperative month, the bed partner of 48 patients (96%) reported that snoring was gone, 2 (4%) said that snoring was no longer a problem, the initial snoring index mean was 214, and 6 months after the procedure it decreased to 12. No patients had any complication related to the surgical procedure.

CONCLUSIONS

Despite the fact that there are a number of techniques for snoring and sleep apnea, we achieved good postoperative results while avoiding the most common complications.

Les séquelles vélopharyngées des fentes labioalvéolopalatovélaires. Les pharyngoplasties dynamiques types orticochea

Sphincter pharyngoplasty is one of the treatments for velopharyngeal insufficiency, in cleft palate patients. After Hynes, Orticochea described a procedure which became the reference. After studying 2 series of patients treated by two different surgical procedures, it appeared that the speech improvement was nearly the same. Improvement of the results was obtained when the surgical procedure took into account the physiopathology of the velopharyngeal insufficiency. When the velar mobility was weak or absent, but with an effective mobility of lateral pharyngeal walls, a pharyngoplasty with a pharyngeal flap and a superior pedicle was chosen. On the opposite, with an effective velar mobility, sphincter pharyngoplasty was chosen. When both were poor (velar and lateral pharyngeal walls), it seems that using a pharyngeal flap with a velum pushback gave the best result. If hypernasality persisted after pharyngoplasty, a second procedure had to be performed.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Analyse, bilan et prise en charge orthophonique

The association of voice and speech defines phonation. Phonation depends on various organs: the lungs for air, the larynx as a vibration generator, and cavities of resonance modeling articulation and tone. The role of the soft palate is important in French and for everyday conversation. Velopharyngeal incompetence is defined as a voice and articulation disruption by anatomic and/or functional deficiency between the soft palate and pharynx. Hypernasality is studied on an acoustic, phonetic, and vocal level and graded in various degrees of hypernasality. The various clinical and perceptive tests of velopharyngeal incompetence are described according to age. The difficulty to modelize hypernasality is discussed based on a recent study published in 2007. The differential diagnosis with hyper-closed nasality is discussed. The treatment for this condition is essentially speech therapy associated with pharyngoplasty in some cases. The assessment of children born with a labial-alveolar-velopalatine cleft is mainly clinical and perceptive. Therapeutic management is necessary for the child and his family. The follow-up requires a multidisciplinary approach.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Véloplasties et pharyngoplasties par lambeau pharyngé à pédicule supérieur ou inférieur

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.

Formen der velopharyngealen Dysfunktion bei Spaltpatienten

BACKGROUND

Velopharyngeal dysfunction (VPD) is generally known to be difficult to influence. Dysfunctional velopharyngeal motor patterns during speech were analyzed with the aim of optimizing the therapeutic strategies.

METHODS

Velopharyngeal dysfunctions were videotaped and contextually analyzed during 89 speech sequences in 25 patients. Distinctive features of the motor patterns formed the basis of categorization by three therapists experienced in nasopharyngoscopy. There was a high inter-rater reliability of 94%.

RESULTS

A total of four different function profiles were found: 1. VPD with retracted articulatory placement (compensatory articulation) (38%), 2. VPD with motor coordination problems characterized by mistiming of VP movements and voice onset/offset (15%), 3. VPD with verbal dyspraxia characterized by a silent positioning of VP closure before phonation started and a malregulation of muscle tonus (10%) and 4. phoneme-specific VPD (37%).

CONCLUSION

Specific knowledge regarding the characteristics of dysfunctional speech motor patterns enables specifically tailored therapy.

[Sequels of labial-alveolar-velopalatine clefts observed in charity missions. Analysis and management]

A lot of children with cleft lip and palate are not operated in the developing world, due to a lack of surgeons, hospitals, or simply because the condition is not considered as a priority. Charity missions give the opportunity to repair these malformations. Non-operated cleft lip and palate are the first problem, but our surgery may cause growth disturbances and sometimes a second operation is needed, more difficult than the first one in mission conditions. Repairing a cleft palate needs to be adapted to the type of cleft but also to the age of the child, a velopalatine pharyngoplasty can be performed in some cases.

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth

BACKGROUND

Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth.

METHODS

A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis.

RESULTS

Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm.

CONCLUSION

The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Speech in 6 Year Old Children With Sub-Mucous Cleft Palate

Speech in 83 children (in total) with sub-mucous cleft palate was evaluated at the age of 6 years. Velopharyngeal insufficiency was graded on the basis of perceptual assessment, taking into account the co-existence of various velopharyngeal insufficiency characteristics in speech. Out of 56 patients operated with a velopharyngeal flap to eliminate velo-pharyngeal insufficiency, 42 of them (75%) achieved normal velopharyngeal function in speech. Dento-alveolar misarticulations were found in 35% of the children. Misar-ticulations occurred independently of velopharyngeal insufficiency.