Evaluation of VPI-assessment with videofluoroscopy and nasoendoscopy

The purpose of this study was to investigate how different amounts of visual assessment information influence the recommended treatment for velopharyngeal insufficiency (VPI). Is a patient presented with videofluoroscopy (VF) in lateral projection recommended the same treatment as when frontal projection, nasoendoscopy, or both, are added? Retrospective material with video recorded assessment of VPI was blinded and copied in random order. Each patient was then presented in four separate combinations: VF in lateral projection; VF in lateral and frontal projection; VF in lateral projection and nasoendoscopy; and VF in lateral and frontal projection and nasoendoscopy (all of the available assessment material). The cleft palate team of Göteborg, Sweden, mutually rated velopharyngeal function and recommended action based on the presented material.

SUBJECTS

Nineteen consecutive patients (median age 7:5 years, range 4:4-19:7) investigated with VF in lateral and frontal projection and nasoendoscopy during 1997-99 at the cleft palate centre in Göteborg, Sweden. Post operative assessments were excluded. Percent agreement and Kappa calculations were used to compare the different combinations of parts of information to all of the available information.

RESULTS

Thirteen of the 19 patients (68%) were recommended the same action regardless of the amount of presented information. Percent agreement (Kappa) between parts and all of the available information: VF in lateral projection 84% (0.75), VF in lateral and frontal projection 79% (0.74), and VF in lateral projection and nasoendoscopy 84% (0.72).

CONCLUSIONS

VF in lateral projection is recommended to be the first step in visualising velopharyngeal function, and nasoendoscopy the next when further investigation is required.

Hearing and speech assessment of cleft palate patients after palatal closure. Long-term results

OBJECTIVE

The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty.

MATERIALS AND METHODS

We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity.

RESULTS

Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients.

CONCLUSIONS

Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery--an audit of 148 children born between 1985 and 1997

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications. Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed. We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery. Outcome of surgery was determined by a 'Cleft Audit Protocol for Speech' (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality. Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.

Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy--clinical assessments and cephalometric analysis: a Memorial Sloan-Kettering Study

BACKGROUND

Restoration of speech after surgical resection for oropharyngeal cancer traditionally includes maxillofacial prosthetic intervention. Relatively few publications with objective speech outcomes exist. The purpose of this study was to evaluate speech outcome relative to the size of the surgical defect, the type of speech prosthesis, and the height and position of the speech bulb in relation to the posterior pharyngeal wall in the nasopharynx.

METHODS

Fifty-five patients treated at the Memorial Sloan-Kettering Cancer Center Dental Service who underwent ablative cancer therapy were evaluated. All patients were 4 months or longer after surgery and were using a speech aid or obturator prosthesis at the time of the study. Speech samples for percent intelligibility and perceptual evaluation were collected and analyzed, in addition to aeromechanical measurements of palatopharyngeal function. Lateral cephalograms were taken while wearing the prosthesis using a radiopaque marker placed on the posterior aspect of the prosthesis for evaluating the height and position of the prosthesis obturator-speech bulb component.

RESULTS

After adjustment for the differences between listeners, findings revealed that as the percentage of resection of palate or tongue increased, the intelligibility of speech decreased. Aeromechanical assessment of speech was the only outcome measure sensitive to the type of speech prosthesis. The position of the speech bulb component, as well as the angle measured, was correlated with the percent intelligibility. The amount of the prosthesis physically contacting the posterior pharyngeal wall was not significantly associated with any of the functional outcome measures.

CONCLUSIONS

Speech aid and obturator prostheses contribute to a higher percentage of intelligible speech. A difference in intelligibility exists in relationship to the position of the prosthesis and the anterior tubercle of the atlas vertebrae (C1), both statistically and clinically. The position for optimal speech could not be specifically located mathematically (ie, 3 mm or 3 degrees inferior to the anterior tubercle of the atlas vertebrae) from the analysis. Subjective ratings of the efficacy of the obturator-speech bulbs by the clinicians did not correspond to the percent intelligibility. A strong statistical and clinical correlation exists supporting the efficacy of speech bulb-obturator intervention after velopharyngeal insufficiency for improved intelligibility of both words and sentences.

Collaboration of a dentist and speech-language pathologist in the rehabilitation of a stroke patient with dysarthria: a case study

OBJECTIVE

To elucidate the effectiveness of the collaboration of a dentist and speech-language pathologist (SLP) in the rehabilitation of a stroke patient with dysarthria.

DESIGN

A clinical case report treated in the rehabilitation hospital and dental surgery.

SUBJECT

A 71-year-old Japanese man who was admitted to the rehabilitation hospital for speech rehabilitation 2 years and 5 months after a stroke.

METHODS

Provision of prosthesis (palatal lift prosthesis + palatal augmentation prosthesis) for improving velopharyngeal incompetence (VPI) and articulation by dentist, and speech behavioural management by SLP including self-monitoring and bio-feedback training using the See-Scape.

RESULTS

Speech behavioural management proved useful for promoting improvement in speech intelligibility to a functionally sufficient level after improving VPI by prosthesis.

CONCLUSION

The collaborative efforts of the dentist and SLP in the rehabilitation of post-stroke patients with velopharyngeal incompetence should be encouraged.

Speech and swallowing following radial forearm flap reconstruction of major soft palate defects

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge. Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech. The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.

Intraoral Air Pressure Discrimination under Conditions of Experimental Velopharyngeal Insufficiency

Objective

This study assessed a single subject's ability to detect the difference limen (DLs) for his self-generated intraoral air pressure while his oral and nasal cavities were experimentally coupled.

Method

The subject, a 46-year-old man, uses a speech bulb prosthesis to cover an unrepaired cleft of his hard and soft palates. The subject's oral and nasal cavities were experimentally coupled by drilling different size holes through the speech-bulb component of the prosthesis to approximate conditions of velopharyngeal insufficiency. There were four hole-size conditions (10, 15, 20, and 30 mm2), a no-prosthesis condition, and pre- and postbaseline conditions with the prosthesis intact. The subject blew into a tube connected to a pressure transducer and was presented with a series of paired pressure loads. The first pressure load of each pair was the referent (1, 3, or 5 cm H2O), and the second was a preselected comparator load of a different amount. The subject blew into the tube with sufficient force to center the voltage meter's needle at the zero mark. The subject then reported whether the second pressure load required more, less, or equal breath pressure, compared with the referent pressure load of that pair.

Results

Size of the hole coupling the oral/nasal cavities did not significantly affect the subject's difference limen.

Conclusion

Experimental coupling of the oral/nasal cavities did not affect this subject's ability to detect differences in his self-generated intraoral air pressure.

Obstructive sleep apnoea and anaesthesia

Upper airway obstruction is common during both anaesthesia and sleep, as a result of loss of muscle tone present during wakefulness. Patients with obstructive sleep apnoea (OSA) are vulnerable during anaesthesia and sedation as the effects of loss of wakefulness are compounded by drug-induced depression of muscle activity and of arousal responses, so that they cannot respond to asphyxia. Conversely, those with 'difficult' airways during anaesthesia, either because of problems with maintenance of airway patency without tracheal intubation or because intubation itself is problematic, are at increased risk of OSA. These relationships have clinical importance. On the one hand identification of patients with OSA forewarns the anaesthetist of potential difficulty with airway maintenance intra- and postoperatively, influencing choice of anaesthetic technique and postoperative nursing environment. On the other hand difficulty with airway maintenance during anaesthesia should prompt further investigation for the possibility of OSA.

Velopharyngeal insufficiency following adenoidectomy1

Velopharyngeal insufficiency (VPI) is a well recognized but rare complication of adenoidectomy. Twenty children with this condition were seen and assessed at Great Ormond Street Hospital between 1993 and 2000. The commonest aetiology was occult submucous cleft palate (n = 5) but there was a wide range of other causes. Two children with severe behavioural disorders and normal palates developed mild symptoms, an aetiology not previously reported. Only two children had a classical submucous cleft palate. Nine children required surgical intervention and three revision procedures. Of the 15 treated children for whom follow-up data was available, 13 regained normal or near-normal speech. Many cases of postadenoidectomy VPI was not foreseeable. Following referral to a specialist cleft unit, normal or near-normal speech can be achieved in the majority with a combination of surgery and speech therapy.

Velopharyngeal Dysfunction

This tutorial addresses the complex pathophysiology; various structural and neurologic causes; methods of clinical appraisal; and alternative behavioral, prosthetic, and medicosurgical treatments of velopharyngeal dysfunction. To balance the primary focus of this review on hypernasal resonance and articulation disorders, discussions concerning hyponasal speech characteristics and underlying etiologies are also rendered.

A preoperative sleep study with nasal airway occlusion in pharyngeal flap surgery

PURPOSE

Obstructive sleep apnea is a major complication of pharyngeal flap surgery. The purpose of the present study is to predict preoperatively the risk of upper airway obstruction after surgery.

MATERIAL AND METHODS

We performed an overnight sleep study preoperatively and postoperatively in 16 pediatric patients considered for pharyngeal flap surgery. Preoperative sleep study was done for two nights, once in normal breathing condition and once with complete nasal occlusion by packing of nostril with tampon gauze.

RESULTS

In preoperative sleep recordings in normal breathing condition, all subjects had a normal apnea hypopnea index (AHI) less than 5/h. In preoperative recording with complete nasal occlusion, five patients exceeded 5/h in AHI. In particular, for two patients who had AHI higher than 15/h, we gave up a surgery in one case and performed pharyngeal flap operation for the other following a tracheotomy for severe disturbance of oral breathing. The remaining 14 subjects underwent surgery without airway obstructive complications. There was strong correlation between preoperative AHI with nasal tampon gauze and AHI at two weeks postoperatively (r = 0.88 P < .0001). There was no significant correlation between preoperative AHI in normal breathing condition and postoperative AHI (P > .05).

CONCLUSIONS

These results exhibit preoperative sleep study with complete nasal airway occlusion represent postoperative breathing condition well during early postoperative period. Preoperative sleep study with complete nasal airway occlusion with nasal tampons could be useful for predicting the risk of upper airway obstruction secondary to pharyngeal flap surgery.

Pediatric myasthenia gravis and velopharyngeal incompetence

OBJECTIVE

To determine the clinical course of velopharyngeal incompetence in children with myasthenia gravis (MG).

METHODS

A 30-year retrospective study was performed using the medical records of 538 children who presented with velopharyngeal inadequacy (VPI) to a tertiary care academic pediatric center. Children with velopharyngeal incompetence due to myasthenia gravis were identified and their clinical courses were reviewed.

RESULTS

Four children were identified with velopharyngeal incompetence associated with myasthenia gravis. All four children required intervention for improvement of speech intelligibility. A speech prosthesis was the uniform intervention.

CONCLUSION

Neonatal myasthenia gravis patients should be followed long-term as symptoms may recur as speech impairment. In addition, a high index of suspicion for this entity is required for early diagnosis due to the highly variable presentation and clinical course.

[Palatovelopharyngoplasty at the same time. Our experience in Philippines]

After many surgical charity missions in the same hospital in the Philippines, we have evaluated the child's phonation being operated of cleft palate. We had bad results so we decided to do in the same time an Orticochéa pharyngoplasty and the closure of the palate. These patients were evaluated too, the results were improved.

Sphincter Pharyngoplasty as a Treatment of Velopharyngeal Incompetence in Young People

BACKGROUND

Sphincter pharyngoplasty (SP) appears to be the more "physiologic" surgical technique to treat velopharyngeal incompetence (VPI). This procedure creates a dynamic sphincter of variable diameter and keeps the flexibility of the soft palate. SP also induces velopharyngeal size reduction, mainly in the transverse diameter, which may cause upper airway (UA) occlusions during sleep.

AIM

To prospectively evaluate the effects of SP by a modified Orticochea procedure on sleep structure and sleep respiratory disturbances.

METHODS

Polysomnographic studies before and after surgery in 17 consecutive patients treated by a modified Orticochea procedure SP for VPI.

RESULTS

For the whole group, SP did not induce significant impairment of apnea-hypopnea index or nocturnal oxygen saturation. Slow-wave sleep (SWS) was significantly reduced after surgery (25 +/- 9% of total sleep time [TST] vs 28 +/- 9% of TST before SP [p = 0.04]). Following surgery, there was a trend for an increase in the microarousal index) (p = 0.09) and more specifically in respiratory-related microarousals.

CONCLUSION

SP, although creating a clinically obvious reduction of velopharyngeal diameter, generally did not lead to the occurrence of an obstructive sleep apnea syndrome. However, we found a significant reduction of SWS quantity and a trend toward an increase in the number of cortical microarousals. These findings suggest that the reduction of UA diameter associated with the surgical technique leads to increases in respiratory effort sufficient to induce sleep fragmentation and SWS reduction, even in the absence of apneas or hypopneas.

The role of anatomic measurements of velopharynx in the indication of velopharyngeal insufficiency surgical repair

The article is focused on an evaluation of some anatomic features of velopharynx (e.g. pharyngeal depth, velar length) that are evaluated together with dynamic clinical examinations before surgery to predict the best indication for pharyngoplasty. (Tab. 3, Fig. 2, Chart 2, Ref. 10.)

Velopharyngeal insufficiency and its associated pathologies in cleft patients

OBJECTIVE

A daily contact with cleft patients affected by velopharyngeal insufficiency (VPI) of various types and origins has stimulated us to analyze the associated disorders participating in the achieved functional results. In our experience, an early palate closure (in the first year of life) reduces the incidence of VPI and therefore the need of pharyngoplasty. (Tab. 6, Fig. 1, Ref. 12.)

An Evaluation of Continuous Positive Airway Pressure (CPAP) Therapy in the Treatment of Hypernasality Following Traumatic Brain Injury

OBJECTIVE

To evaluate the effectiveness of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury (TBI).

DESIGN

An A-B-A experimental research design. Assessments were conducted prior to commencement of the program, midway, immediately posttreatment, and 1 month after completion of the CPAP therapy program.

PARTICIPANTS

Three adults with dysarthria and moderate to severe hypernasality subsequent to TBI.

OUTCOME MEASURES

Perceptual evaluation using the Frenchay Dysarthria Assessment, the Assessment of Intelligibility of Dysarthric Speech, and a speech sample analysis, and instrumental evaluation using the Nasometer.

RESULTS

Between assessment periods, varying degrees of improvement in hypernasality and sentence intelligibility were noted. At the 1-month post-CPAP assessment, all 3 participants demonstrated reduced nasalance values, and 2 exhibited increased sentence intelligibility.

CONCLUSIONS

CPAP may be a valuable treatment of impaired velopharyngeal function in the TBI population.

Naturalistic intervention in cleft palate children

AIM

To compare two modalities of speech intervention (SI) in cleft palate children with compensatory articulation disorder (CAD). The first modality was a phonologic based intervention, the second modality was a naturalistic intervention. The main purpose was to study whether a naturalistic intervention may reduce the total time of speech therapy necessary for correcting CAD in cleft palate children as compared to a phonologic intervention.

MATERIALS AND METHODS

A prospective, comparative, and randomized trial was carried out. Cleft palate children with velopharyngeal insufficiency and CAD were included in the study group. Only patients with an age ranging from 3 to 7 years were included. A total of 30 patients were selected and were divided randomly into two groups. Fifteen patients were included in the first group (control) and received phonologic SI. The other 15 patients were included in the second group (active) and received naturalistic SI. The speech pathologist in charge of the SI was the same in all cases. A blind procedure was utilized whereby each patient was evaluated independently by two speech pathologists every 3 months until both examiners were convinced that CAD had been completely corrected. The mean total time of SI required for the normalization of speech in the two groups of patients was compared.

RESULTS

Median age in the control group was 54.5 months, and 57.5 months in the active group. A Mann-Whitney rank sum test demonstrated a non-significant difference (P=0.803). The mean total time of SI in the control group was 14.53, and 16.27 in the active group. A student's t-test demonstrated that the total time of SI was not significantly reduced (P=0.331) when a naturalistic intervention was utilized.

CONCLUSIONS

Naturalistic based SI did not reduce the time necessary for correcting CAD in cleft palate children.

[The analysis of formant characteristics of vowels in the speech of patient with cleft palate]

OBJECTIVE

To analyze the formant frequency of vowels in the sequence therapy of patient with cleft palate.

METHODS

The formant frequency of vowels [a], [e], [i], [u] of normal children and postoperative patients with and without speech therapy was measured and analyzed by VS-99.

RESULTS

1. The mean value of F1, F2, F3 of [a] did not show significant difference among the three groups (P > 0.05). 2. The difference of mean value of [e] was significant between control group and pre-speech-therapy group, and between pre-speech-therapy and post-speech-therapy group (P < 0.05), but no significant difference was found between post-speech-therapy and control group(P > 0.05). The mean value of the formant in post-speech-therapy was higher than that of pre-speech-therapy. 3. The difference of mean value of [i] was significant between pre-speech-therapy and post-speech-therapy (P < 0.05), the mean value of F2, F3 in post-speech-therapy group decreased significantly compared with control (P < 0.05). 4. The difference of mean value of [u] showed significance between pre-speech-therapy and post-speech-therapy (P < 0.05), while the differences among other groups were insignificant (P > 0.05).

CONCLUSION

Surgical repair of cleft palate cannot make all patients obtain perfect Velopharyngeal competence (VPC), while speech therapy can improve patient's pronunciation. Speech spectrum analysis can judge the effect of cleft palate therapy objectively.

Velopharyngeal Incompetence:

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.

Management of Velopharyngeal Dysfunction: Differential Diagnosis for Differential Management

A single surgeon's 20 year experience in one cleft center with differential diagnosis for differential management of velopharyngeal dysfunction (VPD) is reviewed. The specific diagnostic and functional status of each affected individual is determined to select the method of VPD management. Two types of diagnostic evaluation of velopharyngeal function, perceptual and instrumental, are used to make that determination. There are four broad etiologic categories of VPD: anatomic deficiency, myoneural deficiency, anatomic and myoneural deficiency, and neither anatomical nor myoneural deficiency. The type of VPD management is specific for each etiologic category. The management options are between prosthetic appliances (lift, obturator, "liftorator") and operations (intravelar veloplasty, velar Z-plasty, pharyngeal flap, sphincter pharyngoplasty, posterior pharyngeal wall augmentation). The objective of differential management based on differential diagnosis is to optimize the function of the velopharynx for speech tasks while minimizing the morbidity of the intervention on the upper airway. A personal experience, in the context of an interdisciplinary cleft team, with such an approach over the past 20 years validates the assumption that differential management of VPD based on differential diagnosis can achieve this goal.

Refinement of the free radial forearm flap reconstructive technique after resection of large oropharyngeal malignancies with excellent functional results

BACKGROUND

Wide resection of oropharyngeal malignancies implicates the risk of velopharyngeal insufficiency, which can cause nasal regurgitation and hypernasality. A meticulous reconstruction is necessary to avoid impairment and handicap in deglutition and speech. In the classic reconstructive techniques for large oropharyngeal defects, functional outcome only regards deglutition. We also focus on nasality, because hypernasality often occurs as a consequence in this type of reconstruction.

METHODS

In four patients, the surgical defect is closed with a free radial forearm flap sutured to the posterior side of the hard palate, thus imitating a caudally based pharyngeal flap. Speech is assessed by an independent speech pathologist, perceptually and acoustically. Deglutition is evaluated by a questionnaire and videofluoroscopy.

RESULTS

All patients had normal food intake. They did not report alterations in speech quality or verbal communication. Perceptual evaluation of articulation, voice, and nasality was optimal. Objective measurements with acoustical analysis and nasality scores confirmed the excellent functional outcome. Videofluoroscopy showed an unimpaired bolus transport with a complete velopharyngeal closure and optimal oral and pharyngeal clearance times.

CONCLUSIONS

This meticulous reconstructive technique ensures an excellent functional outcome. The absence of nasality, in particular, proves the value of this refinement. The technique allows wide surgical margins and complete velopharyngeal closure.

Cleft palate with congenital midline teratoma

A 4-year-old girl presented with hypernasal speech. On examination, in addition to velopharyngeal incompetence noted by speech examination, a palatal tumor was found in between the cleft palate. The computed tomographic and magnetic resonance imaging examinations were suspicious for midline teratoma. Total excision of the nasopalatal tumor was performed, and the pathology revealed benign teratoma. After 6 months of follow-up, no recurrence was noted. A two-flap palatoplasty with a superior-based pharyngeal flap was then performed to reconstruct the palatal defect and to correct the velopharyngeal incompetence. An anterior oronasal fistula developed after the operation, but a tongue flap was transferred to cover the defect successfully. The purpose of this case report is to present the relationship between a congenital midline nasopalatal tumor and cleft palate.