Non-cleft causes of velopharyngeal dysfunction: implications for treatment

An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis

BACKGROUND

Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature.

METHODS

This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications.

RESULTS

The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases.

CONCLUSIONS

Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.

Soft Palate Dysplasia: Properties and Surgical Techniques

BACKGROUND

The authors aimed to report a hitherto undescribed class of patients with the obvious phenotype of a novel soft palate dysplasia (SPD) combining unilateral soft palate hypoplasia with a fully developed uvula. The authors also aimed to investigate and evaluate the corresponding surgical approaches.

METHODS

Twelve patients were clinically diagnosed with SPD. Clinical examination, including radiographic tests, was performed to characterize the congenital deformity. The effectiveness of velopharyngeal closure and speech were tested preoperatively and postoperatively.

RESULTS

SPD was featured with velopharyngeal insufficiency, food regurgitation, and speech disorders. It was commonly manifested as structural deformities of the soft palate, tongue palatine arch, pharyngeal palatine arch, and pterygomandibular fold, but with complete uvula shape. According to radiographic analysis, in five patients, the lateral pterygoid processes were poorly developed, and other malformations were present. Velopharyngoplasty based on the unilateral posterior pharyngeal flap can well restore the velopharyngeal closure and speech intelligibility without respiration obstruction.

CONCLUSIONS

SPD is characterized as congenital velopharyngeal insufficiency manifested as a primary soft palate defect. It is highly associated with other physical deformities but independent of conventionally known syndromes. The cause may be an abnormal development of the pterygoid process. Unilateral velopharyngoplasty based on the posterior pharyngeal flap is a great technique to repair SPD.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Incidence of Velopharyngeal Insufficiency in Stickler Syndrome

OBJECTIVE

Stickler Syndrome (SS) is an inherited collagenopathy characterized by heterogenous orofacial, ocular, auditory, and skeletal abnormalities. The orofacial manifestations are variable and some patients present with cleft palate and velopharyngeal insufficiency (VPI). The incidence of VPI in SS is poorly studied and no studies have compared the incidence of VPI between Type I (COL2A1) and Type II (COL11A1) SS. The objective of this study is to compare the incidence of VPI between SS subtypes and discuss the surgical techniques used to treat them.

DESIGN

Single-institution, retrospective chart review.

SETTING

Tertiary pediatric hospital.

PATIENTS/PARTICIPANTS

Forty-three children were diagnosed with SS between January 2003 and December 2018. Genetic testing results, genetics notes, craniofacial clinic notes, and operative reports were reviewed. Patients without genetic testing or craniofacial/otolaryngologic evaluation were excluded. Thirty-one patients met criteria and were included.

MAIN OUTCOME MEASURE

Primary outcome was VPI incidence.

RESULTS

There were 18 patients with Type I SS and 13 with Type II SS. Five (16%) patients had VPI, 2 (11%) with Type I SS compared to 3 (23%) with Type II SS (P > .05). All patients with VPI underwent surgery with either sphincter pharyngoplasty (3) or pharyngeal flap (2). Two patients with Type II SS underwent revision sphincter pharyngoplasty, with one conversion to pharyngeal flap.

CONCLUSION

VPI is common for patients with SS. In this study, there was no significant difference in the incidence of VPI between SS subtypes. Future studies are needed to confirm these findings, which could be important for patient counseling and treatment planning.

Velopharyngeal insufficiency, speech, and language impairment in craniofacial microsomia: a scoping review

This review provides a comprehensive overview of the literature on velopharyngeal insufficiency, associated anomalies, and speech/language impairment in patients with craniofacial microsomia (CFM). A systematic search of the literature was conducted to identify records on VPI and speech impairment in CFM from their inception until September 2022 within the databases Embase, PubMed, MEDLINE, Ovid, CINAHL EBSCO, Web of Science, Cochrane, and Google Scholar. Seventeen articles were included, analysing 1,253 patients. Velopharyngeal insufficiency results in hypernasality can lead to speech impairment. The reported prevalence of both velopharyngeal insufficiency and hypernasality ranged between 12.5% and 55%, while the reported prevalence of speech impairment in patients with CFM varied between 35.4% and 74%. Language problems were reported in 37% to 50% of patients. Speech therapy was documented in 45.5% to 59.6% of patients, while surgical treatment for velopharyngeal insufficiency consisted of pharyngeal flap surgery or pharyngoplasty and was reported in 31.6% to 100%. Cleft lip and/or palate was reported in 10% to 100% of patients with CFM; these patients were found to have worse speech results than those without cleft lip and/or palate. No consensus was found on patient characteristics associated with an increased risk of velopharyngeal insufficiency and speech/language impairment. Although velopharyngeal insufficiency is a less commonly reported characteristic of CFM than other malformations, it can cause speech impairment, which may contribute to delayed language development in patients with CFM. Therefore, timely recognition and treatment of speech impairment is essential.

A custom nasal obturator for velopharyngeal dysfunction: A dental technique

Removable nasal obturators provide a treatment option for a range of patients presenting with velopharyngeal dysfunction without eliminating the possibility for future surgery, speech therapy, or the provision of other devices. The presented technique describes the fabrication of a 1-piece silicone nasal obturator to reduce hypernasality and nasal airflow errors without causing significant hyponasality. The obturator has minimal visibility and minimal risk of inhalation.

Velopharyngeal Incompetence in Musicians: A State-of-the-Art Review

The velopalatine sphincter is a muscular valve that creates a hermetic seal between the nasopharynx and the oropharynx. It guarantees phonation, swallowing, and breathing (forces expirations). In wind musicians, sphincter closure must be precise during sound generation. Its failure will cause velopharyngeal incompetence (VPI) and the end of professional success. The objective of this article was to conduct a state-of-art review of VPI in wind musicians with a systematic approach based on the PRISMA Statement. The etiology, epidemiology, clinic, diagnosis, and treatment of VPI in wind musicians were evaluated. The research was carried out in different databases (PubMed/MEDLINE, the Cochrane Library, Scielo) and through the Mergullador metasearch engine. A total of 20 publications were selected. VPI is a pathology that affects around one-third of wind musicians according to studies. It causes pharyngeal noises and nasal air emissions during performance. The main etiology seems to be the fatigue of the velopalatine sphincter muscles. The most used diagnostic techniques consist of clinical history, physical examination, and nasofibroscopy. There is no consensus among authors about therapeutic management. Future investigations are necessary to confirm that fatigue of velopalatine sphincter muscles and other factors that increase it are the main causes of VPI in wind musicians.

Articulating the issues: speech assessment and intervention in cleft lip and palate

This paper describes the impact of cleft lip and palate on speech. It provides an overview for the dental clinician of the key issues affecting speech development and clarity. The paper summarises the complex speech mechanism and cleft-related factors that affect speech, including palatal, dental and occlusal anomalies. It outlines the framework for speech assessment throughout the cleft pathway and provides a description of cleft speech disorder, as well as describing treatment approaches for cleft speech and velopharyngeal dysfunction.This is followed by a spotlight on speech prosthetics for treating nasal speech, with an emphasis on joint management by the Speech and Language Therapist and Consultant in Restorative Dentistry. This includes the core multidisciplinary approach, clinician and patient-reported outcome measures, and brief discussion of national developments in this area.The importance of multidisciplinary cleft care is highlighted and, within this, the essential interaction between speech and dental clinicians in providing routine care, as well as in delivering a highly specialist speech prosthetics service.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

Clinical perspectives on nasopharyngeal morphology in humans

The nasopharynx is an integral component of the upper aerodigestive tract, whose morphologic features share an intimate relationship with a vast array of clinical, functional, and quality of life conditions related to contemporary humans. Its composite architecture and central location amidst the nasal cavity, pharyngotympanic tube, palate, and skull base bears implications for basic physiologic functions including breathing, vocalization, and alimentation. Over the course of evolution, morphological modifications of nasopharyngeal anatomy have occurred in genus Homo which serve to distinguish the human upper aerodigestive tract from that of other mammals. Understanding of these adaptive changes from both a comparative anatomy and clinical perspective offers insight into the unique blueprint which underpins many clinical pathologies currently encountered by anthropologists, scientists, and otorhinolaryngologists alike. This discussion intends to familiarize readers with the fundamental role that nasopharyngeal morphology plays in upper aerodigestive tract conditions, with consideration of its newfound clinical relevance in the era of the COVID-19 pandemic.

Velopharyngeal Inadequacy-Related Quality of Life Assessment: The Instrument Development and Application Review

Objective

For the patient-reported outcome (PRO) measures related to patients with velopharyngeal inadequacy (VPI), different quality of life (QOL) instruments have been developed. The present systematic review was designated to identify current VPI-related QOL instrument development, validation, and applicability.

Methods

Pubmed, Cochrane, Embase, Web of Science, and EBSCO databases were searched in January 2022. “Velopharyngeal” or “palatopharyngeal” and “quality of life” or “life quality” were searched in title, abstract, and keywords. This study followed Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Two investigators independently reviewed abstracts and full texts of the identified literature. An established checklist was used to evaluate the measurement properties of each identified instrument.

Results

A total of 375 articles and 13 instruments were identified, which can be divided into nine types of families according to their development procedures. Developmental and measurement characteristics, evidence of conceptual model, content validity, reliability, construct validity, scoring, interpretation, respondent burden, and presentation for all instruments were shown.

Conclusion

The patient's self-report assessment and parent-proxy assessment are both valuable. The conclusion that any QOL instrument is absolutely the best for patients with velopharyngeal inadequacy could not be drawn. Understanding the development and characteristics of different QOL instruments, including their reliability, validity, aim, target, language, and resource, should be important before application in clinic or research.

Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques

BACKGROUND

The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors.

METHODS

A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age.

RESULTS

Mean perceptual scores improved significantly postoperatively (p < .0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p < .001, p < .02], [audible nasal emissions: p < .002, p < .05], [velopharyngeal function: p < .001, p < .05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p < .001) or sphincter pharyngoplasty (66.7%, p < .001). No significant difference was identified in success rate based on syndrome or cleft status.

CONCLUSION

Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed.

Treatment of active nasal fricatives substituting /s/ in young children with normal palatal function using motor-based intervention

Purpose: The aim was to evaluate the effect of a motor-based, hierarchically structured intervention directed at active nasal fricatives substituting /s/ in young children with normal palatal function.Method: An experimental single-subject design was replicated across three children, aged 4-6 years, with normal palatal function, who substituted oral /s/ with active nasal fricatives. Treatment was performed weekly by a speech-language pathologist and included home training conducted by parents. Audio documented probes were registered regularly and /s/-production evaluated as oral or nasal.Result: All children achieved 98-100% oral production of /s/ in six probed linguistic contexts at treatment end and exhibited good maintenance at follow-up. The four-year-olds showed gradual or inconsistent response and slower progress, the six-year-old direct response and faster progress.Conclusion: The study provides preliminary evidence suggesting positive intervention effects for treating active nasal fricatives in children with normal palatal function. However, possible confounding effects such as maturation or repeated testing could not be ruled out; thus, results need to be replicated with increased experimental control. Nevertheless, the study adds to the currently meagre empirical evidence-base for the population. Individual treatment response and progress patterns were found and data suggests that the intervention may be beneficial from age 4.

The relation of velopharyngeal coupling area to the identification of stop versus nasal consonants in North American English based on speech generated by acoustically driven vocal tract modulations

The purpose of this study was to determine the threshold of velopharyngeal coupling area at which listeners switch from identifying a consonant as a stop to a nasal in North American English, based on V₁CV₂ stimuli generated with a speech production model that encodes phonetic segments as relative acoustic targets. Each V₁CV₂ was synthesized with a set of velopharyngeal coupling functions whose area ranged from 0 to 0.1 cm². Results show that consonants were identified by listeners as a stop when the coupling area was less than 0.035-0.057 cm², depending on place of articulation and final vowel. The smallest coupling area (0.035 cm²) at which the stop-to-nasal switch occurred was found for an alveolar consonant in the /ɑCi/ context, whereas the largest (0.057 cm²) was for a bilabial in /ɑCɑ/. For each stimulus, the balance of oral versus nasal acoustic energy was characterized by the peak nasalance during the consonant. Stimuli with peak nasalance below 40% were mostly identified by listeners as stops, whereas those above 40% were identified as nasals. This study was intended to be a precursor to further investigations using the same model but scaled to represent the developing speech production system of male and female talkers.

Adenoidectomy and persistent velopharyngeal insufficiency: Considerations, risk factors, and treatment

IMPORTANCE

Persistent velopharyngeal insufficiency (VPI) is a rare but well-recognized complication of adenoidectomy. VPI can have a significant impact on the communication of a child.

OBJECTIVE

To describe the pathophysiology of post-adenoidectomy VPI, identify its associated risk factors, and illustrate the techniques used to treat the entity.

EVIDENCE REVIEW

A search of English or translated English articles concerning adenoidectomy, partial adenoidectomy, superior adenoidectomy; and velopharyngeal insufficiency, speech and voice from 1980 to 2021 was performed using Pubmed and Embase. Data from prospective and retrospective studies and their relevant references were pooled.

RESULTS

By objective measures, hypernasality is noted in many pediatric patients post-adenoidectomy, but this typically resolves in 3-6 months. Risk factors for the development of post-adenoidectomy VPI include low birth weight, family history of hypernasality, and history of speech problems or nasal regurgitation. The cleft palate, submucous cleft palate, poor palate mobility, and a deep pharynx may indicate susceptibility to VPI. Speech therapy is successful in up to 50% of patients, while surgical intervention may be tailored based on the diagnostic evaluation of the velopharynx with videofluoroscopy or nasoendoscopy.

CONCLUSION

We present a comprehensive review of the literature on the pathophysiology, risk factors, and treatment of post-adenoidectomy VPI. We hope to bring awareness to the factors that can lead to a rare but potentially devastating complication in one of the most common procedures performed by Otolaryngologists.

The impact of hearing loss on speech outcomes in 5-year-old children with cleft palate ± lip: A longitudinal cohort study

OBJECTIVES

To investigate the impact of hearing loss (using longitudinal measurements of hearing) on speech outcomes at age 5 (5 years 0 months-5 years 11 months) in children born with cleft palate ± lip. Other variables which may impact upon the speech outcomes at age 5 in this population were also investigated.

METHODS

A retrospective longitudinal cohort study of children, without a named syndrome, born with cleft palate ± lip, and treated at a Cleft Centre in the United Kingdom. Data collected from infancy to 5 years 11 months, included hearing test results from three specific time points (7 months-1 year 2 months [age A]; 2 years 0 months-2 years 11 months [age B]; 5 years 0 months-5 years 11 months [age C]) and speech outcome data at age 5 years (5 years 0 months-5 years 11 months). Hearing test results at each age were compared to identify how hearing changes with age. Correlations between hearing test results and speech outcomes at age 5 were analysed.

RESULTS

Hearing loss was frequent but predominantly mild. There were no significant correlations between speech outcomes and hearing results at any age. Mild hearing loss remained prevalent at age 5, although a significant age-related hearing improvement was found. A significant relationship between cleft type and cleft speech characteristics was found (P < .001); children with Bilateral Cleft Lip and Palate achieved the poorest articulation outcomes.

CONCLUSION

Although mild hearing loss was common in the cohort, there was no association between hearing loss and the speech outcomes investigated. In contrast, the type of cleft was significantly associated with the presence of cleft speech characteristics. Further longitudinal measurement of hearing is required to substantiate the findings of this study.

Ectomesenchymal Chondromyxoid Tumor: A Rare Association With an Asymmetrical Soft Palate Cleft

Ectomesenchymal chondromyxoid tumor (ECT) is a rare oral lesion first described by Smith et al. in 1995. These tumors are typically painless, slow growing and benign masses occurring predominantly on the anterior tongue dorsum. Prior to this seminal report, many ECTs may have been misdiagnosed due to the histological similarities with other lesions. Immunohistochemical stains aid in definitive diagnosis of an ECT. A total of 39 papers since published have reported 96 patients with ECT. Most lesions involve the anterior aspect of the tongue, with only 6 occurring in the posterior tongue and 2 involving the hard palate. ECTs are considered to develop from ectomesenchymal cells of neural crest cells that have migrated to the tongue during embryological development. This paper is of a rare case of ECT of the posterolateral tongue occurring in association with an unusual asymmetrical soft palate cleft. It is postulated that since the tongue develops before the formation of the soft palate, an ECT lesion occurring on the posterior aspect may have a causal contribution to the development of the soft palate cleft.

Management of noncleft velopharyngeal insufficiency

PURPOSE OF REVIEW

Velopharyngeal insufficiency in the absence of an overt cleft-palate is a less common and often missed cause of a resonance disorder. The purpose of this manuscript is to provide the reader with an overview of the clinical assessment. Highlight the need for multidisciplinary involvement. Discuss the process of decision-making related to a repair and finally comment on the preoperative, intra-operative, and postoperative considerations.

RECENT FINDINGS

With the advent of small calibre videonasendoscopes, evaluation of the size, location, and closure pattern of the velopharyngeal gap has improved the surgeons' ability to provide a tailored repair. Evolutions in technique including posterior pharyngeal wall augmentation and buccal flap advancement in palatal lengthening have all increased the options available to the patient and treating team.

SUMMARY

Multidisciplinary assessment by trained specialist from speech and language pathology and surgery remain the cornerstone in the evaluation and management of this patient cohort. Many have a chromosomal anomaly that should be tested for and managed accordingly. These patients are often diagnosed late and have developed additional compensatory speech disorders that often need to be addressed following repair of the palate. Targeted thoughtful assessment will allow for a greater likelihood of successful repair.

Intensive voice treatment (the Lee Silverman Voice Treatment [LSVT®LOUD]) for individuals with Wilson's disease and adult cerebral palsy: two case reports

Objective: In this case report, we aimed to examine the effects of an intensive voice treatment (the Lee Silverman Voice Treatment [LSVT^®LOUD]) for Wilson's disease (WD), and adult cerebral palsy (CP), and dysarthria.Method: The participants received LSVT^®LOUD four times a week for 4 weeks. Acoustic, perceptual (GRBAS) analyses were performed and data from the Voice Handicap Index (VHI) were obtained before and after treatment.Results: Besides the Harmonics-to Noise Ratio (HNR) value (dB) of the participant with WD, for both participants' fundamental frequencies (Hz), jitter (%), and shimmer (%) values showed significant differences (p < .05) after therapy. Both participants showed significant improvements (p < .05) in the duration (s) and the sound pressure level (dB, SPL) of sustained vowel phonation (/a/), in SPL (dB) of pitch range (high and low /a/) and reading and conversation (p < .01). There was a positive improvement in the high-frequency values (Hz) of both participants but not in the low-frequency values (Hz) in the participant with WD. Perceptual analysis with GRBAS judgements of sustained vowel (/a/) and paragraph reading of two participants also showed improvement. After therapy, perceived loudness of the participants' voice increased.Conclusions: The findings provide some preliminary observations that the individuals with WD and the adult individuals with CP can respond positively to intensive speech treatment such as LSVT^®LOUD. Further studies are needed to investigate speech treatments specific to WD and adult CP.

The importance of neurology and genetic testing in the patient with non-cleft velopharyngeal dysfunction

OBJECTIVE

A significant proportion of the referrals made to a speech investigation clinic in a cleft unit include patients with non-cleft velopharyngeal dysfunction (VPD). This study aims to quantify the underlying diagnoses of these patients and describe the investigative pathway and diagnostic information subsequent to presentation in our clinic.

MATERIALS AND METHODS

The case notes of 136 consecutive patients with non-cleft VPD who attended our Velopharyngeal Investigation (VPI) clinic from July 2014-December 2019 were reviewed.

RESULTS

In the paediatric group (n = 118) the most common cause was 22q11 chromosomal anomalies (n = 46), while post palatal tumour resection was the commonest cause of acquired non-cleft VPD in adults (n = 8). Fifty-nine patients were referred to the clinic with a known underlying pathology such as a syndromic diagnosis. Of those presenting without a known aetiology, fifty-eight were referred onto our genetics and/or neurology colleagues. Although a genetic or neurological cause could not be identified in some of those patients, thirty-one patients received a new diagnosis, with subsequent implications for ongoing care.

CONCLUSION

There are a wide range of diagnoses resulting in non-cleft VPD, but there are very few large-scale studies focusing on investigating these patients for an underlying aetiology. This study highlights the role of genetics and neurology in the diagnosis and management plan for this cohort of patients.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence

OBJECTIVE

To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication.

DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded.

INTERVENTION

Modified pharyngeal flap with through-and-through dissection of the soft palate.

MAIN OUTCOME MEASURE(S)

Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale.

RESULTS

The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours.

CONCLUSIONS

This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Adoption of Telemedicine for Multidisciplinary Care in Pediatric Otolaryngology

OBJECTIVE

The COVID-19 pandemic has introduced a period of social isolation that has challenged the ability of providers to uphold in-person patient care. Although commonplace in pediatric otolaryngology, multidisciplinary clinics pose a unique challenge during this time due to increased infection risk from multiple patient-provider interactions. Guidance on the application of telemedicine for multidisciplinary clinics in pediatric otolaryngology is limited.

METHODS

We provide comprehensive guidance on best practices for conducting telemedicine visits for a number of multidisciplinary otolaryngology clinics using our experiences at a single tertiary care children's hospital. A review of literature to support the adoption of telemedicine in multidisciplinary pediatric otolaryngology is also incorporated.

RESULTS

Telemedicine was successfully adopted for 7 multidisciplinary pediatric clinics with a variety of specialists: aerodigestive disorders, congenital hearing loss, microtia/aural atresia, orofacial clefting, sleep disorders, tracheostomy care, and velopharyngeal dysfunction.

CONCLUSIONS

Telemedicine is feasible for a variety of multidisciplinary clinics and its optimization is critical for providing care to complex pediatric otolaryngology patients during the COVID-19 pandemic and beyond.

Nasalance in adolescents with autism spectrum disorders

Purpose: Listener judgments indicate atypical nasal resonance in individuals with Autism Spectrum Disorders (ASD); however, listener perceptions are susceptible to bias and may give unreliable information about a speaker's production of nasal resonance. The current study used Nasometry to obtain an objective estimation of nasal resonance among adolescents with ASD and neurotypical controls.Method: The Nasometer II 6450 (PENTAX Medical, Lincoln Park, New Jersey) was used to collect nasalance from adolescents aged 15-17 years with ASD (n = 11) and matched controls (n = 11) across two separate speech tasks: (1) passage reading and (2) spontaneous speech.Result: Adolescents with ASD evidenced significantly higher nasalance scores compared to controls, particularly in the passage loaded with bilabial plosives and some nasals (Bobby) as well as non-nasal words extracted from spontaneous speech. In addition, adolescents with ASD had significantly higher nasalance ratios than controls. Significant group differences were driven by a subset of participants with ASD.Conclusion: Perceptual judgements of nasality noted in previous autism studies are quantified by an increase in nasal energy compared to oral energy. The current data suggest hypernasality is present in a subset of people with ASD rather than being a general feature of speech in autism.

Measurement of Nasalance Scores Without Touching the Philtrum for Better Comfort During Speech Assessment and Therapy: A Preliminary Study

OBJECTIVE

The Kay Pentax nasometer uses a separator plate that touches the philtrum of a patient to separate the nasal and oral sound energies for nasalance measurement. However, the separator plate can restrict the natural movement of the patient's upper lip and generate unpleasant pressure on the patient's philtrum. The present study was intended to measure nasalance scores without touching the philtrum for better comfort during speech assessment and therapy.

METHODS

Nasalance scores of 10 males and 10 females having no speech disorders were measured under 4 levels (0, 5, 10, and 15 mm) of the gap between the plate and the philtrum (denoted as plate-to-philtrum gap) using Nasometer II 6450 for nasal (Nasal Sentences) and oral (Zoo Passage) stimuli. Regression formulas were established to examine the relationships between nasalance score and plate-to-philtrum gap for the stimuli. To provide nasalance scores equivalent to those measured for the contact condition, compensation factors for the 5 mm plate-to-philtrum gap measurement condition were identified for the stimuli.

RESULTS

The nasalance scores were significantly different between the 4 different plate-to-philtrum gaps for the stimuli. Compensation factors for the Nasal Sentences and the Zoo Passage were identified as 1.17 and 0.71, respectively.

CONCLUSIONS

The 5 mm plate-to-philtrum gap condition after multiplying the compensation factors can provide equivalent nasalance scores to the conventional contact measurement condition which may provide better comfort in speech assessment and therapy.

The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis

BACKGROUND

Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness.

METHODS

PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale.

RESULTS

Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572).

CONCLUSIONS

Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Quality of life outcomes following velopharyngeal insufficiency surgery

OBJECTIVES

Velopharyngeal insufficiency (VPI) may be due to functional or anatomic causes, and can lead to speech deficits, communication difficulty, and emotional strain on patients and their caregivers. The VPI Effects on Life Outcomes (VELO) instrument quantifies quality of life outcomes in VPI patients both before and after VPI surgery. This study aims to identify pre-operative patient characteristics associated with better post-operative quality of life.

METHODS

This study is a retrospective chart review of 51 patients who underwent VPI surgery between 2009 and 2018 at a tertiary free-standing children's hospital. A 26-item parent-proxy VELO questionnaire was administered by telephone to parents to assess their child's quality of life post-VPI surgery.

RESULTS

Twenty-seven parents responded to the VELO questionnaire. Average post-operative VELO score was significantly higher in non-syndromic patients as compared with syndromic patients. Average post-operative VELO score was not significantly different between patients with and without submucous cleft (SMC) or those with mild to moderate versus severe pre-operative hypernasality. On multivariate analysis, absence of genetic syndrome, lack of submucous cleft, and presence of severe-pre-operative hypernasality were significantly and positively associated with increased post-operative VELO scores.

CONCLUSION

Children who undergo VPI surgery are more likely to have better post-operative quality of life outcomes if their VPI was not associated with a genetic syndrome or submucous cleft. Non-syndromic and non-SMC patients with severe pre-operative hypernasality may benefit significantly from VPI surgery and have improved post-operative quality of life.

A Preliminary Dynamic Investigation on Velopharyngeal Movements During Blowing: A New Approach for Evaluation

PURPOSE

To explore an alternative approach to evaluate velopharyngeal function on those speakers with compensatory misarticulation.

METHOD

Nasopharyngeal endoscopy was used to observe the velopharyngeal movement on 26 adult Mandarin speakers during articulation and different nonverbal state, including SCPS, DCPS, and ABS.

RESULTS

There were significant differences for the rate of velopharyngeal incompetence (RVPI) among the 4 different states. The RVPI was least for the Articulation State, followed by the Air Blowing and DCPS. The RVPI was largest for the SCPS.

CONCLUSION

The result indicated that the ABS may be used as an alternative approach to evaluate the velopharyngeal function instead of the articulation samples while patients cannot make clear articulation due to compensatory misarticulation habits. It merits further study on nonverbal activities, which could lay a foundation for exploring more effective approach for evaluation of the velopharyngeal function.

Assessing health-related quality of life in patients with cleft palate in resource-limited countries: A preliminary evaluation of the VELO questionnaire in Uganda

BACKGROUND AND AIMS

Studies evaluating health-related quality of life (HRQoL) in patients with cleft palate living in resource-limited countries such as Uganda are scarce. The VELO questionnaire evaluates the impact of speech (and swallowing) difficulties on the patient's HRQoL. The aim was to evaluate an adapted English version of the VELO questionnaire with reduced response options in Ugandan patients with a cleft lip and palate in order to identify influencing factors and future perspectives to implement HRQoL assessement in this population.

METHODS

Based on the responses of 16 parents of patients with cleft palate, 6 adolescent/adult patients with cleft palate and 12 control participants without cleft palate, observations regarding linguistic and cultural difficulties were noted and the discriminant validity and internal consistency of this adapted version of the questionnaire were evaluated. Additionally, the relationship between these responses and perceptually assessed speech parameters was assessed.

RESULTS

Half of the participants (11/22) completed the questionnaire independently, frequently resulting in incomplete responses (8/11). Difficulties with wording and cultural aspects influencing the responses were identified. The subscales showed excellent internal consistency, with the exception of the subscale 'swallowing problems'. The score on the subscale 'perception by others' of the parent report showed no significant difference with the score of the control group. The total score on the parent report and the youth report was (borderline) significantly related to the speech variables speech understandability, speech acceptability and the VPC-SUM.

DISCUSSION AND CONCLUSION

Promising results regarding the validity and internal consistency of the adapted instrument were found, indicating the potential of the VELO questionnaire for HRQoL assessment at the CoRSU hospital in Uganda. However, results should be interpreted cautiously, given that all participants had a primary language other than English, the small sample size with skewed distribution of speech characteristics, and the bias induced by socially desirable responses. In future studies, adaptations based on qualitative research to account for linguistic and cultural aspects, followed by a rigorous forward-backward translation of the questionnaire to English and Luganda are needed.

Effects of Error Experience on Learning to Lower Speech Nasalance Level

Purpose This research aims to examine the effects of error experience when learning to speak with lowered nasalance level. Method A total of 45 typical speakers were instructed to learn to lower speech nasalance level in either an errorless (restricted possibility for committing errors) or an errorful (unrestricted possibility for committing errors) learning condition. The nasality level of the participants' speech was measured by a nasometer and quantified by nasalance scores (in percent). Errorless learners practiced producing speech with lowered nasalance level with a threshold nasalance score of 50% (the easiest target) at the beginning, which gradually decreased to a threshold of 10% (the most difficult target) at the end. The same set of threshold targets was presented to errorful learners, but in reverse order. Errors were defined by the proportion of speech, with a nasalance score exceeding the threshold. Retention and transfer tests were administered. Results Errorless learners displayed fewer errors and lower mean nasalance scores than errorful learners during the acquisition phase. Furthermore, errorless learners achieved lower mean nasalance scores than errorful learners in the retention and transfer tests. Conclusion These results suggest that errorless learning is more effective than errorful learning and that error experience has a detrimental effect on the acquisition of a novel speech motor task that requires minimization of the nasality level. Errorless learning may be a useful paradigm for the intervention and management of hypernasality in clinical settings where behavioral treatments are needed.

Comparison of three different surgical techniques for designing pharyngeal flaps according to findings of videonasopharyngoscopy and multiplanar videofluoroscopy

BACKGROUND

Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter (VPS) is unable to completely seal anatomical closure between the nasal and oral cavities during speech. Palatal repair can restore VPS function but the prevalence of VPI after repair has been reported ranging from 20% to 40%. The combination of flexible videonasopharyngoscopy (FVNP) and multiplanar videofluoroscopy (MPVF) has been reported as the best approach for assessing the VPS mechanism and planning effective surgical procedures aimed to correct VPI.

OBJECTIVE

To study the outcome of three different techniques for performing pharyngeal flaps with the common denominator of individually designing the flap according to findings of VFNP and MPVF.

MATERIAL AND METHODS

A total of 140 cases of pharyngeal flap surgery were reviewed. Three surgeons performed 3 different surgical techniques. All cases underwent nasometry, VNP and MPVF preoperatively. All surgical procedures were carefully planned and designed according to findings of VNP and MPVF.

RESULTS

Nasal emission was completely eliminated in all cases. One-hundred-thirty-four patients (95%) demonstrated mean nasalance within normal limits after the surgical procedure whereas 6 patients persisted with mean nasalance scores above reference values postoperatively. There were no intraoperative or postoperative complications in any of the cases. No clinical data of sleep disordered breathing was detected in any of the cases after 2 months of postoperative follow-up. However, one case presented with clinical data of sleep disordered breathing 8 months postoperatively.

CONCLUSIONS

The results of this study suggest that as long as pharyngeal flaps are being designed according to the findings of imaging procedures, different surgical techniques can provide similar successful outcomes with minimal complications.

The relationship between health-related quality of life and speech in patients with cleft palate

INTRODUCTION

In health-care, current efforts focus on providing patient-centered care. Specifically for patients with velopharyngeal insufficiency, and by extent patients with cleft palate, the Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) questionnaire (Skirko et al., 2012; 2013) allows the clinician to map the impact of speech and swallowing difficulties on the patient's health-related quality of life (HRQoL). The current study evaluated the hypothesized association between this speech-related HRQoL measure and perceptually and instrumentally assessed speech variables, to provide evidence for the construct validity of the Dutch version of the VELO questionnaire.

MATERIALS AND METHODS

Thirty participants, twenty-five patients with cleft palate and five controls, were enrolled. Perceptual speech assessment was conducted following the recently developed Belgian Dutch outcome tool for perceptual speech assessment in patients with cleft palate. In addition, nasalance values and the Nasality Severity Index (NSI) 2.0 were determined. The relationship between these speech outcomes and the scores on the VELO parent report was determined using Spearman rank-order correlation coefficients.

RESULTS

Moderate to strong correlations were found between the total score on the VELO parent report and five speech variables: the VPC-SUM score (r_s = -0.476), speech understandability (r_s = -0.657), passive CSC's (r_s = -0.654), speech acceptability (r_s = -0.591) and the need for C(L)P-related speech therapy (r_s = -0.711). Furthermore, these variables were associated with at least one subscale of the VELO questionnaire.

DISCUSSION AND CONCLUSION

Correlations between speech outcomes and the Dutch version of the VELO questionnaire provide evidence for the construct validity of this version of the instrument. Furthermore, insights in these associations may lead the way to efficient therapy approaches, targeting speech features with the greatest impact on the patient's health-related quality of life.

Acquired Velopharyngeal Dysfunction: Survey, Literature Review, and Clinical Recommendations

PURPOSE

The aim of this study was to describe the clinical assessment recommendations for acquired velopharyngeal dysfunction (AVPD) and, through a literature review and online survey, summarize current practice patterns for evaluation and treatment pathway determination for this target population.

METHOD

An online survey to query current assessment procedures and treatment pathway recommendations for AVPD was developed. Following survey results, a literature review was completed to determine evidence-based recommendations for assessment procedures and intervention recommendations based on assessment findings. Literature search terms included the following: acquired velopharyngeal dysfunction, hypernasality, non-cleft velopharyngeal dysfunction, velopharyngeal dysfunction, velopharyngeal dysfunction AND iatrogenic, velopharyngeal dysfunction AND neurogenic, velopharyngeal dysfunction AND assessment OR evaluation, velopharyngeal dysfunction AND treatment OR intervention, velopharyngeal dysfunction AND practice patterns OR clinical guidelines, velopharyngeal insufficiency. Inclusion criteria were limited to practice patterns/recommendations for assessment and/or treatment recommendations for AVPD, English language articles published between 2000 and 2017, and peer-reviewed journals. Studies regarding solely congenital or cleft palate velopharyngeal dysfunction and intervention outcome studies were excluded. Forty articles met inclusionary criteria.

RESULTS

The online survey results indicated lack of consensus for AVPD assessment and treatment recommendation protocols, with 93% of respondents indicating the need for a clinical guide for developing treatment recommendations. The majority of recommendations were filtered into an algorithm for clinical decision making.

CONCLUSIONS

Clinical uncertainty among speech-language pathologists surveyed and the paucity of published clinical guidelines for assessing individuals with AVPD indicate the need for additional clinical research for this disorder, one that is heterogeneous and distinct from those with congenital velopharyngeal dysfunction. The proposed evidence-based clinical worksheet may assist in determining management for patients with AVPD and may serve as a starting place for validation of a clinical guideline.

Prosthetic Rehabilitation with Palatal Lift/Augmentation in a Patient with Neurologic/Motor Deficit Due To Cancer Therapy for Chondrosarcoma

This clinical report describes the prosthetic rehabilitation of a 25-year-old man with a history of grade II chondrosarcoma at the skull base who had undergone surgical resection and thereafter developed velopharyngeal incompetency (VPI), dysarthria, and dysphagia. Upon baseline fiberoptic endoscopic evaluation of swallowing (FEES), the patient had an atypical pattern of VPI with minimal to no velar lift during speech, blow, or suck tasks, but near complete velar lift and seal during swallowing. A palatal augmentation prosthesis combined with a resilient palatal lift extension was fabricated to enhance speech by displacing the soft palate and to decrease hypernasality, while avoiding interference with bolus transport. A resilient wrought wire extension was necessary to accommodate the velar movement upon swallowing while keeping the integrity of the velar lift during speech. In conclusion, this unique combination prosthesis was able to help the patient's atypical pattern of VPI by improving speech and preserving swallowing function, which was confirmed during a post-endoscopic evaluation.

GWAS reveals loci associated with velopharyngeal dysfunction

Velopharyngeal dysfunction (VPD) occurs when the muscular soft palate (velum) and lateral pharyngeal walls are physically unable to separate the oral and nasal cavities during speech production leading to hypernasality and abnormal speech reduction. Because VPD is often associated with overt or submucous cleft palate, it could be present as a subclinical phenotype in families with a history of orofacial clefting. A key assumption to this model is that the overt and subclinical manifestations of the orofacial cleft phenotype exist on a continuum and therefore share common etiological factors. We performed a genome-wide association study in 976 unaffected relatives of isolated CP probands, 54 of whom had VPD. Five loci were significantly (p < 5 × 10^-8) associated with VPD: 3q29, 9p21.1, 12q21.31, 16p12.3 and 16p13.3. An additional 15 loci showing suggestive evidence of association with VPD were observed. Several genes known to be involved in orofacial clefting and craniofacial development are located in these regions, such as TFRC, PCYT1A, BNC2 and FREM1. Although further research is necessary, this could be an indication for a potential shared genetic architecture between VPD and cleft palate, and supporting the hypothesis that VPD is a subclinical phenotype of orofacial clefting.

A Pediatrician's Guide to Communication Disorders Secondary to Cleft Lip/Palate

This article describes how different types of clefts affect the child's function and, in particular, the child's communication abilities. This article also describes the evaluation process and various options for the treatment of affected speech. Because these children have many complicated needs over their entire growth period, it is important that they are referred by the pediatrician to a cleft palate/craniofacial team for the best care and best ultimate outcomes.

Musculo-mucous web velum and velopharyngeal dysfunction associated with 8q22.1-22.2 microduplication

This report presents a rare case of isolated non-cleft velopharyngeal dysfunction (VPD). An eight-year-old child presented 1. a phenotypically unique band-gap pattern of the velar musculature with anteroposterior insertion; 2. a mosaic partial trisomy on chromosome 19 as well as microduplications on chromosomes 8 and 22. Following cytogenetic analysis, microduplication on chromosome 8 was found in another member of her family. A family history of VPI with hypernasality and nasal regurgitation was reported over three different generations on the patient's maternal side. Since only one case of velum malformation is found in this family, we cannot conclude to a link between the palatal anomaly or VPD and the DNA rearrangements.

Treatment of Stress Velopharyngeal Incompetence With Injection of Hyaluronic Acid

Stress velopharyngeal incompetence (VPI) is a challenging clinical entity that can be managed by a variety of surgical and nonsurgical approaches. We describe the case of a clarinetist who presented with nasal air escape while playing. She had successful improvement in her symptoms after targeted injection of a hyaluronic acid compound to her posterior pharyngeal wall. Our objective is to describe the safety and efficacy of this technique, to emphasize the multidisciplinary management of patients with stress VPI, and to review the importance of both nasopharyngoscopy and videofluoroscopy in their evaluation.

Can overnight stenting be safely eliminated following a pharyngeal flap? A matched comparison study

OBJECTIVE

Determine if overnight stenting is warranted after pharyngeal flap for management of velopharyngeal insufficiency (VPI) in pediatric patients METHODS: This is a retrospective age-matched cohort study from a single tertiary pediatric facility. Patients who underwent a posterior pharyngeal flap for VPI from January 1, 2013, to December 31, 2016, were included. Two equal groups were constructed based on when their nasal stents were removed, that is, postoperative day (POD) 0 or POD 1. Primary outcome measure was oxygen desaturation after surgery. Secondary outcome measures were total length of stay, need for narcotics, and oral intake based on POD. Additional information was gathered and evaluated as possible prognostic variables.

RESULTS

There were 27 matched pairs included in the study. One patient from each group required supplemental oxygen during the night of surgery. No escalation of care was needed in either case. The group whose stents were removed on POD 0 were discharged earlier than the group whose stents were removed on POD 1, P < 0.0001. The POD 0 group took significantly more oral intake on POD 0 than the POD 1 group, P = 0.03. The POD 0 group had significantly more genetic syndromes than the POD 1 group, P = 0.02.

CONCLUSION

There was no benefit with overnight stenting. Earlier discharge from the hospital was achieved in the POD 0 group. No patient experienced need for reintubation, escalation of clinical care, postoperative hemorrhage, or death.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:750-755, 2018.

Health-related quality of life in patients with cleft palate: Validity and reliability of the VPI Effects on Life Outcomes (VELO) questionnaire translated to Dutch

BACKGROUND

Disease-specific health-related quality of life (HRQOL) questionnaires provide the clinician with important information regarding the impact of the disease on functioning and well-being. For patients with velopharyngeal insufficiency (VPI), the VPI Effects on Life Outcomes (VELO) questionnaire was developed and validated in English by Skirko et al. (2012). However, a valid and reliable Dutch translation of this questionnaire is not available yet.

METHODS

The English questionnaire was translated to Dutch following a forward-backward translation procedure. A linguistic validation and the evaluation of the internal consistency (Cronbach's α) of this Dutch version were performed based on the responses of 39 parents of patients with cleft (lip and) palate (mean age: 6.8 years) (parent report) and the responses of 14 patients older than 8 years (mean age: 9.5 years) (child report). Additionally, the concurrent validity was assessed by comparing the scores on the parent report to those on the pediatric voice handicap index. Furthermore, the validity of the parent proxy assessment and the relationship between age and responses on the VELO questionnaire were investigated. Based on the responses of an age and gender matched control group without cleft palate, the discriminant validity was evaluated.

RESULTS

The parent report was easy to complete for all parents. Nine of the fourteen (64%) patients were able to complete the child report independently. The median scores on the parent report and the child report were 82.7 and 95.1 respectively. The patient group had a significantly worse perception of HRQOL compared to the control group (p < 0.001; p = 0.029). There were no significant differences between the responses of the parent and their child's (p = 0.345). A significant positive correlation was found between the score on the parent report and the age of the patients (p = 0.001). Furthermore, a significant negative correlation was found between the parent report and the P-VHI (p < 0.001). Cronbach's α was 0.955 and 0.817 for the parent report and the child report respectively.

CONCLUSION

The Dutch VELO questionnaire is a valid, reliable and user-friendly tool that provides important information about HRQOL in patients with cleft (lip and) palate.

Velopharyngeal videofluoroscopy: Providing useful clinical information in the era of reduced dose radiation and safety

BACKGROUND

The state of the art for correcting velopharyngeal insufficiency (VPI) is a surgical procedure which is customized according to findings on imaging procedures: multiplanar videofluoroscopy (MPVF) and flexible videonasopharyngoscopy (FVNP). Recently, the use of MPVF has been challenged because of the potential risk of using ionizing radiation, especially in children.

OBJECTIVE

To study whether using a protocol for performing MPVF can effectively decrease radiation dose in patients with VPI while providing useful information for planning surgical correction of VPI in combination with FVNP. The methodology used for performing the imaging procedures is described as well as the effectiveness of the surgical procedure.

MATERIAL AND METHODS

Eighty - nine patients (Age range = 3-17 years; median = 5.5 years) with VPI resulting from multiple etiologies were studied. All patients underwent MPVF and FVNP for planning surgical correction of VPI. Radiation dosage data in each case was recorded. Forty of the 89 patients also completed a postoperative evaluation. Eleven out of the remaining 49 patients have not completed a postoperative evaluation and 38 patients are still pending surgical correction.

RESULTS

Radiation dosage ranged from 1.00 to 8.75 miliSieverts (mSv); Mean = 2.88 mSv; SD = 1.575 mSv. Preoperative nasometry demonstrated mean nasalance ranging from 41%-95%; Mean = 72.30; SD = 4.54. Postoperatively mean nasalance was within normal limits in 36 (90%) out of 40 cases, ranging from 21% to 35%; Mean = 28.10; SD = 5.40. Nasal emission was eliminated postoperatively in all cases.

CONCLUSION

MPVF provides useful information for planning the surgical procedure aimed at correcting VPI. The combination of MPVF and FVNP is a reliable procedure for assessing velopharyngeal closure and to surgically correcting VPI with a highly successful outcome.

Short-term effect of short, intensive speech therapy on articulation and resonance in Ugandan patients with cleft (lip and) palate

OBJECTIVES

The purpose of the current study was to assess the short-term effectiveness of short and intensive speech therapy provided to patients with cleft (lip and) palate (C(L)P) in terms of articulation and resonance.

METHODS

Five Ugandan patients (age: 7.3-19.6 years) with non-syndromic C(L)P received six hours of individualized speech therapy in three to four days. Speech therapy focused on correct phonetic placement and contrasts between oral and nasal airflow and resonance. Speech evaluations performed before and immediately after speech therapy, including perceptual and instrumental assessment techniques, were compared.

RESULTS

Post-therapy, improvement of speech was noted for most of the patients, although to varying degrees. Clinically relevant progress of objective nasalance values and/or articulation was obtained in four patients. Overall, two patients showed normal speech intelligibility, while three patients required additional speech therapy.

CONCLUSION

These preliminary short-term results demonstrate that short and intensive speech therapy can be effective for patients with C(L)P in countries with limited access to speech-language therapy. However, further research is needed on the long-term effectiveness and the advantages of applying this treatment protocol in countries with good access to speech therapy.

LEARNING OUTCOMES

The reader will be able to (1) list the challenges in resource poor-countries to achieve access to speech-language therapy services, (2) describe when the application of speech therapy is appropriate in patients with C(L)P, (3) describe the speech therapy that can be applied to reduce compensatory articulation and resonance disorders in patients with C(L)P, and (4) list the (possible) advantages of short, intensive speech therapy for both resource-poor and developed countries.

Recent insights into the morphological diversity in the amniote primary and secondary palates

The assembly of the upper jaw is a pivotal moment in the embryonic development of amniotes. The upper jaw forms from the fusion of the maxillary, medial nasal, and lateral nasal prominences, resulting in an intact upper lip/beak and nasal cavities; together called the primary palate. This process of fusion requires a balance of proper facial prominence shape and positioning to avoid craniofacial clefting, whilst still accommodating the vast phenotypic diversity of adult amniotes. As such, variation in craniofacial ontogeny is not tolerated beyond certain bounds. For clarity, we discuss primary palatogenesis of amniotes into in two categories, according to whether the nasal and oral cavities remain connected throughout ontogeny or not. The transient separation of these cavities occurs in mammals and crocodilians, while remaining connected in birds, turtles and squamates. In the latter group, the craniofacial prominences fuse around a persistent choanal groove that connects the nasal and oral cavities. Subsequently, all lineages except for turtles, develop a secondary palate that ultimately completely or partially separates oral and nasal cavities. Here, we review the shared, early developmental events and highlight the points at which development diverges in both primary and secondary palate formation.

Analysis of human soft palate morphogenesis supports regional regulation of palatal fusion

It is essential to complete palate closure at the correct time during fetal development, otherwise a serious malformation, cleft palate, will ensue. The steps in palate formation in humans take place between the 7th and 12th week and consist of outgrowth of palatal shelves from the paired maxillary prominences, reorientation of the shelves from vertical to horizontal, apposition of the medial surfaces, formation of a bilayered seam, degradation of the seam and bridging of mesenchyme. However, in the soft palate, the mechanism of closure is unclear. In previous studies it is possible to find support for both fusion and the alternative mechanism of merging. Here we densely sample the late embryonic-early fetal period between 54 and 74 days post-conception to determine the timing and mechanism of soft palate closure. We found the epithelial seam extends throughout the soft palates of 57-day specimens. Cytokeratin antibody staining detected the medial edge epithelium and distinguished clearly that cells in the midline retained their epithelial character. Compared with the hard palate, the epithelium is more rapidly degraded in the soft palate and only persists in the most posterior regions at 64 days. Our results are consistent with the soft palate following a developmentally more rapid program of fusion than the hard palate. Importantly, the two regions of the palate appear to be independently regulated and have their own internal clocks regulating the timing of seam removal. Considering data from human genetic and mouse studies, distinct anterior-posterior signaling mechanisms are likely to be at play in the human fetal palate.