The evaluation of velopharyngeal function using flexible nasendoscopy

Incorporating Velopharyngeal MRI into the Clinical Decision-Making Process for a Patient Presenting with Velopharyngeal Dysfunction Following a Failed Palatoplasty

This clinical report describes the implementation of magnetic resonance imaging (MRI) to evaluate a patient with long-standing velopharyngeal dysfunction. She was referred to the craniofacial clinic at age 10 with no prior surgical history and subsequently completed a Furlow palatoplasty due to a suspected submucous cleft palate. However, results were unfavorable with minimal improvement in speech or resonance. The clinical presentation, treatment, outcomes, and contributions from MRI for secondary surgical planning are described. Addition of MRI into the clinical workflow provided insights into the anatomy and physiology of the velopharyngeal mechanism that were unable to be obtained from nasendoscopy and speech evaluation alone.

Magnetic Resonance Imaging of the Velopharynx: Clinical Findings in Patients with Velopharyngeal Insufficiency

BACKGROUND

Magnetic resonance imaging (MRI) is the only imaging modality capable of directly visualizing the levator veli palatini (LVP) muscles: the primary muscles responsible for velopharyngeal closure during speech. MRI has been used to describe normal anatomy and physiology of the velopharynx in research studies, but there is limited experience with use of MRI in the clinical evaluation of patients with velopharyngeal insufficiency (VPI).

METHODS

MRI was used to evaluate the velopharyngeal mechanism in patients presenting for VPI management. The MRI followed a fully awake, nonsedated protocol with phonation sequences. Quantitative and qualitative measures of the velopharynx were obtained and compared with age- and sex-matched individuals with normal speech resonance.

RESULTS

MRI was completed successfully in 113 of 118 patients (96%). Compared with controls, patients with VPI after cleft palate repair had a shorter velum (P < 0.001), higher incidence of LVP discontinuity (P < 0.001), and shorter effective velar length (P < 0.001). Among patients with persistent VPI after pharyngeal flap placement, findings included a pharyngeal flap base located inferior to the palatal plane [11 of 15 (73%)], shorter velum (P < 0.001), and higher incidence of LVP discontinuity (P = 0.014). Patients presenting with noncleft VPI had a shorter (P = 0.004) and thinner velum (P < 0.001) and higher incidence of LVP discontinuity (P = 0.014).

CONCLUSIONS

MRI provides direct evidence of LVP muscle anomalies and quantitative evaluation of both velar length and velopharyngeal gap. This information is unavailable with traditional VPI imaging tools, suggesting that MRI may be a useful tool for selecting surgical procedures to address patient-specific anatomic differences.

Subjective and Objective Evaluation of Speech in Adult Patients With Repaired Cleft Palate

OBJECTIVE

To explore the speech outcomes of adult patients with repaired cleft palate through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with complete velopharyngeal closure (VPC) and velopharyngeal insufficiency (VPI) patients.

PARTICIPANTS AND INTERVENTION

Subjective evaluation indicators included speech intelligibility, nasality and consonant missing rate, for objective acoustic analysis, we used speech sample normalization and objective acoustic parameters included normalized vowel formants, voice onset time and the analysis of 3-dimensional spectrogram and spectrum, were carried out on speech samples produced by 3 groups of speakers: (a) speakers with velopharyngeal competence after palatorrhaphy (n=38); (b) speakers with velopharyngeal incompetence after palatorrhaphy (n=70), (c) adult patients with cleft palate (n=65) and (d) typical speakers (n=30).

RESULTS

There was a highly negative correlation between VPC grade and speech intelligibility (ρ=-0.933), and a highly positive correlation between VPC and nasality (ρ=0.813). In subjective evaluation, the speech level of VPI patients was significantly lower than that of VPC patients and normal adults. Although the nasality and consonant loss rate of VPC patients were significantly higher than that of normal adults, the speech intelligibility of VPC patients was not significantly different from that of normal adults. In acoustic analysis, patients with VPI still performed poorly compared with patients with VPC.

CONCLUSIONS

The speech function of adult cleft palate patients is affected by abnormal palatal structure and bad pronunciation habits. In subjective evaluation, there was no significant difference in speech level between VPC patients and normal adults, whereas there was significant difference between VPI patients and normal adults. The acoustic parameters were different between the 2 groups after cleft palate repair. The condition of palatopharyngeal closure after cleft palate can affect the patient's speech.

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.

Virtual Reality as Distraction Analgesia and Anxiolysis for Pediatric Otolaryngology Procedures

OBJECTIVES/HYPOTHESIS

While virtual reality (VR) has been used as analgesia and anxiolysis for invasive procedures, no literature exists on the use of VR in the pediatric otolaryngology setting. The purpose of this study was to determine the efficacy of VR in reducing pain and anxiety for pediatric otolaryngology patients.

STUDY DESIGN

Randomized controlled trial.

METHODS

A total of 53 patients aged 7-17 undergoing in-office nasal endoscopies were included. Patients were randomized to receive VR or standard of care. Procedural pain, anxiety, and satisfaction scores were recorded from patients and caregivers. The physician filled out a childhood emotional manifestation scale (CEMS).

RESULTS

Patients in VR group reported a significant decrease in pain (0.80 ± 1.06 vs. 2.26 ± 2.38, P = .018) and anxiety (9.50 ± 12.48 vs. 38.48 ± 29.83, P = .0002) and increase in procedural satisfaction (6.40 ± 0.77 vs. 4.74 ± 1.74, P = .0002) compared to patients in control group. CEMS scores were significantly reduced in VR group (5.15 ± 0.46 vs. 9.64 ± 5.66, P = .0001) and caregiver anxiety levels were significantly reduced in VR group (11.50 ± 17.67 vs. 27.39 ± 30.48, P = .041) compared to control group. There were no reported side effects. Procedural time did not significantly differ between groups.

CONCLUSIONS

For pediatric otolaryngology patients undergoing in-office nasal endoscopies, VR is a safe and effective form of distraction analgesia and anxiolysis, significantly reducing pain and increasing procedural satisfaction for patients. In addition, VR significantly reduces anxiety for both patients and caregivers without disrupting procedural efficiency and workflow.

LEVEL OF EVIDENCE

2. Laryngoscope, 131:E1714-E1721, 2021.

Speech and Language Issues in the Cleft Palate Population: The State of the Art

Objective

State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems.

Method

The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether.

Conclusion

Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.

Effects of spectral content on Horii Oral-Nasal Coupling scores in children

A miniature accelerometer and microphone can be used to obtain Horii Oral-Nasal Coupling (HONC) scores to objectively measure nasalization of speech. While this instrumentation compares favorably in terms of size and cost relative to other objective measures of nasality, the metric has not been well characterized in children. Furthermore, the measure is known to be affected by vowel loading, as speech loaded with "high" vowels is consistently scored as more nasal than speech loaded with "low" vowels. Filtering the signals used in computation of the HONC score to better isolate the correlates of nasalization has been shown to reduce vowel-related effects on the metric, but the efficacy of filtering has thus far only been explored in adults. Here, HONC scores for running speech and the vowel portions of consonant-vowel-consonant tokens were calculated for the speech of 26 children, aged 4-9 yrs. Scores were computed using the broadband accelerometer and speech signals, as well as using filtered, low-frequency versions of these signals. HONC scores obtained using both broadband and filtered signals resulted in well-separated scores for nasal and non-nasal speech. HONC scores computed using filtered signals were found to exhibit less within-participant variability.

Pain perception of children undergoing nasendoscopy for investigation of voice and resonance disorders

The primary objective of this descriptive and correlational study was to determine the level of pain and discomfort perceived by children undergoing nasendoscopy for investigation of voice and resonance disorders. The secondary objective was to explore whether gender, age, previous experience of painful or distressing medical procedures, and previous experience of nasendoscopy influenced the perception of pain during nasendoscopy. Twenty-three children self-reported the degree of pain perceived during nasendoscopy using the Wong-Baker Faces Pain Rating Scale. Parents also used this scale to rate their child's perceived pain. Otolaryngologists and speech pathologists rated the intensity and frequency of observed pain-related behaviors using the Child-Adult Medical Procedure Interaction Scale-Revised and the Procedure Behavior Checklist. Children perceived the procedure, on average, to be moderately painful, as did their parents. Only two children reported perceiving no pain during the procedure. The most frequently observed pain-related behaviors were muscle tension (86.96%), physical resistance (69.57%), requiring physical restraint (60.87%), crying (43.48%), and expressions of verbal pain (39.13%). No significant correlations were found between self-reported pain or observed pain and the variables of age, gender, previous experience of nasendoscopy, and previous experience of painful or distressing medical procedures, although children aged 4-7 years reported significantly more pain than children aged 8-18 years. Most children perceive nasendoscopy to be painful to some degree. This perceived pain occurred in conjunction with several observable pain-related behaviors that have the potential to interfere with the success of the procedure.