Growth Effects on Velopharyngeal Anatomy From Childhood to Adulthood

Establishing a Clinical Protocol for Velopharyngeal MRI and Interpreting Imaging Findings

Traditional imaging modalities used to assess velopharyngeal insufficiency (VPI) do not allow for direct visualization of underlying velopharyngeal (VP) structures and musculature which could impact surgical planning. This limitation can be overcome via structural magnetic resonance imaging (MRI), the only current imaging tool that provides direct visualization of salient VP structures. MRI has been used extensively in research; however, it has had limited clinical use. Factors that restrict clinical use of VP MRI include limited access to optimized VP MRI protocols and uncertainty regarding how to interpret VP MRI findings. The purpose of this paper is to outline a framework for establishing a novel VP MRI scan protocol and to detail the process of interpreting scans of the velopharynx at rest and during speech tasks. Additionally, this paper includes common scan parameters needed to allow for visualization of velopharynx and techniques for the elicitation of speech during scans.

Velopharyngeal Characteristics in Aarskog-Scott Syndrome: A Case Report

Aarskog-Scott syndrome (AAS), also known as facio-digito-genital syndrome, is a rare heterogenous syndrome characterized by facial dysmorphism, brachydactyly, and genetic abnormalities. Although severe craniofacial abnormalities have been reported in AAS, little is known about speech and resonance issues in AAS. Specifically, published data to date have only indicated reports of hypernasality associated with a cleft palate in AAS. This case report provides clinical and anatomic information surrounding hypernasal speech in the absence of an overt cleft palate in a patient with AAS.

Measurement Matters: MRI Analysis of Differing Anatomic Measurement Techniques for Velar Length and the Velopharyngeal Needs Ratio

Background

Advances in imaging tools provide opportunities to enhance how velopharyngeal (VP) variables are quantified to facilitate surgical decisions. The purpose of this study was to use magnetic resonance imaging (MRI) to determine if quantitative differences were present between measures of linear and curvilinear velar length, and subsequently, the VP needs ratio.

Methods

Data were prospectively collected from patients presenting with repaired cleft palate and/or congenital palatal insufficiency with or without VPI at a single center tertiary children's hospital. Quantitative measures of the velopharynx using a novel nonsedated MRI protocol were obtained. Paired samples t tests were conducted to assess if differences were present between the VP needs ratio and measurements of linear and curvilinear velar length at rest and during sustained phonation. Intraclass correlation coefficients were calculated to assess intra/inter-rater reliability.

Results

Significant differences were present between measurements of linear and curvilinear velar length at rest (P ≤ 0.001) and during sustained phonation (P ≤ 0.001). Significant differences were also present in the VP needs ratio (P ≤ 0.001). Curvilinear velar length at rest and during sustained phonation was longer than that of linear velar length at rest and during sustained phonation. No significant differences were observed between measures of effective velar length (P = 0.393).

Conclusions

Measurement differences influence the VP needs ratio. This may have implications for comparisons to previously reported normative reference values and for those who are anatomically at risk for VPI. MRI provides an enhanced imaging modality to assess normative benchmarks and the anatomic variables used to define VP anatomy for clinical decision-making.

Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate

OBJECTIVE

The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA).

DESIGN

Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n = 166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified.

INTERVENTIONS

The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty.

MAIN OUTCOME MEASURES

Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA.

RESULTS

Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p < 0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4 ± 2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p = 0.03).

CONCLUSIONS

Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.

Sex Differences in Velopharyngeal Anatomy of 9- and 10-Year-Old Children

OBJECTIVE

Understanding the normal anatomy of velopharyngeal (VP) mechanism and the emergence of sexual dimorphism provides valuable insights into differences of VP anatomy among males and females. The purpose of this study is to examine sex differences in VP anatomy in a large data set of 3,248 9- and 10-year-old children.

METHOD

Static three-dimensional magnetic resonance imaging was used to compare five VP characteristics including velar length, velar thickness, effective velar length, levator veli palatini muscle length, and pharyngeal depth between age-matched males (n = 1,670) and females (n = 1,578). Additionally, these dimensions were used to determine the VP ratio and effective VP ratio.

RESULTS

Males showed significantly larger dimensions for all VP distances and significantly lower ratios of velar length and effective velar length to pharyngeal depth (p < .05). The magnitude of these effect sizes was small to medium, with Cohen's d values ranging from 0.12 to 0.63. Additionally, the VP ratio and effective VP ratio are lower among males compared to females (p < .05).

CONCLUSIONS

Results suggest the presence of sexual dimorphism in the VP mechanism among 9- and 10-year-old children. These findings emphasize the necessity of using different normative data for males and females when making comparisons to patients with cleft palate.

Can Velopharyngeal MRI be Used in Individuals with Orthodontic Devices?

OBJECTIVE

To evaluate the influence of common pediatric orthodontic appliances on velopharyngeal (VP) MRI and to compare MR image sequences to determine if sequence parameters impact the visibility of key VP structures commonly assessed in clinical VP MRI.

DESIGN

Participants undergoing orthodontic treatment completed a VP MRI study. Level of distortion caused by orthodontic devices on 8 anatomical sites of interest and using variable MRI sequences was evaluated.

SETTING

Single institution.

PARTICIPANTS

Nineteen participants undergoing orthodontic treatment.

MAIN OUTCOME

Level of distortion caused by metal artifacts and MR sequence used.

RESULTS

The results of this study demonstrate that appliances such as hyrax palatal expanders and braces with stainless steel brackets are acceptable for a VP MRI, while class II corrector springs are not recommended. The HASTE MRI sequence with 2D imaging techniques should be utilized if the child has orthodontic devices, while FSE and 3D imaging techniques are not recommended. The presence of wire spring coils and molar bands are likely to not to interfere with the MRI evaluation.

CONCLUSIONS

Findings from this study suggest that the presence of orthodontic appliances does not hinder visualization of all velopharyngeal structures during an MRI. Therefore, careful consideration must be made prior to disqualifying or recommending patients for VP MRI.

Preliminary Development of an MRI Atlas for Application to Cleft Care: Findings and Future Recommendations

OBJECTIVE

To introduce a highly innovative imaging method to study the complex velopharyngeal (VP) system and introduce the potential future clinical applications of a VP atlas in cleft care.

DESIGN

Four healthy adults participated in a 20-min dynamic magnetic resonance imaging scan that included a high-resolution T2-weighted turbo-spin-echo 3D structural scan and five custom dynamic speech imaging scans. Subjects repeated a variety of phrases when in the scanner as real-time audio was captured.

SETTING

Multisite institution and clinical setting.

PARTICIPANTS

Four adult subjects with normal anatomy were recruited for this study.

MAIN OUTCOME

Establishment of 4-D atlas constructed from dynamic VP MRI data.

RESULTS

Three-dimensional dynamic magnetic resonance imaging was successfully used to obtain high quality dynamic speech scans in an adult population. Scans were able to be re-sliced in various imaging planes. Subject-specific MR data were then reconstructed and time-aligned to create a velopharyngeal atlas representing the averaged physiological movements across the four subjects.

CONCLUSIONS

The current preliminary study examined the feasibility of developing a VP atlas for potential clinical applications in cleft care. Our results indicate excellent potential for the development and use of a VP atlas for assessing VP physiology during speech.

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.

How Early Can We Predict the Need for VPI Surgery?

Velopharyngeal dimensions change as a child with cleft palate (CP) grows. The aim of this study was to assess if the decision for velopharyngeal insufficiency (VPI) surgery can be made by the age of 3 years among CP children with moderate-to-severe VPI. In addition, we sought to clarify if speech therapy before VPI surgery is beneficial for VPI speech characteristics.

METHODS

This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years.

RESULTS

Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics.

CONCLUSIONS

Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

Growth Effects on Velopharyngeal Anatomy Within the First 2 Years of Life

PURPOSE

Limited quantitative data exist regarding growth of the velopharynx within the first 2 years of life. The purpose of this study was to (a) quantify changes in velopharyngeal structures due to growth during the first 2 years of life, (b) examine the impact of sex and race within this age range, and (c) provide normative measures for comparison to individuals with cleft palate.

METHOD/DESCRIPTION

A retrospective chart review was completed of all patients up to 24 months of age that underwent magnetic resonance imaging of the head for medical necessity within the past 18 months using a three-dimensional fluid-attenuated inversion recovery sequence. Measurements of the velopharynx were obtained from 200 scans consistent with previous literature. Participants were divided into five groups based on corrected age for comparison. Variables of interest included adenoid depth, angle of origin, effective velopharyngeal ratio, effective velar length, levator veli palatini length, origin-origin distance, pharyngeal depth, sagittal angle, velopharyngeal ratio, velar insertion distance, velar length, and velar thickness.

RESULTS

Velopharyngeal dimensions were significantly different among corrected age groups after controlling for sex and race. Regarding age, analyses revealed significant differences in all variables of interest except effective velopharyngeal ratio. Regarding sex, significant differences were observed for angle of origin, effective velopharyngeal ratio, effective velar length, levator veli palatini muscle length, and velar insertion distance. Regarding race, a significant difference was only observed for angle of origin.

CONCLUSIONS

Results of this study demonstrate growth of velopharyngeal anatomy in normative infants with race and sex effects apparent in children up to 24 months of age. Variable growth trends were observed among different velopharyngeal measures.

A Midsagittal-View Magnetic Resonance Imaging Study of the Growth and Involution of the Adenoid Mass and Related Changes in Selected Velopharyngeal Structures

PURPOSE

The adenoids, or pharyngeal tonsils, consist of a pad of lymphoid tissue, located on the posterior pharyngeal wall of the nasopharynx. During childhood, the adenoid pad serves as a contact site for the soft palate to assist with velopharyngeal closure during oral speech. During adenoidal involution, most children are able to maintain appropriate velopharyngeal closure necessary for normal speech resonance. The purpose of this study is to determine age-related trends of normal adenoid growth and involution from infancy through adulthood.

METHOD/DESCRIPTION

Lateral view magnetic resonance imaging was used to analyze velopharyngeal variables among 270 participants, between 3 months and 34 years of age. The velopharyngeal measures of interest included velar length, effective velar length, pharyngeal depth, adenoid height, adenoid thickness, adenoid depth, and adenoid area. Participants were divided into four age groups for statistical comparison.

RESULTS

There was a statistically significant difference (p < .05) in all linear and area measurements between the four age groups. Adenoid depth reached peak growth at age 4 years, whereas adenoid height and adenoid thickness peaked at 8 years of age. Qualitatively, adenoid growth progresses in an anterior and inferior direction whereas involution occurs in a posterior and superior direction.

CONCLUSIONS

This study contributes to the knowledge of time specific changes across an age span for adenoid growth and involution and presents a visualization of the shape and growth trends of adenoids. A new sequence of involution is reported beginning first with adenoid depth, followed by adenoid height at a slightly faster rate than adenoid thickness.

Long-term Morphological Changes of the Velum and the Nasopharynx in Patients With Cleft Palate

OBJECTIVE

To investigate long-term morphological changes in the soft palate length and nasopharynx in patients with cleft palate. We hypothesized that there would be differences in the morphological development of the soft palate and nasopharynx between patients with and without cleft palate and that these developmental changes would negatively affect the soft palate length to pharyngeal depth ratio involved in velopharyngeal closure for patients with cleft palate.

DESIGN

Retrospective, case-control study.

SETTING

Institutional practice.

PATIENTS

Ninety-two patients (Group F) with unilateral cleft lip, alveolus, and palate and 67 patients (Group CLA) with unilateral cleft lip and alveolus not requiring palatoplasty were included.

MAIN OUTCOME MEASURES

The soft palate length, nasopharyngeal size, and soft palate length to pharyngeal depth ratio were measured via lateral cephalograms obtained at three different periods.

RESULTS

Group F showed a shorter soft palate length and smaller nasopharyngeal size than Group CLA at all periods. Both these parameters increased with age, but the increase in amount was significantly less in Group F compared with that in Group CLA. The soft palate length to pharyngeal depth ratio in Group F decreased with age.

CONCLUSIONS

In patients with cleft palate, the soft palate length to pharyngeal depth ratio, which is involved in velopharyngeal closure, can change with age. Less soft palate length growth and unfavorable relationship between the soft palate and nasopharynx may be masked in early childhood but can manifest later on with age.

Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

To determine prognostic factors for postoperative velopharyngeal function following the primary cleft palate repair at the age of five and above. This study reviewed patients with cleft palate who had undergone Furlow palatoplasty at age 5 or older from 2009 to 2014. We obtained intraoperative measurements, including velar length, pharyngeal depth, cleft width, maxillary width, cleft palate index (cleft width/maxillary width) and palatopharyngeal ratio (velar length/pharyngeal depth), as well as speech evaluation results at least 1 year after surgery. Logistic regression and retrospective analyses were performed to determine factors associated with speech performance after the primary cleft palate repair. Among the six intraoperative measurements of velopharyngeal morphology, only pharyngeal depth was incorporated into the regression model, and was found to have an inverse association with postoperative velopharyngeal function, Exp (B) 0.883 (95% CI 0.798-0.976). Moreover, a pharyngeal depth greater than 16 mm was significantly associated with a higher risk of postoperative velopharyngeal insufficiency (P < 0.01). Pharyngeal depth is potentially a prognostic indicator for the primary management of cleft palate in older patients. Pharyngoplasty may need to be considered when the pharyngeal depth is large and the patient's access to surgery is limited.

Nasalance Scores for Normal Speakers of American English Obtained by the Nasometer II Using the MacKay-Kummer SNAP-R Test

OBJECTIVE

To establish nasalance score norms for adolescent and young adult native speakers of American English and also determine age-group and gender differences using the Simplified Nasometric Assessment Procedures (SNAP) Test-R and Nasometer II.

DESIGN

Prospective study using a randomly selected sample of participants.

SETTING

Greater Cincinnati area and Miami University of Ohio.

PARTICIPANTS

Participants had a history of normal speech and language development and no history of speech therapy. Participants in the adolescent group were recruited from schools in West Clermont and Hamilton County, whereas the young adults were recruited from Miami University of Ohio. The participants of both groups were residents of Cincinnati, Ohio or Oxford, Ohio and spoke midland American English dialect.

OUTCOME MEASURES

Mean nasalance scores for the SNAP Test-R.

RESULTS

Normative nasalance scores were obtained for the Syllable Repetition/Prolonged Sounds, Picture-Cued, and Paragraph subtests. Results showed statistically significant nasalance score differences between adolescents and young adults in the Syllable Repetition, Picture-Cued, and Paragraph subtests, and between males and females in the Syllable Repetition and the Sound-Prolonged subtests. A significant univariate effect was found for the syllables and sentences containing nasal consonants and high vowels compared to syllables and sentences containing oral consonants and low vowels. Across all the SNAP Test-R subtests, the females' nasalance scores were higher than the males. A significant univariate effect was also found across nasal syllables, and high vowels such that the females' nasalance scores were higher than the males. Tables of normative data are provided that may be useful for clinical purposes.

CONCLUSION

Norms obtained demonstrated nasalance score differences according to age and gender, particularly in the Syllable Repetition/Prolonged Sound subtest. These differences were discussed in light of potential reasons for their existence and implications for understanding velopharyngeal function. In addition, nasalance scores are affected by the vowel type and place of articulation of the consonant. These facts should be considered when nasometry is used clinically and for research purposes.

Does the Type of MRI Sequence Influence Perceived Quality and Measurement Consistency in Investigations of the Anatomy of the Velopharynx?

PURPOSE

The purpose of this study was to evaluate perceived image quality, confidence in identifying key velopharyngeal landmarks, and reliability of making velopharyngeal measures between 3-dimensional (3-D) and 2-D magnetic resonance imaging (MRI) methods and between T1-, T2-, and proton density (PD)-weighted sequences.

METHODS

Twelve healthy participants completed an MRI study. Three raters assessed overall image quality and their ability to identify key anatomic features within the images. A single rater evaluated the reliability of making measures between imaging methods and sequence types to determine if image type (2-D and 3-D) or image sequence (T1, T2, PD weighted) resulted in different values for key velopharyngeal landmarks.

RESULTS

An analysis of variance test revealed image quality was rated significantly different based on the scan type (P < .001) and the sequence used (P = .015). Image quality was rated higher among 2-D MR images compared to 3-D, and higher among T2 sequences compared to T1- and PD-weighted imaging methods. In contrast, raters favored 3-D sequences over 2-D sequences for identifying velopharyngeal landmarks. Measures of reliability revealed scan type significantly impacted 2 of the 6 variables but to a minimal degree; however, sequence type had no impact on measures of reliability across all variables.

CONCLUSION

Results of the study suggest the scan type and sequence used are factors that likely do not impact the reliability of measures. Based on image quality, the recommended technique for velopharyngeal imaging would be using a 2-D T2-weighted technique. However, based on the ability to identify key landmarks, a 3-D T1- or PD-weighted technique was favored.

Effective Velopharyngeal Ratio: A More Clinically Relevant Measure of Velopharyngeal Function

Purpose Velopharyngeal (VP) ratios are commonly used to study normal VP anatomy and normal VP function. An effective VP (EVP) ratio may be a more appropriate indicator of normal parameters for speech. The aims of this study are to examine if the VP ratio is preserved across the age span or if it varies with changes in the VP portal and to analyze if the EVP ratio is more stable across the age span. Method Magnetic resonance imaging was used to analyze VP variables of 270 participants. For statistical analysis, the participants were divided into the following groups based on age: infants, children, adolescents, and adults. Analyses of variance and a Games-Howell post hoc test were used to compare variables between groups. Results There was a statistically significant difference (p < .05) in all measurements between the age groups. Pairwise comparisons reported statistically significant adjacent group differences (p < .05) for velar length, VP ratio, effective velar length, adenoid depth, and pharyngeal depth. No statistically significant differences between adjacent age groups were reported for the EVP ratio. Conclusions Results from this study report the EVP ratio was not statistically significant between adjacent age groups, whereas the VP ratio was statistically significant between adjacent age groups. This study suggests that the EVP ratio is more correlated to VP function than the VP ratio and provides a more stable and consistent ratio of VP function across the age span.

Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study

OBJECTIVE

To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech.

METHODS

Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech.

RESULTS

Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls.

CONCLUSIONS

The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.