Velopharyngeal dysfunction: current thinking on the cause, effect, assessment and treatment

Using Active-Phonation Cone-Beam Computed Tomography to Evaluate Pediatric Patients With Suspected Velopharyngeal Dysfunction, a Pilot Study

ABSTRACT

Velopharyngeal dysfunction (VPD) is described as the incomplete closure of the velopharyngeal port during a speech production. Nasopharyngoscopy and/or multiplanar videofluoroscopy have been utilized for decades to assess the degree and nature of the dysfunction. Cone-beam computed tomography (CBCT) is presented as an additional diagnostic tool, allowing for clear visualization of the affected structures and the ability to obtain accurate measurements (within 100 microns) of the involved anatomy and defect. This prospective pilot study aims to test the feasibility of using "active-phonation" CBCT to assess suspected VPD in the pediatric and young adult populations and compare the results to nasopharyngoscopy; the current standards of care.Six patients, ages 6 to 26 years, with suspected VPD, defined as the inability to completely close off the nasal airway during an oral speech, seen at an urban medical outpatient craniofacial care center, served as subjects for this pilot study. Each patient received a comprehensive speech evaluation and participated in both active-phonation CBCT and nasopharyngoscopy.Both active-phonation CBCT and nasopharyngoscopy revealed incomplete closure of the velopharyngeal port during a speech in all 6 patients (100%). Two patients (33%) were unable to tolerate a complete nasendoscopic examination. There was no difference between CBCT or nasopharyngoscopy in determining the presence of VPD and noting the severity on a 3-point scale, (P = 0.61) as judged by 4 experienced clinicians.As a functional imaging modality, active-phonation CBCT is a useful adjunct tool for accurate diagnosis of VPD and may be more easily tolerated during a thorough VPD assessment than nasopharyngoscopy. It also provides quantitative data that is useful to augment treatment optimization and surgical planning in this population. Further studies are needed to validate these results.

WITHDRAWN: Interventions for the management of submucous cleft palate

The Cochrane Oral Health Group withdrew this review as of Issue 1, 2016. The review is out of date and does not meet current Cochrane methodological standards.

The editorial group responsible for this previously published document have withdrawn it from publication.

A comprehensive description of functioning and disability in children with velopharyngeal insufficiency

Children with velopharyngeal insufficiency (VPI) experience functional impairments in a variety of areas that extend beyond the primary physical impairment associated with this disorder. At present, the physical deficits associated with VPI have been studied extensively; however, a comprehensive description of social and communicative participation in this population is needed. Therefore, a biopsychosocial framework such as the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), may offer an enhanced understanding of the daily experiences of children with VPI. Specifically, the ICF-CY framework is intended to model complex nonlinear systems, and as such, to describe functioning as the interaction of multiple components from which a limitation in communicative participation may emerge. This paper describes how the ICF-CY framework can be utilized to comprehensively describe functioning and disability in children with VPI by describing the interaction of components of this framework.

LEARNING OUTCOMES

As a result of this activity, the reader will be able to: (1) discuss the utility of the ICF-CY in describing the multi-dimensional nature of velopharyngeal insufficiency (VPI); (2) describe interrelationships between functioning and disability in children with VPI; and (3) identify how limitations in communicative participation may emerge from the interaction of components of the ICF-CY in children with VPI.

An Evaluation of Communication Apprehension in Adolescents with Velopharyngeal Inadequacy

Objective

This investigation evaluated the construct of communication apprehension (CA) in adolescents with velopharyngeal inadequacy (VPI).

Design

Prospective comparative study.

Settings

The investigation was conducted in a hospital-based clinic, voice laboratory, and the homes of participants.

Participants

Two groups of children participated in this study. The first group was composed of 14 children between the ages of 8 and 14 years who attended the velopharyngeal inadequacy (VPI) clinic at our institution, and the second group was composed of 14 age-matched children from the community with no history of speech or voice disorders.

Interventions

The study involved completion of the Measure of Elementary Communication Apprehension (MECA) by all 28 participants (14 experimental and 14 control subjects). Reliability of the subjects’ responses to the MECA was also evaluated.

Outcome Measures

Communication apprehension scores obtained from the MECA were the main focus of the study.

Results

Children with VPI experienced significantly higher levels of CA than did those in the control group. Moderate-to-good reliability of the MECA was found.

Conclusions

Based on these data, children with VPI may be experiencing increased levels of CA. Consequently, the experience of high CA has the potential to affect the communication performance and social functioning of children with VPI.

Interventions for the management of submucous cleft palate

BACKGROUND

Submucous cleft palate (SMCP) is a common congenital malformation of the soft palate which may present as velopharyngeal insufficiency (VPI), which can affect the quality and intelligibility of speech. Surgical techniques, which can be used to reconstruct these structural or anatomical defects and to correct velopharyngeal insufficiency, include palatal repair and procedures that rearrange the muscle attachments of the soft palate.

OBJECTIVES

To provide reliable evidence regarding the effectiveness of surgical interventions to treat velopharyngeal insufficiency and improve speech in patients with submucous cleft palate.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register (to 21st December 2006); Cochrane Developmental, Psychosocial and Learning Problems Group Trials Register (on 12th March 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (from 1966 to 21st December 2006); EMBASE (from 1980 to 21st December 2006); and CINAHL, ERIC, PsycINFO (on 7th March 2007).

SELECTION CRITERIA

Randomised controlled trials comparing surgical interventions to correct velopharyngeal insufficiency in submucous cleft palate.

DATA COLLECTION AND ANALYSIS

Limited data from one included trial precluded pooling of data, and only a descriptive summary is presented.

MAIN RESULTS

This review included one trial, involving 72 participants aged 4 to 7 years with submucous cleft palate associated velopharyngeal insufficiency, which compared minimal incision palatopharyngoplasty (MIPP) to MIPP with additional velopharyngeal surgery, either pharyngeal flap (32) or sphincter pharyngoplasty (3). The trial provided no information about post-operative speech assessment, very limited data on any instrumental assessments and there were no reports of obstructive sleep apnoea or other adverse effects after the interventions. Complete closure occurred in 32 (86%) of the participants in the MIPP group and in 31 (89%) in the additional treatment group, P > 0.05. After eliminating the nine patients with residual velopharyngeal insufficiency, the post-operative gap size during closure was 7.4 +/-3.2% in the MIPP group and 8 +/-4.1% in the additional intervention group (P > 0.5).

AUTHORS' CONCLUSIONS

The trial provided some weak and unreliable evidence that there was no significant difference in the effectiveness of minimal incision palatopharyngoplasty versus the same procedure performed simultaneously with an individually tailored pharyngeal flap or sphincter pharyngoplasty for correcting velopharyngeal insufficiency associated with submucous cleft palate.