Velopharyngeal Structural and Functional Assessment of Speech in Young Children Using Dynamic Magnetic Resonance Imaging

Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair

OBJECTIVE

To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI).

DESIGN

Prospective observational multicenter study.

SETTING

Twelve hospitals across the United States and Canada.

PARTICIPANTS

Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants.

INTERVENTIONS

Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team.

MAIN OUTCOME MEASURE(S)

The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings.

RESULTS

Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter.

CONCLUSIONS

Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date.

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.

Magnetic Resonance Imaging for Assessing Velopharyngeal Function: Current Applications, Barriers, and Potential for Future Clinical Translation in the United States

OBJECTIVE

The use of magnetic resonance imaging (MRI) in the assessment process for children with cleft/craniofacial conditions remains uncommon, particularly for velopharyngeal assessments. The purpose of this study was to analyze the perceived clinical utility of MRI for cleft/craniofacial providers and identify barriers that exist for clinical translation of this imaging modality to this population of patients.

METHODS

A 38-item survey was disseminated to craniofacial team providers. Workplace context and demographics, MRI as a research and clinical tool, access and barriers for use of MRI, and needs for successfully establishing MRI protocols at clinical sites were investigated. Descriptive statistics were used to identify differences in the clinical use of MRI across disciplines. Chi-square analyses were conducted to determine how different specialties perceived potential barriers.

RESULTS

Respondents reported that MRI is likely to be beneficial for clinical assessments (93.5%) and that this imaging modality is available for use (83.8%). However, only 11.8% of providers indicated the use of MRI in their clinical assessments. This discrepancy highlights a potential disconnect between perceived use and implementation of this imaging methodology on cleft and craniofacial teams. A number of barriers were identified by providers. Challenges and opportunities for clinical translation of MRI protocols were highlighted.

CONCLUSION

Results may guide the development for improved clinical feasibility and implementation of MRI for clinical planning in this population of patients. Reported barriers highlight additional areas for translational research and the potential for the development of clinical tools related to MRI assessment and protocol implementation.

Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy

The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.

Optimization of 3D dynamic speech MRI: Poisson-disc undersampling and locally higher-rank reconstruction through partial separability model with regional optimized temporal basis

PURPOSE

To improve the spatiotemporal qualities of images and dynamics of speech MRI through an improved data sampling and image reconstruction approach.

METHODS

For data acquisition, we used a Poisson-disc random under sampling scheme that reduced the undersampling coherence. For image reconstruction, we proposed a novel locally higher-rank partial separability model. This reconstruction model represented the oral and static regions using separate low-rank subspaces, therefore, preserving their distinct temporal signal characteristics. Regional optimized temporal basis was determined from the regional-optimized virtual coil approach. Overall, we achieved a better spatiotemporal image reconstruction quality with the potential of reducing total acquisition time by 50%.

RESULTS

The proposed method was demonstrated through several 2-mm isotropic, 64 mm total thickness, dynamic acquisitions with 40 frames per second and compared to the previous approach using a global subspace model along with other k-space sampling patterns. Individual timeframe images and temporal profiles of speech samples were shown to illustrate the ability of the Poisson-disc under sampling pattern in reducing total acquisition time. Temporal information of sagittal and coronal directions was also shown to illustrate the effectiveness of the locally higher-rank operator and regional optimized temporal basis. To compare the reconstruction qualities of different regions, voxel-wise temporal SNR analysis were performed.

CONCLUSION

Poisson-disc sampling combined with a locally higher-rank model and a regional-optimized temporal basis can drastically improve the spatiotemporal image quality and provide a 50% reduction in overall acquisition time.

The Pediatric Neuroradiologist's Practical Guide to Capture and Evaluate Pre- and Postoperative Velopharyngeal Insufficiency

Up to 30% of children with cleft palate will develop a severe speech disorder known as velopharyngeal insufficiency. Management of velopharyngeal insufficiency typically involves structural and functional assessment of the velum and pharynx by endoscopy and/or videofluoroscopy. These methods cannot provide direct evaluation of underlying velopharyngeal musculature. MR imaging offers an ideal imaging method, providing noninvasive, high-contrast, high-resolution imaging of soft-tissue anatomy. Furthermore, focused-speech MR imaging techniques can evaluate the function of the velum and pharynx during sustained speech production, providing critical physiologic information that supplements anatomic findings. The use of MR imaging for velopharyngeal evaluation is relatively novel, with limited literature describing its use in clinical radiology. Here we provide a practical approach to perform and interpret velopharyngeal MR imaging examinations. This article discusses the velopharyngeal MR imaging protocol, methods for interpreting velopharyngeal anatomy, and examples illustrating its clinical applications. This knowledge will provide radiologists with a new, noninvasive tool to offer to referring specialists.

Assessment of the Velopharyngeal Mechanism at Rest and During Speech in Children With 22q11.2DS: A Cross-Sectional Study

OBJECTIVE

Velopharyngeal dysfunction (VPD) associated with 22q11.2 deletion syndrome (22q11.2DS) has a complex etiology. This study had 3 aims: (1) assess differences in velopharyngeal and levator muscle configuration during rest versus sustained speech production (2) compare differences in velopharyngeal changes between children with and without 22q11.2DS (3) examine the relationship between adenoid thickness, pharyngeal depth, and velopharyngeal changes.

DESIGN

Cross-sectional.

METHODS

A total of 22 participants, 11 with 22q11.2DS and 11 controls with normal speech and velopharyngeal anatomy (ages 4-12 years), underwent nonsedated MRI at rest and during sustained /i/. Differences in velar and levator muscle contraction across the 2 different conditions were analyzed, using matched paired t-tests. Mean differences across participant groups were examined. Correlation analyses were also conducted.

RESULTS

When comparing differences between rest and sustained phoneme production (aim 1), significant (P < .05) differences were noted for all velar and levator muscle variables. For differences in velopharyngeal changes between children with and without 22q11.2DS (aim 2), VP ratio and effective VP ratio were noted to be significantly different. Pharyngeal depth and adenoid thickness were correlated with velar and levator muscle change measures and ratios (aim 3).

CONCLUSION

Results from this study provide quantitative in vivo measurements of the contracted levator muscle and velum in young children with 22q11.2DS. Results demonstrated that VP ratio and EVP ratio are significantly different between children with and without 22q11.2DS and that pharyngeal depth is a strong clinical determinant of VPD in children with 22q11.2DS.

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.

Enhancing linguistic research through 2-mm isotropic 3D dynamic speech MRI optimized by sparse temporal sampling and low-rank reconstruction

PURPOSE

To enable a more comprehensive view of articulations during speech through near-isotropic 3D dynamic MRI with high spatiotemporal resolution and large vocal-tract coverage.

METHODS

Using partial separability model-based low-rank reconstruction coupled with a sparse acquisition of both spatial and temporal models, we are able to achieve near-isotropic resolution 3D imaging with a high frame rate. The total acquisition time of the speech acquisition is shortened by introducing a sparse temporal sampling that interleaves one temporal navigator with four randomized phase and slice-encoded imaging samples. Memory and computation time are improved through compressing coils based on the region of interest for low-rank constrained reconstruction with an edge-preserving spatial penalty.

RESULTS

The proposed method has been evaluated through experiments on several speech samples, including a standard reading passage. A near-isotropic 1.875 × 1.875 × 2 mm³ spatial resolution, 64-mm through-plane coverage, and a 35.6-fps temporal resolution are achieved. Investigations and analysis on specific speech samples support novel insights into nonsymmetric tongue movement, velum raising, and coarticulation events with adequate visualization of rapid articulatory movements.

CONCLUSION

Three-dimensional dynamic images of the vocal tract structures during speech with high spatiotemporal resolution and axial coverage is capable of enhancing linguistic research, enabling visualization of soft tissue motions that are not possible with other modalities.

3D Dynamic Spatiotemporal Atlas of the Vocal Tract during Consonant–Vowel Production from 2D Real Time MRI

In this work, we address the problem of creating a 3D dynamic atlas of the vocal tract that captures the dynamics of the articulators in all three dimensions in order to create a global speaker model independent of speaker-specific characteristics. The core steps of the proposed method are the temporal alignment of the real-time MR images acquired in several sagittal planes and their combination with adaptive kernel regression. As a preprocessing step, a reference space was created to be used in order to remove anatomical information of the speakers and keep only the variability in speech production for the construction of the atlas. The adaptive kernel regression makes the choice of atlas time points independently of the time points of the frames that are used as an input for the construction. The evaluation of this atlas construction method was made by mapping two new speakers to the atlas and by checking how similar the resulting mapped images are. The use of the atlas helps in reducing subject variability. The results show that the use of the proposed atlas can capture the dynamic behavior of the articulators and is able to generalize the speech production process by creating a universal-speaker reference space.

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.

Utilization of 3D MRI for the Evaluation of Sphincter Pharyngoplasty Insertion Site in Patients With Velopharyngeal Dysfunction

Sphincter pharyngoplasty is a surgical method to treat velopharyngeal dysfunction. However, surgical failure is often noted and postoperative assessment frequently reveals low-set pharyngoplasties. Past studies have not quantified pharyngoplasty tissue changes that occur postoperatively and gaps remain related to the patient-specific variables that influence postoperative change. The purpose of this study was to utilize advanced three-dimensional imaging and volumetric magnetic resonance imaging (MRI) data to visualize and quantify pharyngoplasty insertion site and postsurgical tissue changes over time.

A prospective, repeated measures design was used for the assessment of craniometric and velopharyngeal variables postsurgically. Imaging was completed across two postoperative time points. Tissue migration, pharyngoplasty dimensions, and predictors of change were analyzed across imaging time points.

Significant differences were present between the initial location of pharyngoplasty tissue and the pharyngoplasty location 2 to 4 months postoperatively. The average postoperative inferior movement of pharyngoplasty tissue was 6.82 mm, although notable variability was present across participants. The pharyngoplasty volume decreased by 30%, on average.

Inferior migration of the pharyngoplasty tissue was present in all patients. Gravity, scar contracture, and patient-specific variables likely interact, impacting final postoperative pharyngoplasty location. The use of advanced imaging modalities, such as 3D MRI, allows for the quantification and visualization of tissue change. There is a need for continued identification of patient-specific factors that may impact the amount of inferior tissue migration and scar contracture postoperatively.

Developmental Functional Modules in Infant Vocalizations

Purpose Developmental functional modules (DFMs) are biological modules that are defined by their structural (morphological), functional, or developmental elements, and, in some cases, all three of these. This review article considers the hypothesis that vocal development in the first year of life can be understood in large part with respect to DFMs that characterize the speech production system. Method Literature is reviewed on relevant embryology, orofacial reflexes, craniofacial muscle properties, stages of vocal development, and related topics to identity candidates for DFMs. Results The following DFMs are identified and described: laryngeal, pharyngo-laryngeal, mandibular, velopharyngeal, labial complex, and lingual complex. These DFMs and their submodules, considered along with phenomena such as rhythmic movements, account for several well-documented features of vocal development in the first year of life. The proposed DFMs, rooted in embryologic, histologic, and kinematic properties, serve as low-dimensional control variables for the developing vocal tract. Each DFM is semi-autonomous but interacts with other DFMs to produce patterns of vocal behavior. Discussion Considered in relation to contemporary profiles and models of vocal development in the first year of life, DFMs have interpretive and explanatory value. DFMs complement other approaches in the study of infant vocalizations and are grounded in biology.

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.

Identifying Predictors of Levator Veli Palatini Muscle Contraction During Speech Using Dynamic Magnetic Resonance Imaging

Purpose The purpose of this study was to identify predictors of levator veli palatini (LVP) muscle shortening and maximum contraction velocity in adults with normal anatomy. Method Twenty-two Caucasian English-speaking adults with normal speech and resonance were recruited. Participants included 11 men and 11 women (M = 22.8 years, SD = 4.1) with normal anatomy. Static magnetic resonance images were obtained using a three-dimensional static imaging protocol. Midsagittal and oblique coronal planes were established for visualization of the velum and LVP muscle at rest. Dynamic magnetic resonance images were obtained in the oblique coronal plane during production of "ansa." Amira 6.0.1 Visualization and Volume Modeling Software and MATLAB were used to analyze images and calculate LVP shortening and maximum contraction velocity. Results Significant predictors (p < .05) of maximum LVP shortening during velopharyngeal closure included mean extravelar length, LVP origin-to-origin distance, velar thickness, pharyngeal depth, and velopharyngeal ratio. Significant predictors (p < .05) of maximum contraction velocity during velopharyngeal closure included mean extravelar length, intravelar length, LVP origin-to-origin distance, and velar thickness. Conclusions This study identified six velopharyngeal variables that predict LVP muscle function during real-time speech. These predictors should be considered among children and individuals with repaired cleft palate in future studies.

Contracted Extravelar Segments of the Levator Veli Palatini Muscle: A Magnetic Resonance Imaging Morphometric Study

OBJECTIVES

To provide detailed descriptions of contraction-induced morphometric changes in the extravelar segments of the levator veli palatini (LVP) muscle using 3-dimensional (3-D) magnetic resonance imaging (MRI).

DESIGN

Three-dimensional MRI data were acquired at rest and during "silent /i/" from 4 singers. During silent /i/, participants voluntarily sustained velar elevation while breathing orally for the entire scan time. Focusing on the extravelar segments, LVP length, angle of the muscle origin, and cross-sectional area (CSA), measurements were obtained and compared between tasks.

RESULTS

Three of the 4 participants exhibited the expected patterns of change following concentric contraction of the LVP muscle. Consistent changes from the resting to the contracted state included reductions in LVP length by 13.5% and angle of the muscle origin by 9.8%, as well as increases in CSAs by 22.1%, on average.

CONCLUSIONS

This study presented high-resolution data of the LVP muscle behavior with the first in vivo 3-D measurements of the contracted LVP muscle, which can be useful for the validation of computational models that aim at describing biomechanical properties of the LVP muscle in future research. The active behavior of the extravelar LVP muscle also provides some insight on optimal LVP muscle geometry to consider during cleft palate repair.

Age Norms for Auditory-Perceptual Neurophonetic Parameters: A Prerequisite for the Assessment of Childhood Dysarthria

Purpose The aim of this study was to collect auditory-perceptual data on established symptom categories of dysarthria from typically developing children between 3 and 9 years of age, for the purpose of creating age norms for dysarthria assessment. Method One hundred forty-four typically developing children (3;0-9;11 [years;months], 72 girls and 72 boys) participated. We used a computer-based game specifically designed for this study to elicit sentence repetitions and spontaneous speech samples. Speech recordings were analyzed using the auditory-perceptual criteria of the Bogenhausen Dysarthria Scales, a standardized German assessment tool for dysarthria in adults. The Bogenhausen Dysarthria Scales (scales and features) cover clinically relevant dimensions of speech and allow for an evaluation of well-established symptom categories of dysarthria. Results The typically developing children exhibited a number of speech characteristics overlapping with established symptom categories of dysarthria (e.g., breathy voice, frequent inspirations, reduced articulatory precision, decreased articulation rate). Substantial progress was observed between 3 and 9 years of age, but with different developmental trajectories across different dimensions. In several areas (e.g., respiration, voice quality), 9-year-olds still presented with salient developmental speech characteristics, while in other dimensions (e.g., prosodic modulation), features typically associated with dysarthria occurred only exceptionally, even in the 3-year-olds. Conclusions The acquisition of speech motor functions is a prolonged process not yet completed with 9 years. Various developmental influences (e.g., anatomic-physiological changes) shape children's speech specifically. Our findings are a first step toward establishing auditory-perceptual norms for dysarthria in children of kindergarten and elementary school age. Supplemental Material https://doi.org/10.23641/asha.12133380.

Velopharyngeal closure analysis using four-dimensional computed tomography: a pilot study of healthy volunteers and adult patients with cleft palate

Background

Nasopharyngoscopy is a common method to evaluate velopharyngeal closure in patients with cleft palate. However, insertion of a fiberoptic nasopharyngoscope causes discomfort in patients. The aim of this study was to estimate the reliability of short-time exposure images obtained using 320-row area detector computed tomography (320-ADCT) as a novel evaluation method for the assessment of velopharyngeal function.

Methods

We evaluated five healthy adult volunteers and five postoperative adult patients with cleft palate. During a 3.3-s imaging exposure, the participants were asked to perform two tasks: nasal inspiration and subsequent oral expiration through a catheter into a water-filled cup. The movement of the velopharyngeal structures was recorded during each examination, and the presence of velopharyngeal insufficiency (VPI) and velopharyngeal closure (VPC) patterns were estimated. If VPI was detected, the cross-sectional area was also calculated. Cohen’s kappa and weighted kappa coefficients were used to evaluate the concordance of nasopharyngoscopy and 320-ADCT evaluation.

Results

Speech pathology evaluation did not reveal hypernasality in any study participant. Micro-VPI was detected by nasopharyngoscopy in one healthy volunteer and two patients. 320-ADCT detected micro-VPI in two more patients. The cross-sectional area of the VPI in these subjects ranged from 2.53 to 16.28 mm². Nasopharyngoscopy and 320-ADCT were concordant in detecting VPI in eight participants (κ = 0.6) and in assessing VPC patterns in nine (κ = 0.82). Moreover, images obtained using 320-ADCT allowed for reduced dead angle and, thus, easy detection of micro-VPI and Passavant’s ridges.

Conclusion

Although the radiation exposure cannot be ignored, our novel evaluation method using 320-ADCT enables more detailed evaluation of VPC than nasopharyngoscopy. Future studies should investigate the relationship between 320-ADCT findings and speech pathology evaluations.

Electronic supplementary material

The online version of this article (10.1186/s12880-019-0350-4) contains supplementary material, which is available to authorized users.

Velopharyngeal Structural and Muscle Variations in Children With 22q11.2 Deletion Syndrome: An Unsedated MRI Study

Objective:

The 22q11.2 deletion syndrome (22q11.2DS) is the most common genetic cause of velopharyngeal dysfunction; however, limited information exists regarding variations in velopharyngeal anatomy in this clinically challenging population. The purpose of this study was to examine velopharyngeal characteristics among young children with 22q11.2DS in comparison to a normative cohort using an innovative, nonsedated magnetic resonance imaging (MRI) scanning protocol.

Methods:

Fifteen children with 22q11.2DS and 15 age- and gender-matched controls with normal velopharyngeal anatomy (ages 4-12) successfully completed the MRI protocol. Eighteen velopharyngeal and 2 related craniofacial measures were examined. Analysis of covariance was used to compare differences between the experimental and the control groups.

Results:

The 22q11.2DS group demonstrated a significantly thinner velum ( P < .0005) and a larger pharyngeal depth ( P = .007) compared to the matched control group. Findings in the current study also demonstrated that the levator veli palatini muscle is significantly shorter ( P = .037) and thinner ( P = .025) in the 22q11.2DS cohort, with a significantly shorter origin-to-origin distance ( P < .0005) and a greater angle of origin ( P = .001) compared to healthy peers.

Conclusion:

Children with 22q11.2DS demonstrated multiple variations that may contribute to velopharyngeal dysfunction by altering the anatomic characteristics of the velopharyngeal port, the levator muscle, and associated structures. This investigation represents the first and largest attempt to characterize velopharyngeal anatomy in children with 22q11.2DS using a nonsedated MRI protocol.

Anatomical Significance of the Spatial Distribution of the Palatopharyngeus With Regard to Velopharyngeal Closure

OBJECTIVE

Coordination of the various soft palate and pharyngeal muscles should be considered while evaluating velopharyngeal closure. However, it remains unclear whether different muscle bundles have specific functions during velopharyngeal closure. We macroscopically and microscopically examined these muscles in detail and particularly clarified the morphology of the palatopharyngeus (PP) in velopharyngeal closure.

DESIGN

Forty halves of 21 heads from Japanese cadavers (average: 83.9 years) were used for analysis; 37 halves of 19 heads were macroscopically examined and 3 halves of 2 heads were histologically examined.

RESULTS

The PP consisted of muscle bundles originating from the superior and inferior surfaces of the palatine aponeurosis. The most superior part of the superior constrictor (SC) and most lateral part of PP on the palatine aponeurosis initially ran in parallel and subsequently, in superoposterior and inferoposterior directions, respectively. The PP appeared as a single continuous sheet that was radially spread as a whole. Its medial margins, located superior and inferior to the aponeurosis, formed a fold that established the palatopharyngeal arch. The stylopharyngeus (StP) adjoined the base of this arch.

CONCLUSIONS

Since PP consisted of muscle bundles running in various directions, various functions of these bundles should be considered during velopharyngeal closure. The PP can function as a sphincter with SC and as an elevator with StP. In addition, PP forms the medial protrusion in collaboration with StP and SC. Thus, PP plays an important role in velopharyngeal closure with the coordination of various muscles.

Palatal Measurements Pre- and Post-Furlow Cleft Palate Repair: Analysis of Palatal Lengthening and Comparison Within Cleft Types

Objective:

The purpose of this study was to characterize intraoperative palatal lengthening with the modified Furlow cleft palatal repair and to determine whether lengthening correlated with preoperative cleft width, cleft type, or operating surgeon.

Design:

Retrospective study.

Setting:

Academic tertiary care pediatric hospital.

Patients:

One hundred eighty pediatric patients undergoing primary or secondary palatoplasty using the Furlow technique.

Interventions:

Cleft and palatal lengths and widths were measured pre- and post-Furlow cleft palatal repair.

Main Outcome Measures:

Immediate postoperative percentage change in surface palate length, straight palate length, and soft palate length.

Results:

The average cleft widest width and width at the hard–soft palate junction were 10.2 and 9.5 mm, respectively, and varied with Veau cleft type. Following Furlow palatoplasty, lengths of the curved, straight, and soft palate increased by 7.5%, 15.8%, and 30.6%, respectively. Degree of palatal lengthening varied among surgeons and Veau cleft type but was not related to cleft width. Seven (4.0%) patients developed postoperative oronasal fistulas. Patients with a Veau IV cleft and larger cleft widths were at an increased risk for fistula formation.

Conclusions:

This study demonstrates that overall palatal lengthening occurs with the modified Furlow technique. Long-term follow-up studies are needed to determine the clinical relevance of these findings.

Effects of Surgical Intervention and Continuous Positive Airway Pressure Therapy on Velopharyngeal Structure and Function: A Case Report

Changes to the velum and velopharyngeal muscles following Furlow double-opposing Z-plasty in a 7-year-old female with submucous cleft palate and velopharyngeal dysfunction (VPD) were evaluated. Perceptual, instrumental (ie, nasometry and aerodynamic pressure flow), and research magnetic resonance imaging analyses were used during pre- and postsurgical time points at a university research clinic. Continuous positive airway pressure (CPAP) therapy was trialed following a failed surgery for residual VPD in the patient. Increases in velar length and thickness and decreases in levator veli palatini muscle angle of origin and contraction were observed following the Furlow double-opposing Z-plasty surgery. Variable improvements in residual hypernasality following the home-based CPAP therapy protocol were observed.

Effect of motor-based speech intervention on articulatory placement in the treatment of a posterior nasal fricative: a preliminary MRI study on a single subject

BACKGROUND

Posterior nasal fricatives are a learned compensatory articulation error and commonly substituted for oral fricatives. Treatment of such articulation errors requires the modification or teaching of skilled movements. A motor-based approach is designed to teach the complex motor skill movement sequences required in the production of sounds. Although motor learning research is well established, little has been done to determine how the approach changes the underlying physiology of articulatory movements. While the underlying anatomical configuration of the posterior nasal fricative has been described, no studies have quantified anatomic and physiological changes pre- and post-treatment.

AIMS

To use magnetic resonance imaging (MRI) to visualize and quantify the results of motor-based speech-intervention approach on articulatory placement for the treatment of the posterior nasal fricative.

METHODS & PROCEDURES

A 6-year-old male with a history of ear infections and posterior nasal fricative substitution for /s/ underwent six 1-h sessions of a motor-based treatment approach over the course of 2 weeks. Pre- and post-treatment evaluation included perceptual and instrumental assessment of speech and resonance. Perceptual resonance was rated by two speech-language therapists and articulation was assessed at the single-word level. Instrumental assessment included the See-Scape, Nasometer II and MRI during the sustained phonation of /s/. Amira v5.6 Visualization and Volume modelling software used the midsagittal and oblique coronal plane to measure dimensions of the articulatory anatomy.

OUTCOMES & RESULTS

Interrater reliability was assessed using a Pearson product moment correlation (α = .05) and ranged from r = .91 to .95. Intra-rater reliability was assessed using the intra-class correlation coefficient (.976) demonstrating a high degree of reliability with a 95% confidence interval. Articulation improved from 0% accuracy for /s/ in isolation at baseline to 100% for /s/ at the word level and 95% accuracy during conversational speech by session 6. Post-treatment results from this study revealed a greater shortening of the levator veli palatini (levator) muscle length during articulatory movements, more pronounced velar knee and dimple, decreased velar thickness, increased velar length and altered tongue position.

CONCLUSIONS & IMPLICATIONS

This study demonstrated the use of pre- and post-treatment imaging methodology to quantify articulatory changes following an intensive motor-based treatment approach. MRI demonstrated quantifiable changes in articulatory placement. Individuals who exhibit non-developmental and phoneme-specific articulation errors, such as the posterior nasal fricative, may be excellent candidates for short-term, intensive and frequent speech therapy sessions to remediate the production of the posterior nasal fricative.

Can Dynamic MRI Be Used to Accurately Identify Velopharyngeal Closure Patterns?

BACKGROUND

Dynamic magnetic resonance imaging (MRI) has been proposed as a non-invasive, child-friendly, reproducible, and repeatable imaging method providing a 3-dimensional view of the velopharyngeal structures and function during speech. However, the value of dynamic MRI as compared to imaging methods such as nasopharyngoscopy is not well understood. The aim of this study was to compare the ability of nasopharyngoscopy and dynamic MRI to accurately identify velopharyngeal closure patterns among adults without cleft palate.

METHODS

Participants included 34 healthy adults with normal anatomy between 19 and 33 years of age (mean = 23 years; SD = 4.1 years). Participants underwent dynamic MRI and nasopharyngoscopy studies and comparisons were performed to determine the intra- and inter-rater reliability for accurately determining closure pattern. The MRI acquisition was a dynamic acquisition of a 2D plane.

RESULTS

Strong inter- (κ = .824; P < .001) and intra-rater (Rater 1: κ = 0.879, P < .001, 94% agreement between ratings; Rater 2 with 100% agreement) agreement was observed for the identification of closure pattern using nasopharyngoscopy. Inter-rater agreement for ratings using MRI demonstrated moderate agreement (κ = .489; P < .004). Examining point agreement revealed only 27 of the 33 ratings of MRI showed agreement (80%).

CONCLUSION

This demonstrates that inter-rater reliability for determining closure patterns from nasopharyngoscopy is good; however, ratings using MRI was less reliable at determining closure patterns. It is likely that future improvements in dynamic imaging with MRI to enable 3D visualizations are needed for improved diagnostic accuracy for assessing velopharyngeal closure patterns.

Examining a New Method to Studying Velopharyngeal Structures in a Child With 22q11.2 Deletion Syndrome

PURPOSE

To date, no studies have imaged the velopharynx in children with 22q11.2 deletion syndrome (22q11.2 DS) without the use of sedation. Dysmorphology in velopharyngeal structures has been shown to have significant negative implications on speech among these individuals. This single case study was designed to assess the feasibility of a child-friendly magnetic resonance imaging (MRI) scanning protocol in this clinically challenging population and to determine the utility of this MRI protocol for future work in this area.

METHOD

One 6-year-old White girl diagnosed with 22q11.2 DS was imaged using a child-friendly, nonsedated MRI protocol. Quantitative and qualitative measures of the velopharyngeal area and associated structures were evaluated, and comparisons were made to age-matched control subjects with normal velopharyngeal anatomy.

RESULTS

MRI data were successfully obtained using the child-friendly scanning protocol in the subject in the present study. Quantitative and qualitative differences of the levator muscle and associated velopharyngeal structures were noted. Using these MRI and structural analyses methods, insights related to muscle morphology can be obtained and considered as part of the research and clinical examination of children with 22q11.2 DS.

CONCLUSION

The imaging protocol described in this study presents an effective means to counteract difficulties in imaging young children.