Incomplete Velopharyngeal Closure Research Articles

Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers.

Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VParea), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VParea) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VParea, HN, and ModelKataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of ModelKataoka, A 3-P 0, and B F1 for the objective measurement of VPI or HN.

Effects of velopharyngeal size, airflow rate, and microphone placement on nasalance score

Nasometers are designed to measure the nasalance score, which is the ratio of nasal acoustic energy to total (nasal plus oral) acoustic energy during production of sonorant phonemes. However, nasometer microphones can detect hydrodynamic pressure changes in addition to acoustic pressure changes. This can occur when a talker with incomplete velopharyngeal closure leaks airflow through the nasal cavity; these nasal emissions lead to increased aerodynamic flow impinging on the nasal microphone, which may significantly increase the nasalance score. In order to quantify the influence of nasal emissions on the nasalance score, airflow with no voiced component was passed through an [s]-postured airway model based on a subject-specific geometry. Nasometer microphones measured pressure fluctuations exterior to the nose and mouth, from which the nasalance score was calculated. Flow rate, size of the velopharyngeal opening, and microphone position (medial or lateral) were varied in a factorial experiment. It was found that in the presence of nasal emissions, placing the nasometer microphones laterally decreases the nasalance score. Furthermore, the nasalance score generally increases with increased velopharyngeal opening size. These results indicate that hydrodynamic pressure from nasal emissions can increase the nasalance score and that this influence could be mitigated via microphone placement.

Comparison of contrast-enhanced videofluoroscopy to unenhanced dynamic MRI in minor patients following surgical correction of velopharyngeal dysfunction.

To compare dynamic magnetic resonance imaging (MRI) with videofluoroscopy (VFS) regarding image quality and assessment of gap size between soft palate (SP) and posterior pharyngeal wall (PPW) in children and adolescents following surgical correction of velopharyngeal dysfunction (VPD). Twenty-one patients undergoing unenhanced 3-T MRI and contrast-enhanced VFS were included in this IRB-approved prospective study. The MRI scan protocol comprised refocused gradient-echo sequences in transverse and sagittal planes during speech, with TE 1.97ms, TR 3.95ms, flip angle 8°, matrix size 128 × 128, and 5-mm slice thickness. Radial k-space sampling and sliding window reconstruction were used to achieve an image acquisition rate of 28 frames per second (fps). VFS with 30 fps was similarly performed in both planes. Closure of the velopharyngeal port during phonation was evaluated by two experienced radiologists. Eleven (52.4%) patients displayed a complete closure, whereas ten (47.6%) patients showed a post-operative gap during speech. VFS and MRI equally identified the cases with persistent or recurrent VPD. Differences in SP-PPW distance between VFS (3.9 ± 1.6mm) and MRI (4.1 ± 1.5mm) were not statistically significant (p = 0.5). The subjective overall image quality of MRI was rated inferior (p < 0.001) compared with VFS, with almost perfect inter-rater agreement (κ= 0.90). The presence of susceptibility artifacts did not limit anatomical measurements. Dynamic MRI is equally reliable as VFS to assess persistent or recurrent inadequate velum closure in patients following surgical treatment of VPD. • Unenhanced 3-T dynamic MRI and contrast-enhanced videofluoroscopy are equally useful for the identification of patients with incomplete velopharyngeal closure during speech. • MRI using refocused gradient-echo acquisition with radial k-space sampling and sliding window reconstruction generates diagnostic images with 28 frames per second. • MRI can offer a radiation-free alternative to currently established videofluoroscopy for young patients.

OBJECTIVE MEASURES OF PLOSIVE NASALIZATION IN HYPERNASAL SPEECH.

Hypernasal speech is a common symptom across several neurological disorders; however it has a variable acoustic signature, making it difficult to quantify acoustically or perceptually. In this paper, we propose the nasal cognate distinctiveness features as an objective proxy for hypernasal speech. Our method is motivated by the observation that incomplete velopharyngeal closure changes the acoustics of the resultant speech such that alveolar stops /t/ and /d/ map to the alveolar nasal /n/ and bilabial stops /b/ and /p/ map to bilabial nasal /m/. We propose a new family of features based on likelihood ratios between the plosives and their respective nasal cognates. These features are based on an acoustic model that is trained only on healthy speech, and evaluated on a set of 75 speakers diagnosed with different dysarthria subtypes and exhibiting varying levels of hypernasality. Our results show that the family of features compares favorably with the clinical perception of speech-language pathologists subjectively evaluating hypernasality.

Comparison of sensitivity and specificity of mirror test and cephalometry in assessing velopharyngeal insufficiency after reconstruction of cleft palate

The velopharyngeal valve has an important role in controlling the flow of air during speech and incomplete velopharyngeal closure causes problems with speech. There are several modalities to assess velopharyngeal insufficiency, including using the mirror test and cephalometric radiographs. This study aimed to determine the sensitivity and specificity of the mirror test and cephalometric radiography for velopharyngeal insufficiency examination in patients after cleft palate reconstruction. A cross-sectional analytic study with a specific design for a diagnostic test was conducted. Data was grouped in a 2 × 2 table using the gold standard endoscopic examination. Data was obtained from patients aged 5–11 years after reconstruction of cleft palate and speech therapy in the SEHATI Program at Children and Maternal Hospital Harapan Kita Jakarta. Cephalometric radiographs had a higher sensitivity (100%) but lower specificity (33.3%) compared to the mirror test. The false-negative rate of cephalometric radiographs was 66.66%. Cephalometric radiographs have a higher sensitivity than the mirror test (the initial method of examination method) and can be used for velopharyngeal insufficiency examination along with the mirror test.

Three-dimensional imaging of palatal muscles in the human embryo and fetus: Development of levator veli palatini and clinical importance of the lesser palatine nerve.

After palatoplasty, incomplete velopharyngeal closure in speech articulation sometimes persists, despite restoration of deglutition function. The levator veli palatini (LVP) is believed to be significantly involved with velopharyngeal function in articulation; however, the development and innervation of LVP remain obscure. The development of LVP in human embryos and fetuses has not been systematically analyzed using the Carnegie stage (CS) to standardize documentation of development. The anlage of LVP starts to develop at CS 21 beneath the aperture of the auditory tube (AT) to the pharynx. At CS 23, LVP runs along AT over its full length, as evidenced by three-dimensional image reconstruction. In the fetal stage, the lesser palatine nerve (LPN) is in contact with LVP. The positional relationship between LVP and AT three-dimensionally, suggesting that LVP might be derived from the second branchial arch. Based on histological evidence, we hypothesize that motor components from the facial nerve may run along LPN, believed to be purely sensory. The multiple innervation of LVP by LPN and pharyngeal plexus may explain the postpalatoplasty discrepancy between the partial impairment in articulation vs. the functional restoration of deglutition. That is, the contribution of LPN is greater in articulation than in deglutition.

Management of Velopharyngeal Insufficiency: Development of a Protocol and Modifications of Sphincter Pharyngoplasty

Velopharyngeal closure is required for normal speech production. Incomplete velopharyngeal closure manifests as resonance disorders and nasal air escape. Management of velopharyngeal insufficiency requires a general knowledge of speech production as well as a more detailed understanding of the velopharyngeal mechanism. Comprehensive evaluation by a velopharyngeal insufficiency team includes medical assessment focusing on airway obstructive symptoms, perceptual speech analysis, and instrumental assessment, which is utilized to characterize the velopharyngeal gap. Options for intervention include speech therapy, intraoral prosthetic devices, and surgery. Surgical interventions can be categorized as palatal, palatopharyngeal, or pharyngeal procedures. The therapeutic challenge lies in achieving velopharyngeal closure during speech production while maintaining patency of the upper airway. We present our protocol for evaluation of velopharyngeal function with a focus on indications for palatoplasty and pharyngoplasty. We also discuss surgical modifications of sphincter pharyngoplasty.

Triple-A Syndrome: A Rare Etiology of Adult Achalasia

Achalasia is the best-described primary motor disorder of the esophagus. Its association with alacrima and adrenocorticotropin hormone (ACTH)-resistant adrenal insufficiency has been described in childhood. This triple-A syndrome is an autonomic recessive disorder first described by Allgrove in 1978 (1). Variable and progressive neurological impairment involves the central, peripheral, and autonomic nervous systems. Therefore, some authors called this syndrome the 4A syndrome because of an association with signs of autonomic dysfunction such as postural hypotension, impaired cardiovascular reflexes, or unequal pupils (2). Dermatological features such as palmoplantar hyperkeratosis but also facial dimorphism and osteoporosis may be observed in affected patients (3). In some patients, a characteristic hypernasal speech due to an incomplete velopharyngeal closure has been reported (3). Mutations of the achalasia–addisonianism–alacrima syndrome (AAAS) gene has been identified in families with the triple-A syndrome (4, 5). This gene encodes a protein that belongs to the tryptophan–aspartate (WD)-repeat family of regulatory proteins and localizes to nuclear pore complexes (NPCs) (6). When mutated, this protein fails to localize to NPCs and remains in the cytoplasm. A recent study suggested the possibility of diagnosing triple-A syndrome in adults as shown by the 20% prevalence of alacrima in 20 adults with achalasia (7). We report here the first case of incomplete triple-A syndrome

Laryngeal Airway Resistance in Cleft Palate Children with Complete and Incomplete Velopharyngeal Closure

Abstract Objective: This study investigated the effect of velopharyngeal insufficiency on aerodynamic measures of laryngeal function in children with cleft palate. Design: Data were analyzed using analysis of covariance. The independent variable was velopharyngeal closure, and the dependent variables were laryngeal resistance, laryngeal airflow, and transglottal pressure. Age and gender were covariates. Setting: The data were collected at The Craniofacial Center, University of Illinois, a tertiary health care center located in Chicago. Patients: Thirty-six children with cleft palate were recruited from among the patients at The Craniofacial Center. Ten children with velopharyngeal areas > 5 mm2 during oral speech were placed in the incomplete closure group, while 26 children with areas < 1 mm2 were placed in the complete closure group. Outcome Measures: The three dependent variables (transglottal pressure, transglottal airflow, and laryngeal resistance) were measured. Results: Laryngeal resistance and tra...

Laryngeal Airway Resistance in Cleft Palate Children with Complete and Incomplete Velopharyngeal Closure

This study investigated the effect of velopharyngeal insufficiency on aerodynamic measures of laryngeal function in children with cleft palate. Data were analyzed using analysis of covariance. The independent variable was velopharyngeal closure, and the dependent variables were laryngeal resistance, laryngeal airflow, and transglottal pressure. Age and gender were covariates. The data were collected at The Craniofacial Center, University of Illinois, a tertiary health care center located in Chicago. Thirty-six children with cleft palate were recruited from among the patients at The Craniofacial Center. Ten children with velopharyngeal areas >5 mm2 during oral speech were placed in the incomplete closure group, while 26 children with areas <1 mm2 were placed in the complete closure group. The three dependent variables (transglottal pressure, transglottal airflow, and laryngeal resistance) were measured. Laryngeal resistance and transglottal pressure were significantly higher, and transglottal airflow was significantly lower in the group with complete closure. In summary, cleft palate patients with complete velopharyngeal closure exhibited higher laryngeal resistances than those with incomplete closure.

Salvaging the failed pharyngoplasty: intervention outcome.

This paper reports on the rates of failure of operations (pharyngeal flap and sphincter pharyngoplasty) performed for management of velopharyngeal dysfunction, and outcome following their revision. Anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following pharyngeal flap and sphincter pharyngoplasty were critiqued. The results of primary pharyngeal flap were evaluated for 65 patients, and the results of primary sphincter pharyngoplasty were evaluated for 123 patients. All patients were treated for velopharyngeal dysfunction. The definition of surgical failure was based on persistent hypernasality and/or nasal turbulence on perceptual speech evaluation, and incomplete velopharyngeal closure on instrumental evaluation, at least 3 months postoperatively. All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital, a tertiary cleft care center. All patients had failed surgical management initially, either with pharyngeal flap or sphincter pharyngoplasty, and all underwent repeat preoperative and postoperative perceptual speech evaluations; real-time lateral phonation fluoroscopy including still reference views; and flexible nasendoscopy of the velopharynx using standard speech protocols. Revisional surgery for both procedures consisted of either tightening of the sphincter pharyngoplasty or pharyngeal flap port(s) or reinsertion of the sphincter pharyngoplasty or pharyngeal flaps following dehiscence. The main outcome measure was normalcy of velopharyngeal function, i.e., elimination of perceptual hypernasality and instrumental evidence of complete velopharyngeal closure. The rates of pharyngeal flap failure and sphincter pharyngoplasty failure were determined for those patients requiring surgical revision. Thirteen of 65 patients (20%) who underwent primary pharyngeal flap required revisional surgery. Of these 13 patients, eight were managed successfully with a single revisional operation. The remaining five patients (38%) continued to exhibit velopharyngeal dysfunction and underwent a second revision consisting of tightening or augmentation of the lateral ports. Speech results were satisfactory in all patients so treated; however, hyponasality with no other airway morbidity occurred in all five. Twenty of 123 patients (16%) who underwent primary sphincter pharyngoplasty required surgical revision. Of these 20 patients, 17 were managed successfully. For both procedures, the principal cause of failure was partial or complete flap dehiscence. Rates of primary pharyngeal flap failure are roughly equivalent to rates of primary sphincter pharyngoplasty failure. Pharyngeal flap and sphincter pharyngoplasty failures can be salvaged with revisional surgery, which can provide a velopharyngeal mechanism capable of complete closure. Revisional surgery is usually associated with denasal speech.

Laryngeal Airway Resistance in Children with Cleft Palate and Adequate Velopharyngeal Function

Laryngeal airway resistance during vowel production was determined for 10 children without cleft palate and 14 children with cleft palate and adequate velopharyngeal function. The children with cleft palate were further grouped according to either complete or incomplete velopharyngeal closure. All children performed a syllable repetition task with nostrils occluded at self-determined effort and a targeted effort typical of adult speech. Results indicated that all children exhibited significantly greater laryngeal resistance at self-determined effort. No significant differences occurred among the groups of children at either effort level. Some children with incomplete velopharyngeal closure, however, tended to exhibit relatively increased laryngeal resistance at the targeted effort level when their nostrils were unoccluded. Implications for a regulation-control model of speech production and clinical assessment are discussed.

Laryngeal airway resistance in children with cleft palate and adequate velopharyngeal function.

Laryngeal airway resistance during vowel production was determined for 10 children without cleft palate and 14 children with cleft palate and adequate velopharyngeal function. The children with cleft palate were further grouped according to either complete or incomplete velopharyngeal closure. All children performed a syllable repetition task with nostrils occluded at self-determined effort and a targeted effort typical of adult speech. Results indicated that all children exhibited significantly greater laryngeal resistance at self-determined effort. No significant differences occurred among the groups of children at either effort level. Some children with incomplete velopharyngeal closure, however, tended to exhibit relatively increased laryngeal resistance at the targeted effort level when their nostrils were unoccluded. Implications for a regulation-control model of speech production and clinical assessment are discussed.

Hypertrophic Tonsils

This paper presents a case of altered resonance secondary to hypertrophic tonsils. Through nasopharyngoscopy, the tonsils were found to be in the nasopharynx and interposed between the velum and posterior pharyngeal wall. This resulted in incomplete velopharyngeal closure and evidence of hypernasality. This large mass was also felt to obstruct sound transmission into both the oral and nasal cavities, causing a mixture of hyponasality and cul-de-sac resonance. Tonsillectomy resulted in an elimination of all of these characteristics. Resonance was judged to be normal on the postoperative assessment.

Velopharyngeal opening in the formation of voiced stops in Sindhi.

It was proprioceptively felt that voiced and aspirated voiced stops in Sindhi are characterized by a slight nasalization. Nasal airflow during the production of voiced stops was therefore measured with a Froikaer-Jensen Electro-Aerometer. Results suggest that there is an imcomplete velopharyngeal closure which helps to absorb the transglottal airflow and thus prevents the rise in the supraglottal pressure. For the affricated palatal stops of Sindhi, the vocal fold vibrations were, however, maintained by expanding the walls of the supraglottal cavities.