Velopharyngeal Incompetence Research Articles

Duration of speech therapy in patients with or without velopharyngeal insufficency after palatoplasty

To investigate the duration of speech therapy of patients with or without velopharyngeal insufficency after palatoplasty. One hundred and one cleft-palate patients with velopharyngeal incompetence (VPI) and eighty-seven without VPI were selected in the study. The treatment times of the patients who completed the speech therapy were counted and analyzed. The mean treatment frequency in VPI group was 17 times, and in the group without VPI this number was 13 (P < 0.05). In 39 VPI patients with signs of velocardiofaical syndrome, the mean treatment frequency was 19 times, and the mean treatment frequency of the other 62 patents with nonsyndromic VPI was 15 times (P < 0.05). The duration of speech therapy in VPI patients is longger than that in patients without VPI after palatoplasy, but individualized treatment is necessary.

Influence of preoperative velar closing ratio and lateral wall movement on outcomes of Furlow palatoplasty for velopharyngeal incompetence

Currently, there is no consensus regarding how to determine the optimal surgical procedure for a patient with velopharyngeal incompetence (VPI) post-primary palate repair. The purpose of the present study was to assess the effect of preoperative velar closing ratio (VCR) and lateral wall movement (LWM) on nasal emission and hypernasality after Furlow double-opposing Z-plasty. A retrospective analysis involving patients with VPI post-primary palatoplasty whose VPI was treated with double-opposing Z-plasty by a single surgeon was performed. Ten consecutive patients with VPI postpalatoplasty were reviewed. Videonasendoscopy, videofluoroscopy and perceptual speech examinations were performed preoperatively and postoperatively. VCR improved from an mean of 0.5 preoperatively (range 0.1 to 0.95) to 0.9 postoperatively (range 0.55 to 1.0). Postoperative mean LWM was 0.5 (range 0.3 to 0.9), unchanged from preoperative ratings. A trend toward an inverse relationship between preoperative VCR and improvement in hypernasality and resolution of nasal emission was observed. No relationship was noted between the degree of preoperative LWM and mean improvement in hypernasality. However, patients with worse preoperative LWM experienced better resolution of nasal emission postoperatively.

Velopharyngeal incompetence in patients with cleft palate, flexible video pharyngoscopy and perceptual speech assessment: a correlational pilot study.

To assess the role of video endoscopy in evaluating velopharyngeal incompetence and investigate a possible relationship between velopharyngeal incompetence type and speech defect in cleft palate patients. A prospective study of 28 pre- or post-operative cleft palate patients with speech defects who attended Plastic Surgery-Cleft Palate and ENT out-patient clinics was performed. The velar defect type was determined using a flexible endoscope and findings were video recorded. Speech pathology was assessed using the cleft palate audit protocol for speech. A significant, clinically relevant relationship was noted between the perceived characteristics of hypernasality and velopharyngeal insufficiency type. Hypernasal speech was a definite clinical indicator of velopharyngeal incompetence, and the type 1 velopharyngeal defect was most common. Type 1 velopharyngeal coronal-type dysfunction was strongly associated with hypernasality (p < 0.05). When speech substitution was noted, type 2 velopharyngeal (or sagittal) incompetence could be predicted (p < 0.05). In the management of cleft palate patients, it is important that surgical correction of the defect and achieving velopharyngeal competency for speech are performed simultaneously. Pre-operative velopharyngeal endoscopy with speech assessment will define the anatomical and functional bases for velopharyngeal correction and assist in planning and tailoring the pharyngeal flap.

Effect of nasal speaking valve on speech intelligibility under velopharyngeal incompetence: a questionnaire survey.

Velopharyngeal incompetence is known as a contributing factor to speech disorders. Suwaki etal. reported that nasal speaking valve (NSV) could improve dysarthria by regulating nasal emission utilising one-way valve. However, disease or condition which would be susceptible to treatment by NSV has not been clarified yet. This study aimed to evaluate the effect of NSV by questionnaire survey using ready-made NSV. Subjects were recruited through the internet bulletin, and NSV survey set was sent to the applicant. Sixty-six participants, who agreed to participate in this study, used NSV and mailed back the questionnaire which included self-evaluation and third-party evaluation of speech intelligibility. Statistical analysis revealed that the use of NSV resulted in significant speech intelligibility improvement in both self-evaluation and third-party evaluation (P<0·01). Regarding the type of underlying disease of dysarthria, significant effect of NSV on self-evaluation of speech intelligibility could be observed in cerebrovascular disease and neurodegenerative disease (P<0·01) and that on third-party evaluation in neurodegenerative disease (P<0·01). Eighty-six percent of subjects showed improvement of speech intelligibility by shutting up nostrils by fingers, and the significant effect of NSV on both self-evaluation and third-party evaluation of speech intelligibility was observed (P<0·001). From the results of this study, it was suggested that NSV would be effective in cerebrovascular disease and neurodegenerative disease, as well as in subjects whose speech intelligibility was improved by closing nostrils.

Analysis of Complications in Primary Cleft Lips and Palates Surgery

A series of retrospectively recorded patients with cleft lip and palate was uniquely investigated to demonstrate and analyze the complications after cleft repairing operations in a selected Chinese population. From January 2005 to January 2012, a selected group of 2100 patients with cleft lip and/or palate who have complete records were chosen from a large sample in the units. Complete data were retrieved, including sex, age, clinical classification, surgical modality, complications, and follow-up results. The complications were classified into 2 categories: early and long-term complications. After surgery, most patients with cleft lip remained in the hospital for 7 days and cleft palate repairs for 10 days. A standard regimen of antibiotics was administered for 3 to 5 days clinically. Of the 2100 patients, there were 1360 males and 760 females who had congenital cleft deformity with complete clinical records in the department of oral and maxillofacial surgery. The age distribution was as follows: 1600 patients in the group of 3 months to 2 years, 320 patients in the group of 2 to 10 years, 130 patients in the group of 11 to 19 years, and 50 patients in the group of older than 20 years. As to the treatment modality, cleft lips were repaired by rotation advancement method with various minor modifications or Tennison modality. The cleft palates were closed using the von Langenbeck, Veau/Wardill/Kilner, or Furlow technique. The overall complication rate was 16.8% of the patients. Of the early complications, there were 6 cases of asphyxia, 17 cases of pyrexia, 5 cases of edema of the respiratory tract, 8 cases of upper respiratory tract infection, 6 cases of bronchiolitis, 7 cases of pneumonia, 9 cases of diarrhea and vomiting, 6 cases of hemorrhage, 5 patients of odontoptosis, 11 cases of erosion of the corner of mouth, 5 cases of drowsiness, 11 cases of incision dehiscence, 9 cases of wound infection, 6 cases of palatal dehiscence/fistula, 3 cases of nostril floor breakdown, 7 cases of conjunctivitis, as well as 3 cases of mortality. The long-term complications included 30 cases of secondary lip/nasal deformity, 10 cases of dehiscence of lip, 14 cases of palatal fistula/decencies, 18 cases of hearing problem/otitis media, 21 cases of poor ventilation/snoring, 66 cases of velopharyngeal incompetence, and 58 cases of voice disorder. Complications after cleft surgery are unavoidable clinically. More attention should be paid to the etiologic factors to minimize the prevalence of complications. Mortality can be found in patients with cleft, which is a deadly complication. Problems of respiratory tract and hemorrhage should be emphasized and treated seriously.

Impact of Maxillary Advancement on Speech and Velopharyngeal Function in Patients with Cleft Lip and Palate

Objective : Patients with cleft lip and palate (CLP) and maxillary retrognathia are usually treated with maxillary advancement (Le Fort I osteotomy). The aim of this study was to investigate the impact of maxillary advancement on the velopharyngeal function (VPF) and symptoms of velopharyngeal incompetence in patients with CLP. Design : Retrospective group study before and after treatment. Participants : All patients who had undergone Le Fort I osteotomy due to maxillary retrognathia from 2007 to 2010 at Karolinska University Hospital, Sweden (n = 13). Pre- and postoperatively standardized examinations were used. Blinded audio recordings were independently assessed by three experienced speech pathologists. Acoustical data (nasometry) and information on VPF (videoradiography and nasoendoscopy) were collected from the medical records. Two patients with additional malformations were considered outliers, and group data were based on a sample size of n = 11. Main Outcome Measures : Perceptual and acoustic symptoms of velopharyngeal incompetence and overall assessment of VPF. Results : No assessment method showed a significant deterioration of the VPF postoperatively. Individual data revealed that 6 of the 13 patients had no or only one symptom pre- and/or postoperatively. The two patients with additional malformations had most symptoms pre- and postoperatively and did not change. Three patients had an increased number of symptoms postoperatively by at least two symptoms. No associations between the outcome and possible prognostic factors were found. Conclusions : Maxillary advancement did not have a significant impact on the VPF at the group level, but three individuals had a somewhat deteriorated VPF postoperatively.

Prosthetic rehabilitation of a child with velopharyngeal dysfunction – A case report

The speech of person is a unique mode of expression for an individual. Alterations or deviation from normal speech leading to nasal and unintelligible speech have enormous effects on the psychological well being of a person as it hampers social interactions. The anatomic or functional anomalies occurring as a result of congenital or traumatic defects leading to velopharyngeal dysfunctions influence the speech by making it completely atypical. The cleft palate patients may have residual velopharyngeal inadequacy even after surgical repair. A removable palatal lift appliance in conjuction with speech therapy is a viable treatment option for such patients as it is economical, easy to fabricate and easy to use.

Under-recognition of 22q11.2 deletion in adult Chinese patients with conotruncal anomalies: Implications in transitional care

22q11.2 deletion syndrome (22q11.2DS) is a multi-systemic disorder with high phenotypic variability. Under-diagnosis in adults is common and recognition of facial dysmorphic features can be affected by age and ethnicity. This study aims to determine the prevalence of undiagnosed 22q11.2DS in adult Chinese patients with conotruncal anomalies and to delineate their facial dysmorphisms and extra-cardiac manifestations. We recruited consecutively 156 patients with conotruncal anomalies in an adult congenital heart disease (CHD) clinic in Hong Kong and screened for 22q11.2DS using fluorescence-PCR and fluorescence in-situ hybridization. Assessment for dysmorphic features was performed by a cardiologist at initial screening and then by a clinical geneticist upon result disclosure. Clinical photographs were taken and childhood photographs collected. Eighteen patients (11.5%) were diagnosed with 22q11.2DS, translating into 1 previously unrecognized diagnosis of 22q11.2DS in every 10 adult patients with conotruncal anomalies. While dysmorphic features were detected by our clinical geneticist in all patients, only two-thirds were considered dysmorphic by our cardiologist upon first assessment. Evolution of facial dysmorphic features was noted with age. Extra-cardiac manifestations included velopharyngeal incompetence or cleft palate (44%), hypocalcemia (39%), neurodevelopmental anomalies (33%), thrombocytopenia (28%), psychiatric disorders (17%), epilepsy (17%) and hearing loss (17%). We conclude that under-diagnosis of 22q11.2DS in Chinese adults with conotruncal defects is common and facial dysmorphic features may not be reliably recognized in the setting of adult CHD clinic, referral for genetic evaluation and molecular testing for 22q11.2DS should be offered to patients with conotruncal defects.

Reconstruction of the Premaxilla by Segmental Distraction Osteogenesis for Maxillary Retrusion in Cleft Lip and Palate

We present a strategy to target one of the main areas causing retruded maxilla, the premaxillary region for patients with cleft lip and palate (CLP). Advancement of the premaxilla by distraction osteogenesis is attempted, and the retruded anterior maxilla, the collapsed dental space, and the arch shape are sufficiently improved. This strategy also prevents deterioration of the velopharyngeal incompetency function. The procedure seems to be a good option for the treatment of maxillary retrusion and malocclusion for CLP.

Influence of preoperative velar closing ratio and lateral wall movement on outcomes of Furlow palatoplasty for velopharyngeal incompetence.

Currently, there is no consensus regarding how to determine the optimal surgical procedure for a patient with velopharyngeal incompetence (VPI) post-primary palate repair. The purpose of the present study was to assess the effect of preoperative velar closing ratio (VCR) and lateral wall movement (LWM) on nasal emission and hypernasality after Furlow double-opposing Z-plasty. A retrospective analysis involving patients with VPI post-primary palatoplasty whose VPI was treated with double-opposing Z-plasty by a single surgeon was performed. Ten consecutive patients with VPI postpalatoplasty were reviewed. Videonasendoscopy, videofluoroscopy and perceptual speech examinations were performed preoperatively and postoperatively. VCR improved from an mean of 0.5 preoperatively (range 0.1 to 0.95) to 0.9 postoperatively (range 0.55 to 1.0). Postoperative mean LWM was 0.5 (range 0.3 to 0.9), unchanged from preoperative ratings. A trend toward an inverse relationship between preoperative VCR and improvement in hypernasality and resolution of nasal emission was observed. No relationship was noted between the degree of preoperative LWM and mean improvement in hypernasality. However, patients with worse preoperative LWM experienced better resolution of nasal emission postoperatively.

Cephalometric evaluation of adenoids, upper airway, maxilla, velum length, need ratio for determining velopharyngeal incompetency in subjects with unilateral cleft lip and palate.

Children with cleft lip and palate (CLP) are seen to have reduced airway size and large adenoids, which might lead to different characteristics in the upper airway and surrounding tissues from both morphological and functional perspectives. Decrease in adenoid size and increase in need ratio in cleft patients might lead to velopharyngeal incompetency (VPI) and development of nasality in adulthood. No studies have been conducted on the Indian population with variables contributing to VPI. So the aim was to evaluate the size and position of the adenoids, upper airway, maxilla, velum length and need ratio contributing to VPI in subjects with and without unilateral cleft lip and palate (UCLP) during juvenile and adolescent stages. Cephalograms of 120 subjects with 6-17 years were taken and various linear and angular measurements were measured and data was analyzed using the unpaired t test. Adenoids were significantly larger and the upper airway smaller in the juvenile and adolescent cleft group than in the non-cleft group. In the adolescent cleft group, airway was larger than that in the adolescent non-cleft group. The maxilla was small and retropositioned in juvenile and adolescent subjects as compared to non cleft cases. Length of velum was smaller and need ratio was larger in both juvenile and adolescent groups as compared to the non-cleft group, suggestive of velopharyngeal incompetence. Decreased Adenoids, restricted airway, small, retruded maxilla, smaller velum length and larger need ratio larger were seen in the cleft group as compared to the non-cleft group, which was suggestive of VPI.

An Old Flame Reignites: Vagal Neuropathy Secondary to Neurosyphilis

This report describes neurosyphilis presenting as vocal fold paresis and velopharyngeal incompetence. This represents the first reported case of neurosyphilis presenting as a vagal neuropathy since1963. Case report. Review of medical records and literature search. The patient presented with voice changes and nasopharyngeal reflux of liquids. Examination showed a left vocal fold paresis and moderate velopharyngeal incompetence. Laryngeal electromyography revealed evidence of denervation, and neurologic evaluation showed bilateral Adie's pupils and a positive CSF VDRL. A remote history of syphilis treated with one intramuscular injection was obtained. The patient was treated with 6 weeks of penicillin and regained normal vocal function with minimal residual intermittent hypernasality. Given the recent increase in the incidence of syphilis in the United States, this case serves as a reminder of the importance of including syphilis in the differential diagnosis of cranial neuropathies and the increasing likelihood of syphilis presenting to otolaryngology and speech pathology practices. Syphilis, a disease whose incidence had declined progressively for 60 years in the United States, is now resurgent and must be considered in the evaluation of patients presenting with unexplained cranial neuropathies.

Effects of preoperative speech therapy on the speech intelligibility of patients with velopharyngeal incompetence

EnAbstract Background Improved articulatory placement through speech therapy may eliminate compensatory errors, improve velopharyngeal function, minimize perception of hypernasality, and improve speech intelligibility. Aim The aim of this work was to study the effect of preoperative speech therapy on the speech intelligibility in patients with residual velopharyngeal insufficiency in order to provide a better speech outcome in such patients. Patients and methods This study included 41 patients diagnosed with residual velopharyngeal insufficiency after cleft palate repair. Patients were divided into two groups: group I included 22 patients scheduled to undergo speech therapy 6 months preoperatively, and group II included 19 patients who did not receive preoperative speech therapy. Both groups underwent speech therapy for 6 months postoperatively. Evaluation was carried out through auditory perceptual assessment (APA) including the type and degree of open nasality, consonant precision, compensatory articulatory mechanisms (glottal articulation and pharyngealization of fricatives), audible nasal emission of air, and overall intelligibility of speech. All these elements are graded along a five-point scale in which 0 is normal and 4 is severe affection. Documentation of APA is performed by high fidelity speech and voice audio recording and endoscopy. Formal speech intelligibility testing was carried out using the Arabic Speech Intelligibility test, which is designed to provide an estimation of the overall speech intelligibility of children by providing a total score in percentage. Nasometry was performed for all patients using a Kay nasometer, which provides the ‘nasalance score’. Results On comparing the APA assessment of group I after 6 months of speech therapy postoperatively with the preoperative data, a highly significant decrease with regard to all parameters was revealed; however, in group II, the same comparison revealed a highly significant decrease as regards the degree of open nasality and nasal emission of air and a significant difference in terms of glottal articulation, pharyngealization of fricatives, and overall speech intelligibility. On comparing the two groups postoperatively, a significant difference in glottal articulation, pharyngealization of fricatives, and overall speech intelligibility, being more improved in group I, was revealed. Nasometry showed a significant difference between the postoperative results after speech therapy compared with the preoperative results, with a nonsignificant difference between the two groups postoperatively. In group I, the results of the Arabic Speech Intelligibility test showed a highly significant decrease in the number of patients with unintelligible speech and poor speech intelligibility, a significant decrease in number of patients with fair speech intelligibility, and a highly significant increase in the number of patients with good and excellent speech intelligibility. In group II, there was a significant decrease in the number of patients with unintelligible speech and poor speech intelligibility and a significant increase in the number of patients with fair, good, and excellent speech intelligibility. Conclusion and recommendations Speech therapy before surgery for residual velopharyngeal insufficiency can improve the results of postoperative therapy, with a better speech intelligibility outcome. Therefore, it is recommended to schedule a speech therapy program before secondary repair of the velopharyngeal valve in order to attain better speech intelligibility.

Don't Blow This Therapy Session!

Blowing exercises and other nonspeech oral motor exercises (NSOMEs) are commonly used therapeutic techniques for children with repaired cleft palate and velopharyngeal inadequacy. Blowing exercises have a long history in the field, dating back to the early days of speech-language pathology when clinicians relied upon expert opinion to influence clinical practice. However, for more than 60 years, NSOMEs such as blowing have been questioned and many empirical studies have been conducted that demonstrate the ineffectiveness of these exercises. This article provides reasons why NSOMEs, mainly blowing, should not be used in therapy. It also traces the history of blowing exercises and then summarizes some of the seminal research articles that show that they do not work. Effective evidence-based treatments for compensatory errors are also reviewed.

Palatal bone distraction an option for velopharyngeal incompetency after repeatedly failed velopharyngeal flap surgery

Palatal bone distraction an option for velopharyngeal incompetency after repeatedly failed velopharyngeal flap surgery

The Prevalence of Platybasia in Patients with Velopharyngeal Incompetence

Objectives : To estimate the prevalence of platybasia in patients with velopharyngeal incompetence (VPI) and its relation with palatal anomalies and syndromes. Design and Settings : Retrospective case analysis. Setting : A university-affiliated hospital. Patients : The VPI patients (n = 366) included five groups with either cleft lip and palate (CLP), cleft palate (CP) only, submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), or non-CP. The control group (n = 126) comprised healthy, normal-speech individuals. Outcome Measures : The cranial-base angle was measured by lateral cephalometric radiography. The prevalence of platybasia (defined as cranial base angle ≥ 137°) was estimated and the patient's syndromes were recorded. Results : The prevalence of platybasia was significantly higher in the VPI group (28.7%) than in the normal controls (2.4%) (P < .001). A significant difference (P < .01) was found in the prevalence of platybasia among the five VPI groups: 16.7%, 20.3%, 28.8%, 33.7%, and 40.3% for CLP, CP only, SMCP, OSMCP, and non-CP, respectively. No significant difference was found between the cranial-base angle of VPI patients and of controls and between the cranial-base angle of the five VPI groups. The VPI nonplatybasic patients had a significantly smaller cranial-base angle than normal controls (P < .01). Platybasia was the highest among patients with velocardiofacial syndrome (50%), followed by those with Pierre Robin syndrome (27.3%). Conclusions : Platybasia, which may cause enlargement of the nasopharyngeal space and difficulties in achieving velopharyngeal closure, can be found in high numbers of VPI patients with or without CP. This supports the belief that velopharyngeal anomaly may be part of a more complex craniofacial anomaly influenced by the cranial-base flexure.

Velopharyngeal Incompetence as a Complication of Grisel Syndrome

Velopharyngeal Incompetence as a Complication of Grisel Syndrome

Hogan’s modification of the Sanvenero-Rosselli velopharyngoplasty

A competent velopharyngeal mechanism is essential for the production of intelligible speech and the secondary procedure of the posterior pharyngeal flap may be necessary in some patients to achieve this goal. The purpose of this study was to examine short and long-term results between the Sanvenero-Rosselli and Hogan's modification of the cranially based velopharyngoplasty. During a 20-year period, 17 patients underwent secondarily a posterior pharyngeal flap to treat velopharyngeal incompetence. All the patients were treated in the same institution and under the supervision of the same stuff surgeon. Nine patients were operated on according to the Sanvenero-Rosselli method and eight according to Hogan's modification, which consists of the preparation of two mucosal flaps on the dorsal side of the soft palate. Both mucosal flaps are sutured at the base of the pharyngeal flap and cover its raw surface. Comparing the post-operative condition of the patients in two groups to their pre-operative state, it was observed that speech and comprehensibility were significantly improved, but Hogan's technique produced better speech results. According to our limited experience, additional surgical effort to create mucosal flaps on the nasal surface of the soft palate in Hogan's technique is compensated for by the reliable and substantial advantages that this technique holds, compared to Sanvenero-Rosselli's original proposition.

Postoperative malignant middle cerebral artery infarction following autologous fat injection for velopharyngeal incompetence

SummaryThe minimally invasive technique of autologous fat injection in the head and neck is generally considered to be a safe procedure with few complications. We report a case of malignant middle cerebral artery infarction, managed with decompressive hemicraniectomy, following autologous fat injection for the treatment of velopharyngeal incompetence. Perioperative stroke in nonvascular surgery is rare but is associated with high mortality and disability, irrespective of the cause. The potential difficulties in the diagnosis of perioperative stroke, the proposed mechanism post autologous fat injection and its management are reviewed.

Stress Velopharyngeal Incompetence in Collegiate Trombone Players

Objectives : Symptoms of stress velopharyngeal incompetence (SVPI) have been reported by many wind instrument players. The current study was designed to determine (1) if symptoms of SVPI were accompanied by aeromechanical signs of SVPI and (2) if signs of SVPI differed across musical tasks. Design : Participants were studied during a single recording session. Setting : The study was conducted in a university laboratory. Participants : Participants were 10 collegiate trombone players. They were separated into two groups: six who reported symptoms of SVPI and four who reported no symptoms. Main Outcome Measure : Nasal pressure recorded during trombone playing was used to determine velopharyngeal status (open or closed). Results : None of the participants exhibited an open velopharynx during trombone playing; however, all participants had positive nasal pressure (indicating an open velopharynx) immediately prior to sound onset on at least some of their breath groups. Two participants had positive nasal pressure prior to the vast majority of their productions and were given biofeedback and instruction to change this behavior. Conclusions : Symptoms of SVPI do not necessarily indicate the presence of a velopharyngeal-nasal leak during wind instrument playing but may reflect awareness of air leaks immediately prior to sound production. Pre-sound velopharyngeal-nasal air leaks may be amenable to behavioral modification by biofeedback and instruction. Nasal pressure measurement (using a nasal cannula) provides a simple, yet powerful, way to identify SVPI.