Velopharyngeal Area Research Articles

An outcome evaluation of sphincter pharyngoplasty for the management of velopharyngeal insufficiency.

Sphincter pharyngoplasty is frequently used for the management of children with velopharyngeal insufficiency. The purpose of this study was to evaluate outcome and revision rates of sphincter pharyngoplasty at the authors' institution. Two hundred fifty patients underwent sphincter pharyngoplasty for velopharyngeal insufficiency between January of 1987 and March of 2001. There were 117 female patients and 133 male patients, with a mean age at primary sphincter pharyngoplasty of 7.6 years (range, 1 to 45 years). Diagnoses included velopharyngeal insufficiency alone (n = 63), velopharyngeal insufficiency associated with cleft palate (n = 127), velocardiofacial syndrome (n = 32), submucous cleft (n = 15), and other (n = 13). Pharyngoplasty revision was defined as any secondary surgical revision of the sphincter as determined by clinical evaluation and objective speech assessment. The pharyngoplasty revision rate was found to be 12.8 percent (n = 32). A favorable outcome was demonstrated in 30 of these patients (93.8 percent) after pharyngoplasty revision. Two patients, one with a diagnosis of a submucous cleft and velocardiofacial syndrome and the other with a cleft palate, required a second revision because of persistent velopharyngeal insufficiency. The revision rate was highest in those patients with velocardiofacial syndrome (21.8 percent) and lowest in patients with velopharyngeal insufficiency alone (6.3 percent). Patients who required revision had significantly higher preoperative oral sentence nasometry (55.2 percent versus 46.1 percent; p < 0.01) and larger velopharyngeal areas (23.7 mm2 versus 18.9 mm2). There was no significant difference in age or sex for those patients who required a revision compared with those who did not require revision. Mean follow-up was 2.4 years (range, 4 months to 13.6 years). Sphincter pharyngoplasty is an effective procedure for the treatment of velopharyngeal insufficiency using revision rate as the standard of success. It had an 87 percent primary success rate that increased to 99 percent after a single revision. Patients with velocardiofacial syndrome, more severe preoperative hypernasal resonance, and larger velopharyngeal areas were more likely to require pharyngoplasty revision.

Effects of Orthognathic Surgery on Speech and Breathing of Subjects With Cleft Lip and Palate: Acoustic and Aerodynamic Assessment

Abstract Objective: To evaluate the impact of orthognathic surgery on acoustic nasalance of subjects with cleft and investigate the causes of possible changes by analyzing velopharyngeal function and nasal patency. Design/Patients: Nasalance was measured in 29 subjects with operated cleft palate ± lip before (PRE) and 45 days (POST1) and 9 months (POST2) after surgery, on average. In 19 of the patients, the minimum velopharyngeal (VP) and nasal cross-sectional (N) areas were also determined. Interventions: Le Fort I osteotomy with maxillary advancement in combination with procedures involving the nose, maxilla, mandible or all three. Main Outcome Measures: Nasalance, VP area, N area. Results: We observed: (1) a significant (p < .05) increase in mean nasalance at POST1 and POST2, compared with PRE during the reading of oral sentences and nasal sentences; at POST2, high nasalance on the oral sentences was observed in 45% of the patients with normal nasalance at PRE, and 57% of patients with low nasalance on...

Clinical significance of sleep-related breathing disorder in narcolepsy.

Both the influence of comorbid obstructive sleep apnea-hypopnea syndrome (OSAHS) on daytime sleepiness and its pathological mechanism in 10 narcoleptic patients was studied. Mild elevation of esophageal negative pressure and obstruction in the velopharyngeal area, as observed by upper airway magnetic resonance imaging, during apneic episodes was observed in the subjects. Severity of the disorder was correlated positively with body mass index, and the latencies of the multiple sleep latency tests were not improved with nasal continuous positive airway pressure treatment in subjects. Pathogenesis of OSAHS in narcolepsy was thought to be almost similar to typical OSAHS, and that the disorder seemed to lack a pathological influence on daytime sleepiness.

Effects of pharyngeal muscle activation on airway size and configuration.

Fiberoptic imaging was performed in six decerebrate, tracheotomized cats to determine the effect of pharyngeal muscle activation on the pharyngeal airway. The fiberoptic scope was advanced through the rostral trachea into the pharynx. Computer-based planimetry was used to measure airway area and maximum anteroposterior and lateral diameters in the rostral oropharynx, velopharynx, and caudal oropharynx. Cuff electrodes stimulated the bilateral distal cut ends of the following nerves: medial hypoglossus (MHG), lateral hypoglossus (LHG), glossopharyngeus, and pharyngeal branch of vagus (PBV). The velopharyngeal area increased with stimulation of the MHG, MHG plus LHG, and glossopharyngeus. The velopharyngeal area decreased with PBV stimulation. Similar effects occurred in the caudal oropharynx. The percent increase in velopharyngeal area with combined MHG and LHG stimulation was greater than the sum of the increases stimulating either branch alone. In the rostral oropharynx, airway area increased with individual and combined stimulation of the MHG and LHG. Changes in airway area at the different levels were concentric with the HG stimulations, but glossopharyngeal stimulation resulted in a greater increase in lateral than anteroposterior wall movement. The results indicate that the mechanical effects of pharyngeal muscle contraction depend on the airway level and the specific muscles that are activated.

Developmental changes in collapsibility of the passive pharynx during infancy.

The upper airway configuration significantly changes during the first year of life in humans, possibly leading to alteration of collapsibility of the pharyngeal airway. The present study evaluated developmental changes of passive pharyngeal mechanics in nine normal infants ranging in age from 2 to 12 mo. The static pressure-area relationship of the passive pharynx was quantified under general anesthesia with complete paralysis. We found a direct association between age and maximal velopharyngeal area (r = 0.840, p = 0.005). Velopharyngeal closing pressure progressively decreased with increasing age (r = -0.809, p = 0.008) and the closing pressures were below atmospheric pressure in all infants (range: -0.7 to -9.8 cm H(2)O; mean +/- SD: -3.6 +/- 2.7 cm H(2)O). Shape of the pressure-area curves became steeper in slope with maturation, indicating increased pharyngeal wall stiffness during development. Accordingly, we conclude that anatomic properties of the pharynx gain stability in favor of maintaining patent airway during development in normal infants.

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.

Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects

Anatomic abnormalities of the pharynx are thought to play a role in the pathogenesis of obstructive sleep apnea (OSA), but their contribution has never been conclusively proven. The present study tested this anatomic hypothesis by comparing the mechanics of the paralyzed pharynx in OSA patients and in normal subjects. According to evaluation of sleep-disordered breathing (SDB) by nocturnal oximetry, subjects were divided into three groups: normal group (n = 17), SDB-1 (n = 18), and SDB-2 (n = 22). The static pressure-area relationship of the passive pharynx was quantified under general anesthesia with complete paralysis. Age and body mass index were matched among the three groups. The site of the primary closure was the velopharynx in 49 subjects and the oropharynx in only 8 subjects. Distribution of the location of the primary closure did not differ among the groups. Closing pressure (PC) of the velopharynx for SDB-1 and SDB-2 groups (0.90 +/- 1.34 and 2.78 +/- 2.78 cmH2O, respectively) was significantly higher than that for the normal group (-3.77 +/- 3.44 cmH2O; P < 0.01). Maximal velopharyngeal area for the normal group (2.10 +/- 0.85 cm2) was significantly greater than for SDB-1 and SDB-2 groups (1.15 +/- 0.46 and 1.06 +/- 0.75 cm2, respectively). The shape of the pressure-area curve for the velopharynx differed between normal subjects and patients with SDB, being steeper in slope near Pc in patients with SDB. Multivariate analysis of mechanical parameters and oxygen desaturation index (ODI) revealed that velopharyngeal Pc was the only variable highly correlated with ODI. Velopharyngeal Pc was associated with oropharyngeal Pc, suggesting mechanical interdependence of these segments. We conclude that the passive pharynx is more narrow and collapsible in sleep-apneic patients than in matched controls and that velopharyngeal Pc is the principal correlate of the frequency of nocturnal desaturations.

Hypernasality and velopharyngeal impairment.

Although the primary cause of hypernasality is impaired velopharyngeal (VP) function, a variety of other factors influence the outcome perceived by the listener. The purpose of the current study was to assess the relationship between oral-nasal resonance balance and (1) velopharyngeal orifice area; (2) nasal airflow rate; and (3) duration of nasal airflow. The pressure-flow technique was used to estimate VP area and measure nasal airflow rate and duration. Ratings of oral-nasal balance were made on a 6-point equal-appearing interval scale. Results indicated a moderate correlation between hypernasality rating and VP area (0.66), nasal airflow (0.61), and nasal airflow duration (0.53). Adults tended to be perceived as more hypernasal than children for a given degree of VP impairment. Finally, when the degree of VP opening was small, perceived oral-nasal resonance balance appeared to be related to duration of the opening-closing movements.

Evaluation of the sphincter pharyngoplasty.

The results of the sphincter pharyngoplasty were evaluated in 139 patients with velopharyngeal incompetence (VPI) who demonstrated active velar elevation. All patients underwent perceptual speech evaluation and lateral phonation radiographic study; select patients underwent multiview videofluoroscopic, flexible nasendoscopic, and pressure-flow studies. All but one patient demonstrated improvement and 109/139 (78.42%) demonstrated resolution of VPI. Sixteen of thirty failed pharyngoplasties were revised. Revision was successful in 8/16 patients yielding an overall success rate of 117/139 (84.17%). Success rate was 67.65 percent for patients managed during the first 5 years and improved to 84.78 percent for patients managed during the last 5 years of this 15-year series. Analysis revealed that younger patients were treated more successfully than older patients, large velopharyngeal areas were treated as successfully as smaller ones, and circular closure patterns were treated more successfully than coronal patterns. The primary cause of failure was insertion of the flap below the point of attempted velopharyngeal contact.

Relative values of various standardized passages in the nasometric assessment of patients with velopharyngeal impairment.

A series of 155 patients referred for evaluation at the UNC Craniofacial Center was studied to compare nasometric performance data obtained from the Rainbow Passage to information provided when subjects read two other standardized passages (Zoo Passage and Nasal Sentences). Nasometric findings obtained using the three reading passages were compared to aerodynamic estimates of velopharyngeal area and nasal cross-sectional area as well as clinical judgments of hypernasality and hyponasality. The results suggest that the Rainbow Passage does not provide clinically relevant information that cannot be obtained using the other speech samples studied.

Use of Nasometry as a Diagnostic Tool for Identifying Patients with Velopharyngeal Impairment

A series of 117 patients were studied in an attempt to determine the extent to which acoustic assessments of speech made with a Kay Elemetrics Nasometer corresponded with aerodynamic estimates of velopharyngeal area and clinical judgments of hypernasality. Nasometer data were obtained while patients read or repeated a standardized passage with no nasal consonants. Pressure-flow data were obtained from 96 of these patients during repeated productions of the word "papa." Listener judgments were made in a clinical setting by the senior author using a 6-point equal-appearing interval scale. Nasometer and pressure-flow results were not known to the senior author when making listener assessments. With a cutoff nasalance score of 32, the sensitivity of Nasometer ratings in correctly identifying the presence or absence of velopharyngeal areas in excess of 0.10 cm2 was 0.78 and 0.79, respectively. The sensitivity and specificity of nasometry in correctly identifying subjects with more than mild hypernasality in their speech was 0.89 while the specificity was 0.95. The results suggest that the Nasometer is an appropriate instrument that can be of value in assessing patients suspected of having velopharyngeal impairment.

神経性疾患における鼻咽腔閉鎖機能に関する研究

Speech disorders confirmed in a number of neurological diseases are commonly dysarthria. The author took especial note of the velopharyngeal closure function in dysarthria of these diseases, and made a study of velopharyngeal closure function in patients with neurological diseases using the intelligibility rating examination, aerodynamic examination and nasopharyngeal fiberscopic examination. The subjects were 23 patients of neurological diseases and 15 controls with normal speech. Cases of the neurological diseases investigated in this study were 7 spinocerebellar degeneration, 5 myastenia gravis, 3 Parkinson's disease, 2 amyotrophic lataral sclerosis, and each 1 of myotonic dystrophy, motor neurone disease, pseudobulbar paralysis, oculopharyngeal dystrophy, mitochondrial myopathy, and brain tumor. The results were summarized as follows : 1. The score of the intelligibility rating examination of the neurological disease group (DG) was lower than that of normal group (NG) (p<0.05). 2. The score of the intelligibility rating examination on vowel, Ha-sounds, voiced and voiceless suonds and Ra-sounds of DG was lower than that of NG (p<0.01). That of nasal sounds was the same (p<0.05). On semivowel sounds, however, there was no difference between DG and NG. 3. In the aerodynamic examination, leakage of the air from nose was observed in 12 out of 15 cases when patient blew and pronounced monosyllable sounds. 4. In the aerodynamic examination, air volume of leakage from nose of DG was greater than that of NG and pressure of expiration from the mouth of DG were lower than NG. 5. The nasopharyngeal fiberscopic examination revealed that all 23 cases had some disorder of velopharyngeal closure function. 6. Eighteen out of 23 cases of DG corresponded to Yamaoka's classification. In these cases, 4 were type I c, 1 type II, 5 type III and 8 type IV. Other 5 cases did not correspond to this classification. 7. There was a considerable variety in the state and degree of closure even within each type of this classification. 8. A tremor in the velopharyngeal area at rest in 2 patients was found by the nasopharyngeal fiberscopic examination. The velopharyngeal area at rest in 2 patients was shaped something like a kidney bean. In other 2 patients, when this area moved to close, the paralyzed side of this area was covered by the other side.

The Aerodynamic Characteristics of Speech Produced by Normal Speakers and Cleft Palate Speakers With Adequate Velopharyngeal Function

Pressure-flow data were obtained on 20 noncleft adults with normal speech and 26 adults with repaired cleft palate. All subjects had adequate velopharyngeal function as determined by preliminary aerodynamic assessment. Subjects were considered to have adequate closure if they had velopharyngeal areas no greater than 0.049 cm2 during production of /p/ in the word "hamper." Although the subjects in both groups demonstrated velopharyngeal adequacy, the subjects with cleft palate produced speech with significantly less nasal airflow. In addition, their intra-oral pressure curve was shifted forward in time. These differences suggest that speakers with cleft palate and adequate velopharyngeal function make certain compensatory adjustments that may be necessary because of differences in velopharyngeal movement capabilities. The potential significance of this for treatment planning is discussed.

The Pharyngeal Flap Operation

Patients with velopharyngeal inadequacy require structural modification of the velopharyngeal area by a prosthesis or by surgery in order to provide a mechanism for intelligible speech. The superiorly based, high-attached, lined pharyngeal flap was chosen for the treatment of velopharyngeal incompetency and the operative technique was described. Results showed that 90 per cent of the patients demonstrated significantly improved or normal velopharyngeal adequacy for speech following surgery, and 92 per cent of the patients demonstrated adequate closure of the velopharyngeal orifice as determined by aerodynamic studies.

咽頭弁手術による鼻咽腔機能と形態の変化に関する研究

A follow-up research, before and during 2 years after pharyngeal flap surgery, of 30 patients was undertaken in order to investigate the auditory changes, nasal air escape and the roentgenographical changes in velopharyngeal function and shape. The results were as follows ; 1. Both nasality and nasal air escape disappeared during about the same period. 50% of the subjects showed disappearance of nasality and nasal air escape at 2 months after operation, and 83.7% of them showed disappearance within a year after operation. All of the other subjects, with the exception of those who could not accept the follow-up research, also showed disappearance of nasality and nasal air escape within 18 months after operation, indicating remarkable improvement. The effectiveness of pharyngeal flap surgery was reaffirmed from this. 2. After the pharyngeal flap surgery, the velar length showed an increase but the tendency to constriction was not recognized. However, the velar elevational angle on phonation showed relatively lower degree until 3 months after operation than before operation. 3. The greatest change in the velopharyngeal function and shape, before and after pharyngeal flap surgery, was the reduction of the minimal velopharyngeal distance at the time of rest and phonation. 4. Within a month after operation, the depth of the posterior pharyngeal wall revealed the maximum constriction (forward protrusion) in the area of middle and lower pharynx, and later, within 6 months after operation, revealed the tendency to returning to the pre-operative shape. Coincident with this period of extention, nasality, nasal air escape and "snore" after operation disappeared or reduced, though the upper pharynx above the level of the palatal plane showed no change or a tendency to constriction, which was supposed to be the change caused by existence and growth of adenoid. 5. Pharyngeal flap base showed a tendency to descending until 9 months after operation. The average distance of descending was about 5 mm. The area of flap attached to soft palate also showed much the same tendency to descending until 6 months after operation. 6. Contrary to the descending of the flap base, the elevational mobility of the flap base showed an increase until 9 months after operation, but no striking change was recognized after that. This elevational movement was closely connected with the velar elevation. The coopertive movement between M. constrictor pharyngis superior and M. levator veli palatini was considered with much importance. 7. It seems proper that judgement of results after operation should be done later than 9 months after operation, since, as mentioned above, the velopharyngeal function and shape revealed considerable changes until 9 months after pharyngeal flap surgery. These changes in function and shape are considered to be affected most by the scar tissue. 8. Analysis of the manner of velopharyngeal closure and the improvement after pharyngeal flap surgery showed that pharyngeal flap base should be placed at the level of the palatal plane and in the area containing Passavant's ridge, and that it is difficult to expect successful results if the pharyngeal flap base is placed above the palatal plane. 9. Age, speech training, function of velopharyngeal muscle and shape of upper pharynx were pointed out as factors on improvement of results after pharyngeal flap surgery. In other words, successful results will be obtained regardless of surgical technique in younger patients with pre-operative speech training, Passavant's ridge as well as fairly good function of palatopharyngeal muscle, smaller palatopharyngeal distance, parallel type of nasal air escape and smaller velopharyngeal area as well as "non box-shaped" upper pharynx.

Anatomy of the Normal Velopharyngeal Mechanism

There is considerable disagreement in the current literature with regard to the anatomy of velopharyngeal area. The greatest disagreement seems to arise from textbook and journal article descriptions based on opinion unsubstantiated by data. In this review, an attempt will be made to differentiate areas of evidence from areas of speculation.

Anatomy of the Velopharyngeal Area in Cleft Palate

The cleft of the velum is characterized by the missed or incomplete formation of the aponeurosis. This concept helps to explain velar clefts, submucous clefts, congenital short palates, and even the rare cases of a cleft hard palate with no pathology in the velum. The pathology is confined to the soft palate and should be corrected surgically by an intravelar veloplasty.

Velopharyngeal anatomy.

The velopharyngeal area was studied in seven adult and six fetal heads by gross microscopic dissection, and in one additional fetal head by histologic sectioning and staining. In all cases except one, fibers of the superior constrictor muscle were found to insert into the velum. The salpingopharyngeus muscle was absent bilaterally in six of the 14 heads and was sparse in those heads where it was present. The tensor palatini muscle attached to the lateral membranous wall of the eustachian tube in all cases. The levator palatini muscle always lay lateral to the torus tubarius and inserted into the velum over a broad area extending from the region of the anterior aponeurosis to near the uvula. Speculations regarding muscle function in velopharyngeal closure are presented.

Oral panendoscope for direct observation and audiovisual recording of velopharyngeal and laryngeal areas during phonation.

Oral panendoscope for direct observation and audiovisual recording of velopharyngeal and laryngeal areas during phonation.