Velopharyngeal Orifice Area Research Articles

Effect of maxillary advancement on velopharyngeal function in cleft lip and palate: 20 years of experience

This retrospective study aimed to investigate the impact of orthognathic surgery with maxillary advancement (MA) on the velopharyngeal function (VF) in individuals with cleft lip and palate (CLP).The study included 651 patients with repaired CLP, both sexes, aged over 18 years who underwent MA alone or in combination with nasal procedures and/or mandibular osteotomy, operated between 2000 and 2019. The main outcome measures were nasalance (nasal text-NT and oral text-OT) and velopharyngeal orifice area measurement (VA), determined by nasometry and pressure-flow technique, respectively.Preoperatively, mean nasalance scores for NT and OT indicated normality, and VA demonstrated borderline-inadequate velopharyngeal closure in all patients. Following MA, a significant increase in nasalance scores for NT and OT occurred (p < 0.001), revealing hypernasality in those undergoing MA combined with nasal procedure (MAN, N = 191), bimaxillary orthognathic surgery with nasal procedure (BON, N = 227) and bimaxillary orthognathic surgery (BO, N = 151). Conversely, nasalance scores remained within the normal range for those undergoing isolated maxillary advancement (IMA, N = 82). VA exhibited a significant increase leading to the classification of VF as inadequate in the BON and MAN groups. Overall, MA contributed to VF deterioration, resulting in the appearance of hypernasality and increased VA, particularly when combined with nasal procedures.

Models for Predicting Velopharyngeal Competence Based on Speech and Resonance Errors and Velopharyngeal Area Estimation.

To develop tools for predicting velopharyngeal competence (VPC) based on auditory-perceptual assessment and its correlation with objective measures of velopharyngeal orifice area. Methodological study. Sixty-two patients with repaired cleft palate, aged 6 to 45 years, underwent aerodynamic evaluation by means of the pressure-flow technique and audiovisual recording of speech samples. Three experienced speech-language pathologists analysed the speech samples by rating the following resonance, visual, and speech variables: hypernasality, audible nasal air emission, nasal turbulence, weak pressure consonants, facial grimacing, active nonoral errors, and overall velopharyngeal competence. The correlation between the perceptual speech variables and velopharyngeal orifice area estimates was analysed with Spearman's correlation coefficient. Two statistical models (discriminant and exploratory) were used to predict VPC based on the orifice area estimates. Sensitivity and specificity analyses were performed to verify the clinical applicability of the models. There was a strong correlation between VPC (based on the orifice area estimates) and each speech variable. Both models showed 88.7% accuracy in predicting VPC. The sensitivity and specificity for the discriminant model were 92.3% and 97.2%, respectively, and 96.2% and 94.4% for the exploratory model. Two predictor models based on ratings of resonance, visual, and speech variables and a simple calculation of a composite variable, SOMA (Eng. "sum"), were developed and found to be efficient in predicting VPC defined by orifice estimates categories based on aerodynamic measurements. Both tools may contribute to the diagnosis of velopharyngeal dysfunction in clinical practice.

The Airflow Dynamics of Normal Velopharyngeal Closure and Closure after Posterior Pharyngeal Flap Palatoplasty

For revealing the relationship between the velopharyngeal (VP) orifice areas and the conditions of VP closure, which included adequate closure (AC), adequate/borderline closure (ABC), borderline/inadequate closure (BIC), and inadequate closure (IC), a pressure-flow device was established by Warren last century (1). However, this manufactured device cannot guarantee the accuracy because of its huge difference from human upper airway. Thus, the protocol of surgical maneuvers like the postpharyngeal flap (PF), which was based on the outcomes from Warren’s study, could be less reliable (2). Meanwhile, there are 2 ports after PF, which could also influence the airflow dynamics compared to the normal VP closure. In this study, real-time computational fluid dynamics (CFD) was applied to demonstrate the differences of the airflow dynamics between 1 port and 2 ports of the VP structure, which represented the normal VP closure and VP closure after PF, respectively.

The Effect of Loudness Variation on Velopharyngeal Function in Children with 22q11.2 Deletion Syndrome: A Pilot Study

Objective: Children with 22q11.2 deletion syndrome (22qDS) often require surgical intervention to treat velopharyngeal dysfunction (VPD). Although some studies have documented improved velopharyngeal (VP) closure under increased speaking effort, currently no studies have examined the effect of similar behavioral speech modifications on VP closure in children with 22qDS. The purpose of this pilot study was to explore the effect of loudness on VP closure during speech in children with 22qDS and persisting VPD. Patients and Methods: Four children with 22qDS, posterior pharyngeal flap, and persisting mild VPD underwent pressure-flow testing while repeating words at habitual and increased loudness levels. Using a single-subject A-B design, descriptive statistics and graphical measures were used to examine differences in VP orifice area (VPA) and timing of closure in the habitual versus loud condition. Results: Results were mixed. Median VPA decreased during some stimuli for 3 participants, but increased for 1 subject when speaking louder. Median duration of nasal airflow decreased for 3 participants in the loud condition. Conclusion: This study presents preliminary aerodynamic data regarding the plasticity of VP physiology in the 22qDS group. Further research is needed to determine how loudness impacts VP function in children with 22qDS.

Relationship between velopharyngeal closure, hypernasality, nasal air emission and nasal rustle in subjects with repaired cleft palate.

To investigate the correlation among velopharyngeal closure, hypernasality, audible nasal air emission (NAE) and nasal rustle (NR), in individuals with repaired cleft palate. One hundred patients with repaired cleft palate and lip, submitted to pressure-flow study for measurement of velopharyngeal orifice area (velopharyngeal area) and speech sample recordings. Velopharyngeal area was estimated during the production of the sound /p/ inserted in a sentence, and the velopharyngeal closure was classified as adequate, borderline or inadequate. Hypernasality was rated using a 4-point scale, NAE and NR were rated as absent or present, by three speech language pathologists, using recorded speech samples. Inter and intra-judge agreements were established. Statistical analysis was performed using the Spearman correlation coefficient considering p<0.05. An ordinal logistic regression model was developed to investigate whether the characteristics of speech can predict velopharyngeal closure. For this, the speech samples included in this analysis were those that obtained 100% agreement among raters as to the degree of hypernasality (43 out of 100). Significant correlation was found between hypernasality and velopharyngeal area; audible NAE and velopharyngeal area. A negative correlation was observed between the NR and velopharyngeal area. The regression analysis showed that the perceptual speech characteristics contributed significantly to predict the velopharyngeal closure. There is significant correlation between velopharyngeal closure and hypernasality, NAE and NR. It suggests that the perceptual speech characteristics can predict velopharyngeal closure, favoring the diagnosis and the definition of treatment conduct of velopharyngeal dysfunction.

Technical advances toward an endoscopic-phototransducer approach to investigation of velopharyngeal physiology.

This study aimed to examine the response characteristics of a new generation phototransducer and to test new recording and processing procedures when used with endoscopy to track velopharyngeal closure during normal speech. Integrated phototransducer-endoscopy response linearity was laboratory tested using a wide range of simulated velopharyngeal orifice areas. In vivo speech testing was completed to determine the effect of endoscope to light receptor distance on measurements documenting variations in normal velopharyngeal closure. Phototransducer response linearity was excellent (r = .99) provided an indirect (reflected light) orientation was used between the endoscope and the light-sensing fiber coupled with the phototransducer. Phototransducer response time exceeded expected velopharyngeal movement rates by an order of magnitude. In vivo speech measurements were affected by the distance between the light-emitting endoscope and the light-receiving tip of the light-sensing fiber. Data normalization to a light-out condition effectively controlled for this expected phenomenon. Patterns of velopharyngeal valving during speech were found to be stable and appropriate given the phonetic content of the utterance. Technological and data-processing advances support further exploration of an integrated phototransducer-endoscopic approach to studying velopharyngeal closure for speech. Additional studies involving normal speakers are under way.

Surgical outcome of pharyngeal flap surgery and intravelar veloplasty on the velopharyngeal function

To investigate the postoperative outcomes of pharyngeal flap surgery (PF) and secondary palatoplasty with intravelar veloplasty (IV) in the velopharyngeal insufficiency management regarding nasalance scores and velopharyngeal area. Seventy-eight patients with cleft palate±lips submitted to surgical treatment for velopharyngeal insufficiency, for 14 months on an average, were evaluated: 40 with PF and 38 with IV, of both genders, aged between 6 and 52 years old. Hypernasality was estimated by means of nasalance scores obtained by nasometry with a cutoff score of 27%. The measurement of velopharyngeal orifice area was provided by the pressure-flow technique and velopharyngeal closure was classified as: adequate (0.000-0.049 cm²), adequate/borderline (0.050-0.099 cm²), borderline/inadequate (0.100-0.199 cm²), and inadequate (≥0.200 cm²). Absence of hypernasality was observed in 70% of the cases and adequate velopharyngeal closure was observed in 80% of the cases, in the PF group. In the IV group, absence of hypernasality was observed in 34% and adequate velopharyngeal closure was observed in 50% of the patients. Statistically significant differences were obtained between the two techniques for both evaluations. PF was more efficient than the secondary palatoplasty with IV to reduce hypernasality and get adequate velopharyngeal closure.

Nasometric and Aerodynamic Outcome Analysis of Pharyngeal Flap Surgery for the Management of Velopharyngeal Insufficiency

This study aimed to evaluate the effectiveness of pharyngeal flap surgery (PFS) for the management of velopharyngeal insufficiency in cleft lip/palate patients and to assess the impact of age at surgery, surgeon's skills, and postoperative speech therapy on the outcomes. Prospective preoperative and postoperative assessments were performed on 240 patients aged 6 to 57 years using nasometry and pressure-flow studies.This study was carried out in a quaternary hospital.This study was superiorly based on PFS.Speech nasalance scores were assessed by nasometry and velopharyngeal orifice area assessed by pressure-flow technique, 2 days before and 1 year after PFS, on average. Differences were considered significant when P < 0.05. Significant reduction in nasalance scores was observed in 68% of the cases, and improvement of velopharyngeal area was observed in 66%. Rates of 55% and 48%, respectively, were observed when complete resolution was considered. Higher success rates were observed in children (81%) compared with other age groups analyzed and in patients who had concluded postoperative speech therapy (86%). Results did not differ among surgeons. Pharyngeal flap surgery was shown to be effective in reducing nasalance scores and velopharyngeal area during speech for a significant number of patients. Complete resolution was observed in smaller number of cases. Age at surgery and postoperative speech therapy were relevant factors for treatment success.

The effect of speaking rate on velopharyngeal function in healthy speakers

The purpose of this study was to assess the effect of speaking rate variation on aerodynamic and acoustic measures of velopharyngeal (VP) function. Twenty-seven healthy adult speakers (14 males, 13 females) participated in the study. The modified pressure-flow method was used to collect aerodynamic data of /m/ and /p/ segments in the word ‘hamper’ and the utterances ‘Mama made some lemon jam’ (MMJ) and ‘Buy Bobby a puppy’ (BBP). SPL was collected simultaneously with aerodynamic data for all utterances. A Nasometer was used to obtain nasalance scores and nasalance distance for MMJ and BBP. Sentences were produced at normal, fast, slow, and slowest speaking rates. The results showed that nasal airflow and VP orifice area were unaffected by speaking rate variations in males and females, whereas intra-oral pressure appeared to decrease as speaking rate slowed for both speaker groups. However, this effect was removed by statistically controlling SPL. Nasalance and nasalance distance (MMJ – BBP) did not change with speaking rate variation. There was a statistical difference between nasalance scores produced by male and female speakers. The results suggested that aerodynamic and acoustic measures of velopharyngeal function are not affected by variation in speaking rate in healthy males and females.

Aerodynamic indices of velopharyngeal function in childhood apraxia of speech

Childhood apraxia of speech (CAS) is characterized as a deficit in the motor processes of speech for the volitional control of the articulators, including the velum. One of the many characteristics attributed to children with CAS is intermittent or inconsistent hypernasality. The purpose of this study was to document differences in velopharyngeal function in children diagnosed with CAS from children with typically-developing speech. Pressure-flow techniques were used to estimate the velopharyngeal port size and measure the temporal sequencing of airflow and pressure events associated with production of a nasal + oral plosive sequence in the speech of three children with CAS and three age-matched comparison participants. The results of this pilot study revealed significant differences between the performance of the CAS group and the comparison group in three timing measures of velopharyngeal port closure and velopharyngeal orifice area during speech.

Correlação entre fechamento velofaríngeo e dimensões nasofaríngeas após cirurgia de retalho faríngeo avaliados por meio da técnica fluxo-pressão

OBJETIVO: Verificar se a área dos orifícios velofaríngeos obtida após o retalho faríngeo (RF) durante a respiração de repouso (AVFr) é um indicador do grau de fechamento velofaríngeo durante a fala (AVFf). MÉTODOS: Os sujeitos foram 62 pacientes com fissura de palato, associada ou não à fissura de lábio, de ambos os gêneros, com idades entre seis e 32 anos, submetidos ao RF há, pelo menos, 12 meses. AVFr e AVFf foram determinadas por meio da técnica fluxo-pressão. Valores de AVFr inferiores a 0,500 cm² foram considerados subnormais. A AVFf foi classificada como adequada (0-0,049 cm²), marginal (0,050-0,199 cm²) ou inadequada (&gt;0,200 cm²). A associação entre os valores de AVFr e AVFf pós-cirúrgicos foi analisada por meio de um modelo de regressão logística. RESULTADOS: Após o RF, 92% dos pacientes com valores de AVFr subnormais (&lt;0,500 cm²) apresentaram fechamento velofaríngeo adequado. A proporção de pacientes com valores de AVFr normais (&gt;0,500 cm²) e fechamento velofaríngeo adequado foi menor, porém ainda expressiva (55%). Não houve associação estatisticamente significante entre as duas variáveis. CONCLUSÃO: A maioria dos pacientes com retalho largo apresentou fechamento velofaríngeo adequado durante a fala. Entretanto, os resultados mostraram que as dimensões dos orifícios velofaríngeos durante a respiração de repouso não podem predizer a eficácia do retalho faríngeo para a fala.

Velopharyngeal Port Status During Classical Singing

This investigation was undertaken to examine the status of the velopharyngeal (VP) port during classical singing. Using aeromechanical instrumentation, nasal airflow (mL/s), oral pressure (cm H2O), and VP orifice area estimates (cm2) were studied in 10 classically trained sopranos during singing and speaking. Each participant sang and spoke 3 nonsense words-/hampa/, /himpi/, and /humpu/-at 3 loudness levels (loud vs. comfortable vs. soft) and 3 pitches (high vs. comfortable vs. low), using a within-subject experimental design including all possible combinations. In general, nasal airflow, oral pressure, and VP area estimates were significantly greater for singing as compared to speech, and nasal airflow was observed during non-nasal sounds in all participants. Anticipatory nasal airflow was observed in 9 of 10 participants for singing and speaking and was significantly greater during the first vowel in /hampa/ versus /himpi/ and /humpu/. The effect of vowel height on nasal airflow was also significantly influenced by loudness and pitch. The results from this investigation indicate that at least some trained singers experience regular VP opening during classical singing. Vowel height seems to influence this effect. Future research should consider the effects of voice type, gender, experience level, performance ability, and singing style on VP valving in singers.

Velopharyngeal aerodynamics of /m/ and /p/ in tracheoesophageal speech

Summary The purpose of this study was to compare oral pressure (P o), nasal airflow (V n), and velopharyngeal (VP) orifice area estimates from 12 tracheoesophageal (TE) and 12 laryngeal speakers as they produced /p/ and /m/ in syllable series. The findings were as follows: (1) TE speakers produced greater P o than the laryngeal speakers; (2) for /p/, TE speakers generated V n, and VP orifice area estimates comparable with, or less than, the laryngeal speakers; and (3) for /m/, TE speakers had V n and VP orifice area estimates greater than the laryngeal speakers. The elevated P o could be the result of several factors such as high source driving pressures and vocal tract volume changes postlaryngectomy. Attempts at more precise articulation, and subsequently less coarticulation, by the TE speakers may explain the V n and VP orifice area estimates for /p/ and /m/. TE speakers may be limiting the oral-nasal cavity coupling for /p/ (smaller VP gap, less V n) in an attempt to produce a very precise oral /p/. For /m/, TE speakers may be attempting to overtly mark the consonant as a nasal (greater V n, larger VP gap). Further studies are needed to confirm/refute the explanations postulated here regarding the VP aerodynamic differences that were identified.

Pressure-flow measurements for selected oral sound segments produced by normal children and adolescents: a basis for clinical testing.

Despite advances in surgery, a significant number of patients who undergo cleft palate repair have residual velopharyngeal insufficiency. Maxillary advancement may also result in velopharyngeal openings during speech. Instrumental approaches providing objective measures of palatal function assisting in the accurate diagnosis of these patients include pressure-flow measurements of velopharyngeal valving during speech. There is little information to guide clinicians in interpreting pressure-flow data when testing pediatric patients, however. The primary purpose of this study was to develop a method for categorizing pressure-flow data used in the diagnosis of children and adolescents with suspected velopharyngeal insufficiency. This prospective study involved 56 male and female subjects 5 to 18 years of age. Subjects had normal speech and resonance at the time of testing, no history of speech therapy, no upper respiratory infections or allergies at the time of testing, and no orofacial anomalies. Subjects repeated oral syllables and the word "hamper" after an examiner. Mean pressures, airflows, and velopharyngeal orifice areas were obtained for each utterance produced by each subject. A discriminate function analysis was performed to determine whether data could be grouped by age, gender, or utterance type. Results indicated significant differences in data for age groups 5 to 8 years, 9 to 13 years, and 14 to 18 years. There were no significant differences between data for male subjects versus female subjects or for different utterance types. Pressures generally decreased, whereas airflows and orifice areas increased with age. Results for 14 to 18 year olds were like those for adults. Using these data, a categorization scheme for velopharyngeal function was proposed for use in clinical testing.

Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap.

To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. Prospective cohort study. Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.

Pressure-Flow Measurements for Selected Nasal Sound Segments Produced by Normal Children and Adolescents

Abstract Objective: The purpose of this prospective study was to: (1) report simultaneous oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas for nasal sounds produced by children and adolescents; (2) determine whether data could be statistically classified by age, sex, or utterance type; and (3) provide guidelines for determining typical from atypical productions. Participants: The study involved 56 subjects, with two boys and two girls representing each age from 5 to 18 years. Subjects had no history of speech therapy, were judged as having normal speech and resonance at the time of testing, and had no upper respiratory tract infections or allergies at the time of testing. Methods: All subjects repeated /mɒ/ and “hamper” at normal pitch and loudness after an examiner model. Mean oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas were calculated for each subject's utterances. A discriminate function analysis determined whether data could be grouped by age ...

Pressure-flow measurements for selected nasal sound segments produced by normal children and adolescents.

The purpose of this prospective study was to: (1) report simultaneous oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas for nasal sounds produced by children and adolescents; (2) determine whether data could be statistically classified by age, sex, or utterance type; and (3) provide guidelines for determining typical from atypical productions. The study involved 56 subjects, with two boys and two girls representing each age from 5 to 18 years. Subjects had no history of speech therapy, were judged as having normal speech and resonance at the time of testing, and had no upper respiratory tract infections or allergies at the time of testing. All subjects repeated /mphaaa;/ and "hamper" at normal pitch and loudness after an examiner model. Mean oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas were calculated for each subject's utterances. A discriminate function analysis determined whether data could be grouped by age and sex. Significant differences in mean data for age groups of 5 to 9 years, 10 to 13 years, and 14 to 18 years were observed. Data showed decreases in pressures and increases in nasal airflow and orifice areas with age. Variability in pressure stayed consistent or decreased with age, but variability in nasal airflow and orifice areas increased with age. We propose a scheme for categorizing velopharyngeal function for oral and nasal sound production to be used in clinical testing.

Comparisons of Speech Aerodynamics and Lateral Craniofacial Cephalometrics in Cleft Lip and Palate Patients with and without Finnish /r/-Sound Distortion

To study the associations between the articulation of the Finnish /r/ sound and dentofacial and pharyngeal lateral cephalometric morphology and speech physiology, 18 (12 females, 6 males) young adult cleft patients’ /r/ sound was analysed auditorily by 3 speech experts. Laryngeal resistance (LARE), the smallest nasal cross-sectional area (NASA), nasal resistance (NASAR) and velopharyngeal orifice area (VEPA) were measured with pressure flow technique, and 31 points were identified from the lateral cephalograms to landmark the skeletal structure, pharyngeal airway diameters, and position of the hyoid bone. The present results showed no significant differences in lateral cephalometric skeletal, nasopharyngeal, oropharyngeal or hypopharyngeal morphology between subjects with and without /r/-sound distortion. There were no significant correlations either between /r/ distortions and NASA, NASAR or VEPA. An anteriorly positioned hyoid bone was significantly associated with decreased LARE and /r/ distortion. LARE was significantly lower in subjects with /r/ distortion.

Aerodynamic, acoustic, and perceptual measures of nasality following traumatic brain injury

Data were obtained from 31 subjects who had incurred a traumatic brain injury (TBI). Two expert listeners judged nasality using direct magnitude estimation with a referent. They rated samples of the first sentence of the Rainbow Passage, played backwards, with all pauses removed. Sensitivity was good for nasalance, velopharyngeal airway resistance, and velopharyngeal orifice area, indicating that these measures would accurately identify an individual as nasal. Specificity was reduced, and was adequate only for nasalance. The reduced specificity was due to a high number of false positives, i.e. perceived nasality in the absence of objective corroboration. Analysis of the false positives revealed that a slow speaking rate could mislead a listener's perception of nasality. Overall, for individuals with dysarthria following TBI, the measure of nasalance may most accurately reflect listener perception of nasality.

The Effect of Increased Vocal Effort on Estimated Velopharyngeal Orifice Area

Velopharyngeal deficits are a common component of dysarthria following neurogenic insults. Compensatory strategies may minimize the impact of velopharyngeal deficits on speech production. Velopharyngeal airway resistance measures were obtained for 28 subjects with traumatic brain injury. The measures were converted to velopharyngeal orifice area estimates. Data are reported for the subjects' habitual loudness and for increased vocal effort. Eighty-nine percent of the subjects decreased velopharyngeal orifice area by increasing vocal effort. The decrease ranged from 0.10 mm 2 to 20.19 mm 2 . In several cases, the change would likely affect perceived hypernasality. The reduction in velopharyngeal orifice area with increased vocal effort reflects an ability to compensate for velopharyngeal deficits, as well as a generalization of effects across the speech mechanism. Programs such as the Lee Silverman Voice Treatment, designed to establish high phonatory effort, may be of benefit.