Velopharyngeal insufficiency parag

This seminar gives brief description about introduction, normal anatomy of velopharyngeal structure, different closure pattern of velopharynx, diagnostic aids used, VPI in cleft patients

1. Velopharyngeal insufficiency Presented by - Dr Parag S. Deshmukh

2. Contents : Introduction Causes Normal anatomy Different closure patterns of velopharynx Diagnostic tools Treatment Related article Conclusion

3. Introduction: The terms velopharyngeal "incompetence", " inadequacy " and "insufficiency" historically have been used interchangeably Velopharyngeal insufficiency includes any structural defect of the velum or pharyngeal walls at the level of the nasopharynx with insufficient tissue to accomplish closure, or there is some kind of mechanical interference with closure.

4. Velopharyngeal insufficiency  (VPI) : It is known as a failure of the separation between nose and mouth, because of an anatomical dysfunction of the soft palate, the lateral or posterior wall of the pharynx. Velopharyngeal inadequacy : (VPI) is a malfunction of a velopharyngeal mechanism. The velopharyngeal mechanism is responsible for directing the transmission of sound energy and air pressure in both the oral cavity and the nasal cavity. When this mechanism is impaired in some way, the valve does not fully close, and a condition known as 'velopharyngeal inadequacy' can develop. Definition :

5. VP incompetence: Due to neurological etiologies such as motor disorders ( e.g dysarthria) VP incorrect learning: The result of sensory deficits ( e.g.hearing impairment), or congenital disorders (existing at birth )

6. Velopharyngeal insufficiency (VPI) is a disorder resulting in the improper closing of the velopharyngeal sphincter (soft palate muscle in the mouth) during speech, allowing air to escape through the nose instead of the mouth. During speech, the velopharyngeal sphincter must close off the nose to properly pronounce strong consonants such as "p," "b," "g," "t" and "d.“ To close off the nose from the mouth during speech, several structures come together to achieve velopharyngeal closure.  

7. These include the velum (soft palate or roof of the mouth), the lateral pharyngeal walls (side walls of the throat) and the posterior pharyngeal wall (the back wall of the throat). If the velopharynx is not closed, snort sounds may be produced through the nose or you may hear air coming out of the nose during speech. Improper function of this structure also produces a nasal tone in the voice.

8. Symptoms: The two main speech symptoms of velopharyngeal insufficiency (VPI) are hypernasality and nasal air emission. Hypernasality is sometimes called nasal speech. In English the sounds "m," "n" and "ng" are the only sounds that should resonate nasally. Hypernasality occurs when sounds other than these resonate through the nose, and it varies from mild to severe. Some other consonants can be produced without velopharyngeal closure, including "h," "w," "y," "l" and "r." The rest of the consonants are referred to as pressure consonants because they require buildup of air pressure in the mouth to produce normal sounds.

9. Nasal air emission occurs when air escapes through the nose on pressure consonants, and it can sound like puffs, squeaks or snorts, or it might make speech sound muffled. Children sometimes develop unusual speech sounds to compensate for their VPI. A common one is a glottal stop, produced by stopping air with the vocal cords (as one would do when saying "uh oh "). Some other sounds are made by awkward stopping or restricting air with the tongue in the throat or mouth in unusual ways.

10. Causes : Any child with cleft palate is at risk for VPI. The most common cause of VPI is a history of cleft palate or submucous cleft (cleft covered by the lining or mucous membrane of the roof of the mouth ). About 20% to 30% of children who have cleft palate with or without cleft lip will have persisting VPI after their palate repair . A small percentage of children with submucous cleft palate will also have VPI.

11. Sometimes VPI develops after an adenoidectomy (a surgical procedure to remove adenoids or lymphoid tissue in the back of the nose). Children who are born with weak throat muscles or who suffer a traumatic brain injury that results in weak throat muscles may have VPI. Sometimes children have VPI from an unknown cause.

12. Velopharyngeal insufficiency (VPI) can be caused by a variety of disorders : Structural Genetic Functional Acquired

13. Terms used in the study of VP function/dysfunction : Nasalization: significant communication of the nasal cavity with the rest  of  the vocal tract during speech. Nasality : perceptual quality of nasal resonance. Hypernasality : excessive nasally escaping air reverberating in the nasal   cavity. Hyponasality : blocked nasal resonance caused by nasal  obstruction. Nasal emission: increased nasal instead of oral airflow during  the production of pressure consonants (not necessarily acoustic ). Nasal turbulence: fricative sounds caused by nasal airflow

14. Normal anatomy :

15. The muscles that control its movement can be grouped based on their respective actions on the soft palate. They include elevators , depressors, and tensors. Elevators Depressors Tensor Levator veli palatini palatopharyngeus Tensar veli palatini Musculus uvulae palatoglossus In addition to the five soft palate muscles, there are two other pharyngeal muscles that also arise in pairs and assist in the functional mechanism of velopharyngeal closure : pulling the soft palate to the sides and thereby opening the pharyngotympanic tube during swallowing and yawning

16. Levator Veli Palatini : Bilaterally, the muscle is superiorly attached to the cartilage of the pharyngotympanic tube and the temporal bone and inferiorly attached to the palatine aponeurosis. Since 1953, it has been acknowledged that the principal function of the LVP is to elevate the soft palate. ( Bosma J: A correlated study of the anatomy and motor activity of theupper pharynx and by cinematic study of patients after maxillo -facial surgery . Ann Otol Rhinol Laryngol 1953; 62:51-72 .)

17. Palatopharyngeus : palatopharyngeus has two components: the velar component consisting of two heads that clasp round and insert into the levator , and the pharyngeal component which inserts into the superior constrictor in the lateral and posterior pharyngeal walls . The function of the palatopharyngeus is primarily to lower the palate, which assists the swallowing of food. It may elevate the larynx, which assists in the phonation of high pitched sounds. palatopharyngeus is active in the production of oral sounds as well as nasal speech sounds.

18. Palatoglossus : The palatoglossus is attached superiorly to the palatine aponeurosis and inferiorly to the sides of the tongue . The function of this muscle is to elevate the posterior part of the tongue and assist in depressing the soft palate onto the tongue. The palatoglossus coordinates with the TVP to lower the soft palate to produce nasal sounds. T he palatoglossus raises the tongue against the soft palate to pronounce the consonant k or g.

19. Musculus Uvulae :

20. Superior Constrictor : The superior pharyngeal constrictor is superiorly attached to the pterygoid hamulus , the pterygomandibular raphe, the posterior end of the mylohyoid, and the side of the tongue .

21. T he uppermost fibres of this muscle originate from the medial pterygoid plate, it is known as Passavant’s pad, named after Gustav Passavant (1860s) who first observed a ridge on the posterior pharyngeal wall in cleft palate patients. Prominence  on posterior wall of nasopharynx formed by contraction of  superior  constrictor muscle of pharynx during  swallowing Also   called Passavant  bar, cushion, pad, and ridge.  When present, this pad may assist in effecting a seal with the soft palate as it moves anteriorly with contraction of the superior constrictor muscle. Passavant’s pad has been reported to be more marked in individuals with palatal insufficiency, suggesting that this ridge may develop further when acting to compensate for ineffective velopharyngeal closure

22. Salpingopharyngeus : Attached superiorly to the cartilaginous part of the pharyngotympanic tube and inferiorly to the palatopharyngeal muscle. It was first believed that the muscle elevates the larynx and shortens the pharynx during swallowing and speaking. Some of the fibres of the salpingopharyngeus blend with the fibres of the superior constrictor, which may indicate that the salpingopharyngeus assists the superior constrictor in elevating the pharyngeal wall

23. VELOPHARYNGEAL CLOSURE : The soft palate (or velum) separates the nasopharynx from the oropharynx. During quiet breathing the soft palate suspends between the nasal and oral cavities, allowing air to freely move through the mouth or through the nose. During active breathing in and out through only the mouth, the soft palate will elevate to touch the posterior pharyngeal wall, thus closing the opening between the oropharynx and nasopharynx. This velar closure is known as velopharyngeal or palatopharyngeal closure and is important for swallowing, speech , and blowing.

24. Functional Anatomy of the Soft Palate Applied to Wind Playing Alison Evans, MMus, Bronwen Ackermann, PhD, Medical Problems of Performing Artists, December 2010. Velopharyngeal mechanism :

25. S phincteric mechanism: Firstly , the velar component involves the elevation and posterior movement of the velum . Secondly , the pharyngeal component involves the movement of the pharyngeal walls encompassing the oropharynx and nasopharynx.

26. Croft et al. ( 1981) observed four main types of closure patterns 4. Circular closure with Passavant’s pad is a combination of the circular closure with the anterior movement of the posterior pharyngeal wall. 3. Circular closure requires an equal movement from both the velum and the lateral pharyngeal walls . Sagittal closure involves the medial movement of the lateral pharyngeal walls to meet the velum Coronal closure is achieved by the elevation of the velum to touch the posterior pharyngeal wall;

27. Variations in VP Closure • Non-Pneumatic Closure - swallowing, gagging, and vomiting Closure is high in the nasopharynx and is exaggerated. • Pneumatic Closure - sucking, whistling, blowing, speech Closure may be complete for non-pneumatic activities, but may be insufficient for speech and other pneumatic activities.

28. Evaluation of Velopharyngeal Function : Modulation of the pressurized air stream that emerges from the lungs during expiration produces an auditory phenomenon that is called “ speech” . The tissues comprising the velopharyngeal sphincter are one of several articulators capable of modification of the air stream. Dysfunction of that sphincter impairs the normalcy of speech to varying degrees. There is a lack of consensus on the preferred terminology to describe such dysfunction : velopharyngeal incompetency, velopharyngeal insufficiency , and velopharyngeal inadequacy have all been abbreviated as VPI.

29. It is a physiological impairment without attempting to denote etiology. Diagnostic evaluation : It can be divided into two broad categories: perceptual I nstrumental . “ instrumental” includes all evaluations that use some type of instrumentation.

30. Perceptual : “Perceptual” connotes the use of the evaluator’s unaided senses . Listening for the production of specific phonemes (i.e., auditory perceptual velopharyngeal evaluation ) is the major form of perceptual evaluation. Observing the face for grimacing watching for fogging of a mirror below the nares feeling for airflow through the nares with attempted pronunciation of phonemes that require velopharyngeal function.

31. Instrumental : [Krakow & Huffman, Baken & Orlikoff ]

32. Muscle activities: Electromyography (EMG) Surface electrodes Intramuscular electrodes VP study usually needs the intramuscular one.

33. Imaging : Fiberoptic endoscope X­ray / MRI / Ultrasound

34. Videofluoroscopy : It is a radiographic technique, mostly used to demonstrate the lateral and posterior wall of the pharynx. This is a questionable technique considering these children undergo radiographic examinations frequently . Most of the time barium is used in multiview videofluoroscopy . Besides the fact that videofluoroscopy provides an overview of the lateral and posterior walls of the pharynx, this technique also provides information about the length and movement of the soft palate, the posterior and the lateral walls

35. Speech analysation : To come to the right diagnosis this is the gold standard in VPI evaluation. The speech scientist listens to the voice, articulation, motor speech and the velopharyngeal function of the patient. The main symptom is hypernasality of the voice. The patient is unable to create normal resonance because of nasal air emission.

36. Nasometry :   Nasometry  is a test which calculates a ratio between the nasal and oral sound emissions . The ratios of the patient will be compared with a normal ratio and standard deviation. These ratios will help determine whether the operation was a success. Preoperative ratios will be compared with postoperative ratios.

37. Airflow: Pneumotachograph : split mask with airflow sensors

38. Sound pressure: Microphones ( eg . Probe­mic , Nasometer ) Accelerometers or contact microphones for tissue vibrations

39. The scientist also examines the patient for  Obstructive Sleep Apnea Syndrome (OSAS ) , when this is positive the patient will be treated for  OSAS  first . When there is no sign of oral sleep apnea the patient will conduct a speech analyzation . If is proven that the patient has an indication for surgical treatment, the next step will be visualization of the mouth and pharyngeal cavity. Often the visualization is combined with audiometry or speech analyzation .

40. Nasoendoscopy : Nasoendoscopy is a non radiographic technique in which the physician uses a scope to enter the mouth of the patient. Usually the examiner uses a flexible scope, but in certain situations a rigid scope is used. Nasoendoscopy provides an overview of the anatomy of the velopharynx during phonation. With nasoendoscopy the vocal tract but especially the soft palate and the lateral wall of the pharynx can be visualized . Not only the location but also the movement can be visualized with nasoendoscopy .

41. Limitations : I t is hard to get an overview with nasoendoscopy with a rigid scope in small kids .   Especially when there are abnormalities or obstructions in the nasal cavity, which are frequently found in children with a history of  cleft palate . The nasoendoscope can cause irritations of the mucosa when the child does not cooperate.

42. A third grouping can be based on whether the technique provides “ visualization” of the functioning velopharyngeal port or more indirect assessment by recording changes in airflow , air pressures, or sound or light transmission across the velopharyngeal port, usually by means of oronasal discrimination.

43. Differential Diagnosis of Velopharyngeal Dysfunction

44. Velopharyngeal insufficiency in patients with cleft palate:

45. Speech abnormalities in the cleft patient :

46. Warren’s aerodynamic demands theory :

47. Nasal air emission :

48. Resonance :

49. Articulation :

50. Speech evaluations :

51. Management of cleft-related velopharyngeal insufficiency :

52. When the pharyngeal flap is used, a flap of the posterior wall is attached to the posterior border of the  soft palate . The flap consists of mucosa and the superior pharyngeal constrictor muscle. The muscle stays attached to the pharyngeal wall at the upper side (superior flap) or at the lower side (inferior flap ).   The function of the muscle is to obstruct the pharyngeal port at the moment that the pharyngeal lateral walls move towards each other . ]  It is important that the width and the level of insertion of the flap are properly constructed, because if the flap is too wide, the patient can have problems with breathing through the nose what can result in sleep apnea .  Or a postoperative situation can be created with the same symptoms as before surgery. Although there are complications such as the flaps width can change because of contraction of the flap. This results in a situation with the same symptoms of hypernasality after a few weeks of surgery.

53. superiorly based pharyngeal flap:

54. Inferior based pharyngeal flap :

55. Sphinctoroplasty :

56. Posterior wall Augmentation : T his technique can only be used for small gaps .  When this operation is performed there are a several advantages. It is possible to narrow down the velopharyngeal port without modifying the function of the velum or lateral walls .   Furthermore the chance of obstructing the airway is less, because the port can be closed more precisely. Many materials have been used for this closure:  petroleum jelly ,  paraffin , cartilage , adjacent soft tissue,  silastic ,  fat ,  Teflon  and proplast .

57. Complications of surgery for velopharyngeal insufficiency :

58. Snoring is the audible sound produced when airflow is inefficient through the upper airway. This may not be significant pathophysiologically but may be bothersome to the significant other if the snoring prevents the other’s normal and restful sleep. Upper airway resistance syndrome develops when more significant resistance occurs without clear obstruction and a decrease in effective oxygenation. Obstructive sleep apnea is the clear cessation of breathing during sleep that causes an arousal from the normal sleep cycle. This condition contributes to daytime hypersomnolence and is associated with increased risks for hypertension, cardiovascular disease , and stroke.

59. Non operation techniques : Prosthesis : Prosthesis are used for nonsurgical closure in a situation of velopharyngeal dysfunction .   There are two types of prostheses. One called the speech bulb and the other one the  palatal lift prosthesis .  The speech bulb is an acrylic body that can be placed in the velopharyngeal port and can achieve obstruction.

60. The  palatal lift prosthesis  is comparable with the speech bulb, but with a metal skeleton attached to the acrylic body .   This will also obstruct the velopharyngeal port .   It is a good option for patients that have enough tissue but a poor control of the coordination and timing of velopharyngeal movement. It is also used in patients with contraindications for surgery. It has also been used as a reversible test to confirm if a surgical intervention would help.

61. Related article: Association between velopharyngeal function and dental-consonant misarticulations in children with cleft lip/palate J . Pulkkinen, M.-L. Haapanen, J. Laitinen, M. Paaso and R. Ranta (British Journal of Plastic Surgery (2001), 54 , 290–293)

62. They studied the association between velopharyngeal function and misarticulation of the dental consonants/r /, /s/ and /l/ in children with cleft lip/palate . They assessed 278 6-year-old Finnish-speaking non-syndromic children (115 girls, 163 boys) with isolated cleft palate, cleft lip/alveolus or unilateral or bilateral cleft lip and palate. Auditory analysis of speech and velopharyngeal function, the presence of fistulae, previous velopharyngoplasty and speech therapy, as well as surgical technique and timing of primary palatal surgery were obtained from the hospital records. The misarticulations of the sounds /r/, /s/ and /l/ were evaluated in spontaneous speech by two experienced speech pathologists from the cleft team . Velopharyngeal function was categorised , on the basis of the effect on speech, into competent, marginal incompetent and obvious incompetent. Nasal grimace and distortions due to palatal fistulae were registered. The results indicated that velopharyngeal function was not significantly associated with misarticulation of any of the sounds /r/, /s/ and /l/ or their combinations in any cleft groups. The technique and timing of primary palatal surgery, the presence of fistulae and previous pharyngoplasty were not associated with misarticulations . On the basis of these results we conclude that dental-consonant misarticulations occur independently of velopharyngeal function, primary palatal surgical technique and timing of palatoplasty .

63. Introduction : The prevalence of dental-consonant articulatory errors is higher in cleft patients than in non-cleft patients . earlier studies have shown that, at the age of 6 years, 44 % of cleft patients misarticulate at least one of the sounds /r/, /s/ and /l/; 41% distorted and 5% substituted (2 % both distorted and substituted) at least one sound . Speech aerodynamics and breathing may be distorted in cleft patients .

64. Dentoalveolar dysmorphology , in terms of the severity of the cleft, results in atypical cephalometric dimensions . This is associated with abnormalities in vocal-tract anatomy and may cause abnormal functioning and physiology during breathing and phonation . Alveolar fistulae, and the presence or absence of incisors, may also interfere with the ability to articulate. Aim of this study was to examine the relationship between velopharyngeal function and articulation of the Finnish dental consonants /r/, /s/ and /l /, normally produced by linguoalveolar contact. To control for possible misleading variables , the effects of sex, cleft type, method and timing of primary palatoplasty , palatal fistulae, earlier velopharyngoplasty and speech therapy were also studied.

65. Patients and methods :

66. Number of patients with each type of cleft by sex, misarticulations of /r/, /s/, /l/ or their combinations, obvious or marginal velopharyngeal incompetence (VPI), previous velopharyngoplasty , previous speech therapy and fistulae

67. Specific signs of velopharyngeal incompetence ( VPI) were not included in the misarticulations studied. Speech characteristics associated with VPI were registered for all of the sounds. Those were: 1:nasal air emissions; 2: hypernasality ; 3 : weakness of pressure consonants; and 4 : compensatory articulations (glottal, lingual, pharyngeal stops and nasal and laryngeal fricatives).

68. The inter-judge agreement in the assessment of speech characteristics of velopharyngeal function and psychomotor development ranged from 91.3% to 94.2 %. The data for each patient’s /r/, /s/ and /l/ sounds were evaluated simultaneously by the two speech pathologists; the categorizing of distortions and substitutions was based on a 100 % consensus between them.

69. Results : The occurrences of misarticulation of /r/, /s/ or /l/ or their combinations were statistically compared to velopharyngeal competence , marginal velopharyngeal competence and obvious VPI. No significant differences were observed.

70. There was no significant difference in velopharyngeal function between boys and girls in any cleft group. Thus, boys and girls were combined in later comparisons only significant difference was observed in the bilateral-cleft- lipand - palate group, where all /s/ disorders were in the velopharyngeal competence group.

71. Conclusion: Dental-consonant errors in cleft patients are a separate error category. The treatment of dental-consonant errors could be planned independently of the treatment of VPI. Some features specific to VPI may, of course, also occur in association with dental-consonant misarticulations , but according to our results dental-consonant misarticulations are not significantly related to velopharyngeal function, whether competent or not.

72. Conclusion : The factors that may prevent VPI are not well understood and further research is therefore needed. The function of the soft palate is essential for maintaining upper respiratory tract structure and function under pressure and hence for allowing optimal airflow . It is crucial for patients with cleft palate, some repaired cleft patients, wind and brass players to be able to maintain firm velopharyngeal closure for optimum performance. It is important to increase understanding of the functional anatomy of the soft palate to help better manage injuries that may arise from overuse or misuse of the soft palate muscles.

73. References: Cleft Palate & Craniofacial Anomalies Effects on Speech and Resonance - Ann Kummer . Functional Anatomy of the Soft Palate Applied to Wind Playing (Alison Evans, MM us , Bronwen Ackermann, PhD, and Tim Driscoll, PhD) Management of Velopharyngeal Dysfunction : Differential Diagnosis for Differential Management (Jeffrey L. Marsh, MD St . Louis, Missouri ) Resonance Disorders and Velopharyngeal Dysfunction: Part I. Types, Causes and Characteristics. Ann W. Kummer , PhD, CCC-SLP Wikipedia, the free encyclopedia

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