Inability of the velopharyngeal sphincter to close completely during production of the oral (nonnasal) sounds of speech

• 
  Velopharyngeal insufficiency refers to the inability of the velopharyngeal sphincter to close completely during production of the oral (nonnasal) sounds of speech.
  
• 
  The primary effects of velopharyngeal insufficiency are nasal air escape and hypernasality.
  

• 
  Satisfactory speech results occur in about 80% of pts after primary palatoplasty
  
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  Further 15 % achieve normal speech with speech therapy
  
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  5% require further management with due to insufficient secondary palate closure
  
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  In this 5% air escapes through the nasopharynx when attempting to produce certain sounds precludes normal speech
  
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  Important to realize that the presence of abnormal speech is not an indication for surgery and thorough assessment of the defect is need
  

1. 
   Sphinter remains open
   
   1. 
      Nasal sounds – M N
      
   2. 
      Useful to test for overcorrection post surgery – Mamma made some mittens
      
2. 
   Complete closure required
   
   1. 
      Plosive consonants – K T P – Pick up the book
      
   2. 
      Fricative consonants – F S - Suzy sees the scissors
      

• 
  Voice requires quality, richness and carrying power
  
• 
  Also clear, precise consonants
  

Classification based on aetiology

1. 
   velopharyngeal insufficiency(VPI) - structural origin and includes structural problems associated with the velum or the side walls at the level of the nasopharynx with insufficient tissue to accomplish adequate closure
   
2. 
   velopharyngeal incompetence(VP incompetence) – neurogenic origin
   
3. 
   velopharyngeal mislearning -mislearning or functional origin
   

Velopharyngeal dysfunction – all encompassing term for the above and does not imply a specific etiology

• 
  Previously thought that VP closure resulted from a short velum. And thus the push back procedures were used with little success. Now known that the closure of the VP is a complex mechanism and thus need accurate Ix
  

• 
  Four closure patterns (Skolnick)
  
  1. 
     Coronal - mostly palate (most common)
     
  2. 
     Sagittal - mostly lateral wall (least common)
     
  3. 
     Circular - both palatal and lateral wall
     
  4. 
     Circular with Pasavants ridge – posterior, palatal and lateral walls
     

1. 
   unrepaired
   
2. 
   repaired
   
3. 
   submucous cleft
   
4. 
   fistula
   

1. 
   anatomic
   
2. 
   neuromuscular
   
3. 
   behavioral/functional
   

1. 
   poor muscle sling
   
2. 
   poor elevation
   
3. 
   short palate
   
4. 
   immobile scarred palate
   
   • 
     subclinical disease may manifest later due to:
     
     1. 
        adenoidal involution at the time of puberty
        
     2. 
        adenoidectomy
        
     3. 
        Orthognatic (LeFort) advancement – controversial.
        
        1. 
           Mr Baker says this does not occur
           

> congenitally short palate

> reduced palatal bulk

> deep/enlarged pharynx

>adenoidectomy

> maxillary advancement

> tumour resection

Neuromuscular

> cerebral palsy

> head injury

> cva

velocardiofacial syndrome (shprintzen syndrome)

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  square nose, narrow ala base
  
• 
  long face, retruded chin
  
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  hypotonia
  
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  cardiac defects
  
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  intellectual impairment or learning disabilities(50%)
  

• 
  hypernasality
  
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  nasal emission
  
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  nasal turbulence
  
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  nasal substitution
  
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  compensatory articular patterns (distortions, substitutions, and omissions).
  
• 
  weak omitted consonants
  
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  nasal/facial grimace
  
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  hoarseness
  
• 
  low volume voice
  
• 
  monotonous voice
  
• 
  breathiness
  
• 
  unusual pitch variations
  
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  nasal fluid regurgitation
  
• 
  utterances or sentences are short and their speech tends to take on a choppy pattern because of the leak
  

• 
  size
  
• 
  movement
  
• 
  symmetry
  
• 
  elevation on phonation
  
• 
  dentition
  
• 
  occlusion
  
• 
  fistula
  
• 
  nasal air escape using mirror
  

• 
  attempts to define characteristic speech of vpi and quantify severity
  
• 
  consult speech therapist
  

1. 
   type of closure
   
2. 
   size of vp gap
   
3. 
   evidence of fatigue
   
4. 
   consistency of performance
   

• 
  video recorded radiograph
  
• 
  barium paste nasally
  
• 
  lateral and frontal views
  
• 
  Townes view (30 head down, mouth wide open)
  
• 
  info on size of gap, pattern of closure and degree of palate elevation
  

• 
  barium paste instilled intranasally which coats the surface of the oropharynx and then the pt is asked to duplicate certain sounds while the fluoroscopic images are taken with the lateral , frontal and submental views being the most important
  
• 
  when the adenoids are enlarged the Townes view demonstrates the VP orifice better than the basal views
  

• 
  direct visualization of the velopharyngeal mechanism
  
• 
  recommended in conjunction with video fluoroscopy giving mainly quantitative information and the nasendoscopy giving mainly qualitative information
  
  • 
    fine flexible scope
    
  • 
    rigid scope
    
  • 
    type and degree of closure
    
  • 
    not successful in young children
    
  • 
    useful adjunct to vf in difficult cases
    
  • 
    some use routinely
    

• 
  Nasalance is a ratio of the nasal acoustic output relative to oral plus nasal acoustic output and is expressed as a percentage.
  
• 
  sensitivity and specificity of nasometry in correctly identifying subjects with more than mild hypernasality in their speech - 89% and 95%, respectively.
  

1. 
   accelermeter
   
2. 
   aeromechanics
   

• 
  useful in picking up abnormal medial displacement of the carotid artery
  
• 
  abnormality of the internal carotid is common in VCF syndrome
  
• 
  10% found to be located just under the pharyngeal mucous membrane and thus can be endangered in raising pharyngeal flap
  
• 
  Sommerlad (Cleft Palate Craniofac J. 2004 Jul) - Examination and palpation of the pharyngeal walls after the patient is positioned for surgery appear to be reliable in detecting abnormal pulsations and allow accurate surgical planning. Routine vascular imaging, even in patients with pulsations on preoperative nasendoscopy is not essential and may not always be reliable, as shown by the variation in endoscopic, MRA, and intraoperative findings.
  

• 
  Speech therapy
  
  • 
    generally not enough in itself for structural problems related to VPI.
    
  • 
    It is, however, valuable for small gaps or inconsistent closure
    
  • 
    very valuable either before or after surgery, or both, in order to eliminate compensatory strategies that patients develop over time.
    
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  Prosthesis
  
  • 
    Poorly tolerated in children. Mainly indicated where surgical risks are prohibitive.
    
    
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