Retropharyngeal lipostructure in the treatment of velopharyngeal insufficiency: A prospective study and update.

INTRODUCTION: Retropharyngeal lipostructure is a recent procedure in velopharyngeal insufficiency (VPI), offering an effective alternative to heavier surgery. OBJECTIVES: To update and assess retropharyngeal lipostructure as a treatment for VPI in the University Hospital Center of Rouen (France). TYPE OF STUDY: Single-center prospective study, from May 2012 to May 2014. PATIENTS AND METHODS: Six patients (4 girls, 2 boys) presenting with VPI were treated by retropharyngeal lipostructure. Age at surgery ranged between 6 and 12 years. Four of the patients bore a 22q11 microdeletion. Treatment was indicated in case of Borel-Maisonny type 2b (n=2) or 2m (n=4) despite well-conducted speech therapy and of≥50% velopharyngeal sphincter closure on nasal endoscopy. Patients were assessed preoperatively and at 3 months, by a multidisciplinary team. Borel-Maisonny type was assessed by a speech therapist. Nasality was measured on assisted vocal evaluation (EVA®). Sphincter closure was assessed on dynamic MRI. RESULTS: Between 6 and 8cm3autologous fat was injected. At 3months, 4 children showed 1-grade improvement in Borel-Maisonny type. Nasality decreased systematically, from a mean 14.5% preoperatively to 10.5% postoperatively. MRI showed improvement in all cases, with complete closure in occlusive vowels in 3 children. CONCLUSION: EVA® and MRI provide precise objective assessment of VPI. Retropharyngeal lipostructure is a simple, relatively non-invasive, reproducible technique, providing good results in VPI.

Decision making for residual palatoalveolar cleft defects: a new classification.

Oral rehabilitation of adult patients with cleft lip and palate is related to the severity of the anatomical and functional alterations that hamper the proper closure of the nasopharynx. The ideal treatment is closure by bone graft and orthodontics. However, when surgery is not possible or when the patient does not wish to undergo surgery, a palatal prosthesis may offer the best solution in most clinical situations. The authors of this article propose a new classification to help the practitioner with decision making and prosthetic treatment planning for residual palatoalveolar cleft defects.

Clinical grading system for submucous cleft palate.

Submucous cleft palate is a structural abnormality of the palate. The clinical features vary, as does the functional impairment, which ranges from none to severe. Although there is a poor correlation between the presenting clinical signs and the severity of velopharyngeal insufficiency during speech, a clinical grading system could assist surgical management and allow more meaningful comparisons to be made between outcome studies. The grading system described is based on clinical examination alone and reflects the likely degree of structural abnormality of the musculature of the soft palate.

A comprehensive description of functioning and disability in children with velopharyngeal insufficiency.

UNLABELLED: Children with velopharyngeal insufficiency (VPI) experience functional impairments in a variety of areas that extend beyond the primary physical impairment associated with this disorder. At present, the physical deficits associated with VPI have been studied extensively; however, a comprehensive description of social and communicative participation in this population is needed. Therefore, a biopsychosocial framework such as the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), may offer an enhanced understanding of the daily experiences of children with VPI. Specifically, the ICF-CY framework is intended to model complex nonlinear systems, and as such, to describe functioning as the interaction of multiple components from which a limitation in communicative participation may emerge. This paper describes how the ICF-CY framework can be utilized to comprehensively describe functioning and disability in children with VPI by describing the interaction of components of this framework. LEARNING OUTCOMES: As a result of this activity, the reader will be able to: (1) discuss the utility of the ICF-CY in describing the multi-dimensional nature of velopharyngeal insufficiency (VPI); (2) describe interrelationships between functioning and disability in children with VPI; and (3) identify how limitations in communicative participation may emerge from the interaction of components of the ICF-CY in children with VPI.

Perceptions of audible nasal emission in speakers with cleft palate: a comparative study of listener judgments.

OBJECTIVE: Audible nasal emission is a common speech distortion observed in persons with cleft palate. This study examined the validity and reliability of perceptual judgments of audible nasal emission using interval scaling and magnitude estimation techniques. PARTICIPANTS: Speech samples were collected from six adolescents with repaired cleft palate, all of whom demonstrated audible nasal emission. A total of 31 adults performed rating tasks in which they judged the severity of audible nasal emission in speech samples. MEASURES: Occurrences of audible nasal emission in speech samples were identified using visual and auditory inspection. Using an acoustic modification technique, samples were digitally modified to amplify perceived occurrences of audible nasal emission to create three stimulus conditions. The original recording of the speech samples served as a control condition. The severity of audible nasal emission in the samples was judged by multiple listeners using interval scaling and magnitude estimation without a modulus. Statistical analysis included analysis of variance, regression, and curve-fitting methods. RESULTS: Magnitude-estimation ratings demonstrated stronger evidence of validity and reliability than interval scaling. A curvilinear relationship was found between the sets of ratings. CONCLUSIONS: The results of this study suggest that audible nasal emission may be a prothetic or ratio-level perceptual continua. Listeners should consider using magnitude estimation or other ratio-based methods for perceptual judgments of audible nasal emission.

Maxillary distraction versus orthognathic surgery in cleft lip and palate patients: effects on speech and velopharyngeal function.

This clinical randomized controlled trial was performed to compare the effects of distraction osteogenesis (DO) and conventional orthognathic surgery (CO) on velopharyngeal function and speech outcomes in cleft lip and palate (CLP) patients. Twenty-one CLP patients who required maxillary advancement ranging from 4 to 10 mm were recruited and randomly assigned to either CO or DO. Evaluation of resonance and nasal emission, nasoendoscopic velopharyngeal assessment and nasometry were performed preoperatively and at a minimum of two postoperative times: 3-8 months (mean 4 months) and 12-29 months (mean 17 months). Results showed no significant differences in speech and velopharyngeal function changes between the two groups. No correlation was found between the amount of advancement and the outcome measures. It was concluded that DO has no advantage over CO for the purpose of preventing velopharyngeal incompetence and speech disturbance in moderate cleft maxillary advancement.

Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency.

OBJECTIVE: To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN: Multicenter blinded R (inter) and R (intra) study. SETTING: Eight academic tertiary care centers. PARTICIPANTS: Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES: Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS: The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS: In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

[Different patterns of velopharyngeal dysfunction in cleft palate patients]. / Formen der velopharyngealen Dysfunktion bei Spaltpatienten.

BACKGROUND: Velopharyngeal dysfunction (VPD) is generally known to be difficult to influence. Dysfunctional velopharyngeal motor patterns during speech were analyzed with the aim of optimizing the therapeutic strategies. METHODS: Velopharyngeal dysfunctions were videotaped and contextually analyzed during 89 speech sequences in 25 patients. Distinctive features of the motor patterns formed the basis of categorization by three therapists experienced in nasopharyngoscopy. There was a high inter-rater reliability of 94%. RESULTS: A total of four different function profiles were found: 1. VPD with retracted articulatory placement (compensatory articulation) (38%), 2. VPD with motor coordination problems characterized by mistiming of VP movements and voice onset/offset (15%), 3. VPD with verbal dyspraxia characterized by a silent positioning of VP closure before phonation started and a malregulation of muscle tonus (10%) and 4. phoneme-specific VPD (37%). CONCLUSION: Specific knowledge regarding the characteristics of dysfunctional speech motor patterns enables specifically tailored therapy.

Velopharyngeal insufficiency in hemifacial microsomia: analysis of correlated factors.

OBJECTIVE: To investigate the incidence of unilateral hypodynamic palate (UHP) and velopharyngeal insufficiency (VPI) in hemifacial microsomia (HFM), and to determine the dysmorphic manifestations having significant associations with UHP/VPI in HFM. STUDY DESIGN: This was a nonrandomized study of 48 patients with unilateral HFM without cleft palate. The correlation between each anomaly and UHP/VPI was analyzed statistically. In addition, we observed 4 HFM patients with cleft palate to examine the influence on cleft palate speech. RESULTS: The incidence of UHP in HFM was 50.0% and that of VPI was 14.6%. All the VPI patients had UHP. Severe micrognathia and soft tissue deficiency, macrostomia, and mental retardation were significant risk factors for developing VPI in HFM. Moreover, UHP exacerbated speech in HFM with cleft lip and palate. CONCLUSIONS: Significant correlations were detected between VPI and HFM. This finding should be helpful in the overall management of HFM.

Proposta de classificação da função velofaríngea na avaliação perceptivo-auditiva da fala / Proposal for velopharyngeal function rating in a speech perceptual assessment

TEMA: a avaliação perceptivo-auditiva da função velofaríngea apresenta limitações em função de sua subjetividade. OBJETIVO: propor um método de classificação baseado nos escores atribuídos à hipernasalidade, emissão de ar nasal e distúrbios articulatórios compensatórios. CONCLUSÃO: o uso do método traz inúmeras vantagens em termos de documentação clínica e de pesquisa e para acompanhamento de resultados terapêutico-cirúrgicos.

[Proposal for velopharyngeal function rating in a speech perceptual assessment]. / Proposta de classificação da função velofaríngea na avaliação perceptivo-auditiva da fala.

BACKGROUND: The perceptual assessment of velopharyngeal function during speech presents some limitations due to its subjectivity. AIM: To propose a method for velopharyngeal function rating based on hypernasality, nasal air emission and compensatory articulation deficits scores. CONCLUSION: The proposed method shows several advantages in terms of clinical and research documentation and for an adequate follow-up of therapeutic and surgical outcomes.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes.

OBJECTIVE: To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN: Prospective descriptive study on a cross-sectional sample of children. PATIENTS/PARTICIPANTS: Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP. MAIN OUTCOMES: Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention. CONCLUSIONS: Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

Oclusäo velofaríngea em indivíduos submetidos à nasoendoscopia na Clínica de Educaçäo para Saúde (CEPS) / Velopharryngeal oclusion in people who were submitted to nasoendoscopy at the Center of Health Education (CEPS)

O esfíncter Velofaríngeo (EVF) corresponde anatomicamente à área delimitada pelo véu palatino, paredes laterais e posterior da faringe. Fisiologicamente, há uma grande variabilidade no seu mecanismo de oclusão, o qual, até o presente momento tem sidoo classificado, na literatura em geral, em quatro padrões: coronal, sagital, circular e circular com prega de Passavant. Neste trabalho, procurou-se analisar e comparar os tipos de fechamento velofaríngeo, com os descritos na literatura; relacionar a oclusão EVF, total ou uncompleta, com dados obtidos durante os procedimentos metodológicos utilizados: anamnese, espelho de ressonância e nasoendoscopia. Os resultados obtidos indicaram predomínio de fechamento velofaríngeo do tipo coronal, o que permite concluir que o palato mole teve uma participação mais efetiva na maioria dos indivíduos. Este estudo também indicou a presença de escape de ar nasal e/ou gap velofaríngeo mínimos na maioria dos sujeitos, principalmente durante a vogal /a/, sem relação direta com alterações da função velofaríngea, o que permite concluir que escapes nasais e/ou gap velofaríngeo minimos não caracterizam necessariamente uma inadequação velofaríngea

Aspects of assessment and management of velopharyngeal dysfunction in developing countries.

Proper assessment of patients with velopharyngeal valve incompetence is a mandatory prerequisite for optimal management. The protocol of assessment of Ain Shams University, Phoniatric Department, uses three levels of assessment of velopharyngeal valve incompetence according to the complexity of the armamentarium used. This allows application of those parts of the protocol that suit the needs of the different socioeconomic levels and geographical locations. Firstly, the elementary diagnostic procedures, which are rather simple, noninvasive, but essentially subjective. Despite the clinical feasibility of these procedures, documentation of the data is made utilizing the tools at the second level of assessment in that protocol (clinical diagnostic aids). This level comprises video-nasofiberscopy and high fidelity voice recording. An attempt to extract quasi-quantitative measures from the hitherto qualitative video-nasofiberscopy is made. The third level of assessment, namely additional instrumental measures, comprises CT scanning of the velopharyngeal port, aerodynamics, and acoustic analysis. The results of the three levels of the protocol are presented. Their significance and clinical efficacy are discussed. Some community-related problems that have faced the cleft palate team are outlined. Their sociocultural significance in a developing country is discussed.

A proposal for standardization of speech and hearing evaluations to assess velopharyngeal function.

The article comprises the proposal made by the Cleft Palate Committee of IALP to standardize the parameters of the speech and hearing evaluation in individuals with cleft palate/velopharyngeal incompetence (CP/VPI). The suggested parameters are the following: nasal resonance, nasal escape, articulation and its disorders, facial grimacing, speech intelligibility, patient teachability, expressive language and voice. The authors recommend a five-point scale description system, which can be used also for assessment of hearing, velopharyngeal competence and other attributes of the CP/VPI individual. The most important diagnostic procedures are: X-ray (video/cinefluoroscopy), nasopharyngoscopy, nasometry; in dubious cases it is also fundamental to clarify the etiology with electrophysiological methods. The utilization of this proposal might contribute to a more accurate diagnosis and a more effective treatment on an international basis.

[The functional classification of velopharyngeal closure after uranoplasty]. / Funktsional'naia klassifikatsiia nebno-glotochnogo smykaniia posle uranoplastiki.

The new nasopharyngoscopic functional classification of palatopharyngeal joining is based on the results of examinations of 57 children with congenital uranoschisis after uranoplasty and 19 healthy children aged 5 to 14 years by nasopharyngoendoscopy. The classification defines the causes of palatopharyngeal insufficiency and for the first time takes into consideration the disagreement between the palatopharyngeal lock and articulation. The proposed classification helps select the most effective method of rehabilitation of the above patient population and helps follow up the time course of changes in the function of the palatopharyngeal lock under the effect of treatment.

[Analysis and radiologic staging of the type and severity of aspiration]. / Analyse und radiologisches Staging des Typs und Schweregrades einer Aspiration.

The estimated number of the incidence of undiagnosed chronic aspiration pneumonia after cerebral or cerebrovascular injury seems very high. According to American statistics, at least 6% of these patients die from aspiration pneumonia within the first year. The high temporal resolution of cineradiography with frame rates of the complex process of pharyngeal swallowing lasting 0.7 s. The method enables us to differentiate between so-called pre-, intra- and postdeglutitive aspiration, which means aspiration before, during and after the triggering of the swallowing reflex. Together with an established score for the severeness of the aspiration, the method supplies important data for setting up a functional surgical and/or conservative program for rehabilitation and for follow-up-studies.

Nasometric discrimination of hypernasality and turbulent nasal airflow.

Agreement between nasalance measures and perception of nasality during speech is not consistently strong. A possible reason may be the complicating combined effects of nasal turbulent airflow and nasal resonance. The purpose of this preliminary study was to examine nasalance measures obtained during production of a low pressure speech sample designed to minimize or eliminate the effects of turbulent nasal airflow. The results showed that nasalance measures obtained as some of the subjects produced the new speech sample were significantly different from those obtained when the standard high pressure speech sample was used. Use of both the new low pressure samples and the standard high pressure samples may result in improved agreement between nasalance measures and ratings of speech nasality as well as assist in the identification of subgroups of patients with marginal velopharyngeal insufficiency.