Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function.

ABSTRACT: Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

Analysis of Velopharyngeal Functions Using Computational Fluid Dynamics Simulations.

OBJECTIVES: Competent velopharyngeal (VP) function is the basis for normal speech. Understanding how VP structure influences the airflow during speech details is essential to the surgical improvement of pharyngoplasty. In this study, we aimed to illuminate the airflow features corresponding to various VP closure states using computed dynamic simulations. METHODS: Three-dimensional models of the upper airways were established based on computed tomography of 8 volunteers. The velopharyngeal port was simulated by a cylinder. Computational fluid dynamics simulations were applied to illustrate the correlation between the VP port size and the airflow parameters, including the flow velocity, pressure in the velopharyngeal port, as well as the pressure in oral and nasal cavity. RESULTS: The airflow dynamics at the velopharynx were maintained in the same velopharyngeal pattern as the area of the velopharyngeal port increased from 0 to 25 mm2. A total of 5 airflow patterns with distinct features were captured, corresponding to adequate closure, adequate/borderline closure (Class I and II), borderline/inadequate closure, and inadequate closure. The maximal orifice area that could be tolerated for adequate VP closure was determined to be 2.01 mm2. CONCLUSION: Different VP functions are of characteristic airflow dynamic features. Computational fluid dynamic simulation is of application potential in individualized VP surgery planning.

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.

Evaluating the Accuracy of Using at Rest Images to Determine the Height of Velopharyngeal Closure.

Prior to performing secondary surgeries, lateral cephalograms have been used during phonation to evaluate the point of attempted velopharyngeal contact along the posterior pharyngeal wall relative to the palatal plane and the first cervical vertebra. The ability to quantify the height of velopharyngeal closure is an important aspect of planning corrective surgeries for velopharyngeal dysfunction. However, issues with patient compliance during the imaging process can present difficulties for obtaining adequate preoperative imaging data. The purpose of this study was to assess if the height of velopharyngeal closure can be accurately estimated and quantified from at rest images. Results demonstrate that the height of velopharyngeal closure above C1 can be accurately quantified using at rest images in children with cleft palate. No statistically significant difference was found between the measures obtained at rest or during sustained phonation images (P = 0.573). Thus, quantitative measures from at rest images can aid in the preoperative planning process by providing surgeons with a numeric distance for tissue insertion along the posterior pharyngeal wall above C1. This distance is correlated to the height of velopharyngeal closure and successfully placing tissue at this height is likely tied to improved postoperative speech outcomes.

Structural Changes Following Velopharyngeal Resistance Training (Continuous Positive Airway Pressure Therapy): A Preliminary Report.

OBJECTIVE: To evaluate the feasibility/effectiveness of using magnetic resonance imaging (MRI) to document velopharyngeal (VP) structural changes induced by continuous positive airway pressure (CPAP) therapy. OUTCOME MEASURES: Changes in velar length and thickness, levator veli palatini (LVP) length and thickness, velar volume, and intravelar muscular proportion along the course of CPAP therapy participation (Pre-CPAP, Post-CPAP, and withdrawal). RESULTS: Velar and LVP lengths remained nearly the same, with the median changes (Δ) less than 0.6%, across repeated conditions. Although varying in magnitudes of change, median velar volume (Δ4%), velar thickness (Δ20%), LVP thickness (Δ17%), and intravelar muscular proportion (Δ10%) illustrated a consistent pattern of increases following the 8-week CPAP therapy. These VP structural measurements slightly decreased but remained above the pretraining condition after 8-week detraining. CONCLUSIONS: This report successfully demonstrated that MRI is a viable tool to document CPAP therapy-induced VP structural changes while providing preliminary empirical data.

Contributions of the Musculus Uvulae to Velopharyngeal Closure Quantified With a 3-Dimensional Multimuscle Computational Model.

The convexity of the dorsal surface of the velum is critical for normal velopharyngeal (VP) function and is largely attributed to the levator veli palatini (LVP) and musculus uvulae (MU). Studies have correlated a concave or flat nasal velar surface to symptoms of VP dysfunction including hypernasality and nasal air emission. In the context of surgical repair of cleft palates, the MU has been given relatively little attention in the literature compared with the larger LVP. A greater understanding of the mechanics of the MU will provide insight into understanding the influence of a dysmorphic MU, as seen in cleft palate, as it relates to VP function. The purpose of this study was to quantify the contributions of the MU to VP closure in a computational model. We created a novel 3-dimensional (3D) finite element model of the VP mechanism from magnetic resonance imaging data collected from an individual with healthy noncleft VP anatomy. The model components included the velum, posterior pharyngeal wall (PPW), LVP, and MU. Simulations were based on the muscle and soft tissue mechanical properties from the literature. We found that, similar to previous hypotheses, the MU acts as (i) a space-occupying structure and (ii) a velar extensor. As a space-occupying structure, the MU helps to nearly triple the midline VP contact length. As a velar extensor, the MU acting alone without the LVP decreases the VP distance 62%. Furthermore, activation of the MU decreases the LVP activation required for closure almost 3-fold, from 20% (without MU) to 8% (with MU). Our study suggests that any possible salvaging and anatomical reconstruction of viable MU tissue in a cleft patient may improve VP closure due to its mechanical function. In the absence or dysfunction of MU tissue, implantation of autologous or engineered tissues at the velar midline, as a possible substitute for the MU, may produce a geometric convexity more favorable to VP closure. In the future, more complex models will provide further insight into optimal surgical reconstruction of the VP musculature in normal and cleft palate populations.

Sphincterplasty for Velopharyngeal Insufficiency in the Child Without a Cleft-Palate: Etiologies and Speech Outcomes.

The aim of this study is to report on speech outcomes following surgery for velopharyngeal insufficiency (VPI) on a broad spectrum of patients without a cleft palate. Inclusion criteria included patients without a cleft palate operated on by a single surgeon (JKW) over a 10-year period and postoperative speech evaluation within 1 year. All patients underwent a sphincter pharyngoplasty. The main outcome measures were perceptual speech assessment using a 6-point scale (1 = none or normal, 6 = severe); velopharyngeal function (VPF) (1 = adequate, 2 = marginal, 3 =  dequate); and quantitative nasalance score. Forty children (mean age 7.5 y) were included. Eight unique conditions were identified; the most common was 22q deletion syndromes (27.5%). All patients had a deep nasopharynx, mean nasopharyngeal depth >0.67. Two novel cases are presented in each child with mosaic Trisomy 14 and ring chromosome 18 abnormality. Of all patients, 87.5% improved their postoperative hypernasality score. Preoperatively, all patients had either marginal or inadequate VPF (2 or 3). Postoperatively, 90% of patients (n = 36) achieved adequate velar function, the remainder did not improve at the first postoperative evaluation. Intelligibility and audible nasal emissions improved in between 57% and 65% of patients. Articulation proficiency was the only perceptual rating not to improve initially, but then did so on the most recent postoperative speech evaluation. This study demonstrates successful speech outcomes in a diverse group of patients. It also increases awareness of noncleft VPI amenable to surgical correction.

The effect of sound intensity on velopharyngeal function in normal individuals.

OBJECTIVE: Velopharyngeal closure is an important physiological process contributing to the normal function of speech and swallowing. The aim of this study was to analyze the influence of sound intensity on velopharyngeal function in normal individuals. MATERIALS AND METHODS: Lateral cephalograms of 38 volunteers obtained at rest and during phonation of vowel /i:/ at both high and low sound intensity were carefully analyzed. The digital sound level meter was used to evaluate and record the sound intensity of the phonation process. The angular and linear parameters on the lateral cephalograms were then measured to reveal the correlation between sound intensity and velopharyngeal closure. RESULTS: All the angular parameter values measured in the study were significantly greater in high sound intensity condition. As for linear parameters, all values were found to be significantly larger at high sound intensity, except for the effective velopharyngeal length and the vertical velopharyngeal length. A multiple linear regression model was set up to describe the correlation between the sound intensity, the effective velopharyngeal length, and velopharyngeal closure. With the increase of sound intensity and the decrease of the effective velopharyngeal length, the width of velopharyngeal closure is enlarged. CONCLUSIONS: As one of the characteristic features of sound wave, the sound intensity was found to affect the objectively measured parameters of velopharyngeal closure on lateral cephalograms.

The combination of anatomy and physiology in predicting the outcomes of velopharyngeal surgery.

OBJECTIVES/HYPOTHESIS: To explore whether the variables resulting from anatomical and physiological examinations can be combined to predict the outcomes of velopharyngeal surgery for obstructive sleep apnea (OSA). STUDY DESIGN: Prospective design with a retrospective review. METHODS: A total of 119 patients with OSA received velopharyngeal surgery, including revised uvulopalatopharyngoplasty with uvula preservation and transpalatal advancement pharyngoplasty. The preoperative examinations of these patients, including polysomnography (PSG), physical examination, and three-dimensional computer tomography (3-D CT), were obtained for analysis. RESULTS: The overall success rate was 62.2%. Three factors were found to be predictive in treatment outcomes (P<0.05). These were tonsil size, the percentage of time with oxygen saturation below 90% (CT90), and the vertical distance between the lower edge of the mandible and the lower edge of the hyoid (MH). After changing CT90 and MH into level variables, another regression analysis was performed and the result suggested that all three level variables could be included. A scoring system was then created based on these three variables and their odds ratio values. The total scores of all patients were calculated by the following equation: Total score=2.7 tonsil size (score)+2.2 CT90 (score)+1.6 MH (score). The differences in success rates among patients with total scores of <14, 14 to 17, 17 to 22, and ≥22 were all significant (P<0.05). CONCLUSION: The anatomy of the pharynx and the physiology of OSA are both important in deciding outcomes of velopharyngeal surgery. Variables that could represent these two aspects can be combined to better guide patient selections. LEVEL OF EVIDENCE: 4.

Aging-related geniohyoid muscle atrophy is related to aspiration status in healthy older adults.

BACKGROUND: Age-related muscle weakness due to atrophy and fatty infiltration in orofacial muscles may be related to swallowing deficits in older adults. An important component of safe swallowing is the geniohyoid (GH) muscle, which helps elevate and stabilize the hyoid bone, thus protecting the airway. This study aimed to explore whether aging and aspiration in older adults were related to GH muscle atrophy and fatty infiltration. METHOD: Eighty computed tomography scans of the head and neck from 40 healthy older (average age 78 years) and 40 younger adults (average age 32 years) were analyzed. Twenty aspirators and 20 nonaspirators from the 40 older adults had been identified previously. Two-dimensional views in the sagittal and coronal planes were used to measure the GH cross-sectional area and fatty infiltration. RESULTS: GH cross-sectional area was larger in men than in women (p < .05). Decreased cross-sectional area was associated with aging (p < .05), and cross-sectional area was significantly smaller in aspirators compared with nonaspirators, but only among the older men (p < .01). Increasing fatty infiltration was associated with aging in the middle (p < .05) and posterior (p < .01) portions of the GH muscle. There was no significant difference in fatty infiltration of the GH muscle among aspirators and nonaspirators. CONCLUSION: GH muscle atrophy was associated with aging and aspiration. Fatty infiltration in the GH muscle was increased with aging but not related to aspiration status. These findings suggest that GH muscle atrophy may be a component of decreased swallowing safety and aspiration in older adults and warrants further investigation.