Achieving Clinical Success in Nonsedated Velopharyngeal MRI: Insights for Optimal Data Quality & Effective Patient Selection.

BACKGROUND: The ability of MRI for in vivo visualization of the velopharyngeal (VP) musculature makes it the only imaging modality for this purpose. This underscores a need for exploration into clinical translation of this imaging modality on craniofacial teams. The purpose of this study was to assess outcomes of a clinically feasible VP MRI protocol and describe the ideal patient population for utilization of this imaging protocol. METHODS: Sixty children (2-12 years) with velopharyngeal insufficiency (VPI) underwent a nonsedated, child-friendly MRI protocol. No exclusions based on syndromic conditions were made. Logistic regression assessed predictors of VP MRI success and multinomial logistic regression evaluated factors influencing quality of anatomic data. RESULTS: An 85% overall success rate was achieved, including children as young as two and those with syndromic diagnoses. Stratifying by age revealed a 97.5% success rate in children ages four and up. The regression model [χ2(5) = 37.443, p < 0.001] explained 81.4% of success rate variance, correctly classifying 93.3% of cases. Increased age significantly predicted success (p=0.046), while sex and syndromic conditions did not. Multinomial regression identified preparatory materials (p=0.011) and audio/video during the scan (p=0.024) as predictors for improved image quality. CONCLUSIONS: Implementation of VP MRI is feasible for a broad population of children with VPI, including those with concomitant syndromic diagnoses. Quality is improved by incorporating pre-scan preparation and audio/visual stimuli during scans. This underscores the potential of VP MRI as a valuable tool in clinical settings, especially for pre-surgical assessments.

Measurement Matters: MRI Analysis of Differing Anatomic Measurement Techniques for Velar Length and the Velopharyngeal Needs Ratio.

Background: Advances in imaging tools provide opportunities to enhance how velopharyngeal (VP) variables are quantified to facilitate surgical decisions. The purpose of this study was to use magnetic resonance imaging (MRI) to determine if quantitative differences were present between measures of linear and curvilinear velar length, and subsequently, the VP needs ratio. Methods: Data were prospectively collected from patients presenting with repaired cleft palate and/or congenital palatal insufficiency with or without VPI at a single center tertiary children's hospital. Quantitative measures of the velopharynx using a novel nonsedated MRI protocol were obtained. Paired samples t tests were conducted to assess if differences were present between the VP needs ratio and measurements of linear and curvilinear velar length at rest and during sustained phonation. Intraclass correlation coefficients were calculated to assess intra/inter-rater reliability. Results: Significant differences were present between measurements of linear and curvilinear velar length at rest (P ≤ 0.001) and during sustained phonation (P ≤ 0.001). Significant differences were also present in the VP needs ratio (P ≤ 0.001). Curvilinear velar length at rest and during sustained phonation was longer than that of linear velar length at rest and during sustained phonation. No significant differences were observed between measures of effective velar length (P = 0.393). Conclusions: Measurement differences influence the VP needs ratio. This may have implications for comparisons to previously reported normative reference values and for those who are anatomically at risk for VPI. MRI provides an enhanced imaging modality to assess normative benchmarks and the anatomic variables used to define VP anatomy for clinical decision-making.

Continuing Education Needs of Speech-Language Pathologists for Assessing and Treating Children With Cleft Palate: A National Analysis Across Areas of Varying Population Density.

PURPOSE: The purpose of this study was to identify training gaps and continuing education (CE) needs for speech-language pathologists (SLPs) in evaluating and treating children with cleft palate across and among areas of varying population density. METHOD: An anonymous 35-question survey lasting approximately 10-15 min was created in Qualtrics based on a previously published study. The survey information and link were electronically distributed to American Speech-Language-Hearing Association (ASHA)-certified SLPs through ASHA listservs, social media, individual-state SLP organizations, and an e-mail list of publicly listed SLPs. A total of 359 survey responses were collected. RESULTS: Respondents varied in terms of age, type of certification, practice location, and clinical experience with cleft palate, with the largest percentage (46.7%) of respondents in a school-based setting. Only 28.5% reported currently feeling comfortable treating children with cleft palate. Respondents reported conventions/conferences (25.4%) and webinars (23.2%) were the most helpful resources, but DVDs were frequently not used for CE. Information from the child's cleft team (84.4%) and mentors/colleagues (70%) were considered high-quality resources. Respondents indicated information on treatment of articulation (79.2%) and resonance (78.4%) disorders as well as specific therapy techniques (76.9%) would be very helpful for clinical practice. Population density significantly influenced how respondents ranked the perceived helpfulness and quality of different resources as well as desired topics for future resources. CONCLUSIONS: There is a continued need for adequate training and CE opportunities for SLPs, particularly related to assessing and treating children with cleft palate. Increased access to high-quality CE resources will be key to filling educational gaps present for SLPs, especially in areas of low-population density. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24891423.

Where is the Care? Identifying the Impact of Rurality on SLP Caseloads and Treatment Decisions for Children with Cleft Palate.

Challenges providing cleft/craniofacial care in rural communities are often reported, leading to disparities in resources available to clinicians. The purpose of this study was to identify the impact of rurality on caseloads and practice patterns of speech-language pathologists (SLPs) regarding speech and velopharyngeal function for children with cleft lip and/or palate (CL/P).A national, survey of US-based SLPs (N = 359 respondents) investigated resources, comfort level, caseloads, and practice patterns for children with CL/P. Sub-county classifications that delineated levels of rurality were utilized. Descriptive statistics and chi-square analyses were conducted to determine the impact of population density on assessment and referral decisions.Nearly 83% of SLPs reported providing care for a child with CL/P and 41.4% of these SLPs reported five or more children with CL/P on caseload throughout their career. There were no significant differences in rurality of practice setting and the likelihood of treating a child with CL/P. Significant differences were present between rural, town, suburban, and metropolitan-based SLPs regarding available resources (p = 0.035). SLPs in rural settings reported feeling uncomfortable treating children with CL/P compared to those in metropolitan settings (p = 0.02). Distance to the cleft/craniofacial team and comfort levels impacted referral decisions.Most SLPs report having children with CL/P on caseload regardless of practice location. Rurality impacted assessment and referral decisions, especially surrounding access to resources and comfort levels engaging in team care. Findings have implications for developing support systems and reducing barriers for rural SLPs working with children born with CL/P.

Incorporating Velopharyngeal MRI into the Clinical Decision-Making Process for a Patient Presenting with Velopharyngeal Dysfunction Following a Failed Palatoplasty.

This clinical report describes the implementation of magnetic resonance imaging (MRI) to evaluate a patient with long-standing velopharyngeal dysfunction. She was referred to the craniofacial clinic at age 10 with no prior surgical history and subsequently completed a Furlow palatoplasty due to a suspected submucous cleft palate. However, results were unfavorable with minimal improvement in speech or resonance. The clinical presentation, treatment, outcomes, and contributions from MRI for secondary surgical planning are described. Addition of MRI into the clinical workflow provided insights into the anatomy and physiology of the velopharyngeal mechanism that were unable to be obtained from nasendoscopy and speech evaluation alone.

Magnetic Resonance Imaging for Assessing Velopharyngeal Function: Current Applications, Barriers, and Potential for Future Clinical Translation in the United States.

OBJECTIVE: The use of magnetic resonance imaging (MRI) in the assessment process for children with cleft/craniofacial conditions remains uncommon, particularly for velopharyngeal assessments. The purpose of this study was to analyze the perceived clinical utility of MRI for cleft/craniofacial providers and identify barriers that exist for clinical translation of this imaging modality to this population of patients. METHODS: A 38-item survey was disseminated to craniofacial team providers. Workplace context and demographics, MRI as a research and clinical tool, access and barriers for use of MRI, and needs for successfully establishing MRI protocols at clinical sites were investigated. Descriptive statistics were used to identify differences in the clinical use of MRI across disciplines. Chi-square analyses were conducted to determine how different specialties perceived potential barriers. RESULTS: Respondents reported that MRI is likely to be beneficial for clinical assessments (93.5%) and that this imaging modality is available for use (83.8%). However, only 11.8% of providers indicated the use of MRI in their clinical assessments. This discrepancy highlights a potential disconnect between perceived use and implementation of this imaging methodology on cleft and craniofacial teams. A number of barriers were identified by providers. Challenges and opportunities for clinical translation of MRI protocols were highlighted. CONCLUSION: Results may guide the development for improved clinical feasibility and implementation of MRI for clinical planning in this population of patients. Reported barriers highlight additional areas for translational research and the potential for the development of clinical tools related to MRI assessment and protocol implementation.

Utilization of 3D MRI for the Evaluation of Sphincter Pharyngoplasty Insertion Site in Patients With Velopharyngeal Dysfunction.

Sphincter pharyngoplasty is a surgical method to treat velopharyngeal dysfunction. However, surgical failure is often noted and postoperative assessment frequently reveals low-set pharyngoplasties. Past studies have not quantified pharyngoplasty tissue changes that occur postoperatively and gaps remain related to the patient-specific variables that influence postoperative change. The purpose of this study was to utilize advanced three-dimensional imaging and volumetric magnetic resonance imaging (MRI) data to visualize and quantify pharyngoplasty insertion site and postsurgical tissue changes over time.A prospective, repeated measures design was used for the assessment of craniometric and velopharyngeal variables postsurgically. Imaging was completed across two postoperative time points. Tissue migration, pharyngoplasty dimensions, and predictors of change were analyzed across imaging time points.Significant differences were present between the initial location of pharyngoplasty tissue and the pharyngoplasty location 2 to 4 months postoperatively. The average postoperative inferior movement of pharyngoplasty tissue was 6.82 mm, although notable variability was present across participants. The pharyngoplasty volume decreased by 30%, on average.Inferior migration of the pharyngoplasty tissue was present in all patients. Gravity, scar contracture, and patient-specific variables likely interact, impacting final postoperative pharyngoplasty location. The use of advanced imaging modalities, such as 3D MRI, allows for the quantification and visualization of tissue change. There is a need for continued identification of patient-specific factors that may impact the amount of inferior tissue migration and scar contracture postoperatively.

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.

Effect of motor-based speech intervention on articulatory placement in the treatment of a posterior nasal fricative: a preliminary MRI study on a single subject.

BACKGROUND: Posterior nasal fricatives are a learned compensatory articulation error and commonly substituted for oral fricatives. Treatment of such articulation errors requires the modification or teaching of skilled movements. A motor-based approach is designed to teach the complex motor skill movement sequences required in the production of sounds. Although motor learning research is well established, little has been done to determine how the approach changes the underlying physiology of articulatory movements. While the underlying anatomical configuration of the posterior nasal fricative has been described, no studies have quantified anatomic and physiological changes pre- and post-treatment. AIMS: To use magnetic resonance imaging (MRI) to visualize and quantify the results of motor-based speech-intervention approach on articulatory placement for the treatment of the posterior nasal fricative. METHODS & PROCEDURES: A 6-year-old male with a history of ear infections and posterior nasal fricative substitution for /s/ underwent six 1-h sessions of a motor-based treatment approach over the course of 2 weeks. Pre- and post-treatment evaluation included perceptual and instrumental assessment of speech and resonance. Perceptual resonance was rated by two speech-language therapists and articulation was assessed at the single-word level. Instrumental assessment included the See-Scape, Nasometer II and MRI during the sustained phonation of /s/. Amira v5.6 Visualization and Volume modelling software used the midsagittal and oblique coronal plane to measure dimensions of the articulatory anatomy. OUTCOMES & RESULTS: Interrater reliability was assessed using a Pearson product moment correlation (α = .05) and ranged from r = .91 to .95. Intra-rater reliability was assessed using the intra-class correlation coefficient (.976) demonstrating a high degree of reliability with a 95% confidence interval. Articulation improved from 0% accuracy for /s/ in isolation at baseline to 100% for /s/ at the word level and 95% accuracy during conversational speech by session 6. Post-treatment results from this study revealed a greater shortening of the levator veli palatini (levator) muscle length during articulatory movements, more pronounced velar knee and dimple, decreased velar thickness, increased velar length and altered tongue position. CONCLUSIONS & IMPLICATIONS: This study demonstrated the use of pre- and post-treatment imaging methodology to quantify articulatory changes following an intensive motor-based treatment approach. MRI demonstrated quantifiable changes in articulatory placement. Individuals who exhibit non-developmental and phoneme-specific articulation errors, such as the posterior nasal fricative, may be excellent candidates for short-term, intensive and frequent speech therapy sessions to remediate the production of the posterior nasal fricative.

Changes in the Height of Velopharyngeal Closure Relative to the Cervical Spine From Infancy Through Adolescence in Patients With Cleft Palate.

OBJECTIVE: Palpation is often used to identify C1, an intraoperative landmark, for placement of the pharyngoplasty. However, little is known about the relationship between the palatal plane (PP) and this cervical spine landmark across select variables. This study seeks to analyze variations in the height of velopharyngeal closure relative to C1 across differing cleft types and age groups. DESIGN: Retrospective, cross-sectional analysis. SETTING: Large, multidisciplinary center for craniofacial disorders. METHODS: Clinical lateral cephalograms were analyzed in nonsyndromic patients who underwent primary palatoplasty. Regression analysis and analysis of covariance were completed to determine how age and cleft type impact underlying cervical and velopharyngeal measures. RESULTS: Age ( P < .001) and cleft type ( P = .036) were significant predictors of the distance between the height of velopharyngeal closure and C1. Those with greater severity of clefting demonstrated larger distances between the height of velopharyngeal closure and C1. Compared to normative data, children with cleft palate have significantly larger distances between the PP and C1. The height of velopharyngeal closure above C1 was observed to range from 3.6 to 12.6 mm across cleft populations. CONCLUSIONS: This study demonstrates the variability in C1 as a landmark across variables including cleft type and age. Because of differences in the height of velopharyngeal closure across cleft types relative to C1, it is necessary to preoperatively quantify the vertical distance between the PP and palpable intraoperative landmark, C1, to determine the appropriate height of pharyngoplasty insertion.

Relationship Between Age and Diagnosis on Volumetric and Linear Velopharyngeal Measures in the Cleft and Noncleft Populations.

The purpose of this study was to create a 3D volumetric segmentation from magnetic resonance imaging (MRI) of the nasopharyngeal space and adenoid tissue and to examine the relationship between nasopharyngeal volume (NPV), adenoid volume, and linear measures of the velopharyngeal structures, pharynx, and vocal tract in children with and without cleft palate. A total of 24 participants including 18 typically developing children (4-8 years of age) and 6 children (4-8 years of age) with varying degrees of cleft palate were imaged using MRI. Linear and volumetric variables varied significantly based on age. Overall, NPV demonstrates a modest increase with age. Nasopharyngeal volume was positively correlated with age (P = 0.000), oronasopharyngeal volume (P = 0.000), velar length (P = 0.018), and velar thickness (P = 0.046). These variables tend to increase together. Differences in NPV between groups (bilateral cleft lip and palate, submucous cleft lip and palate, unilateral cleft lip and palate [UCLP], and noncleft) were statistically significant (P = 0.007). Participants with bilateral cleft lip and palate demonstrated greater NPVs than those with UCLP and submucous cleft palate.

Age-Related Changes Between the Level of Velopharyngeal Closure and the Cervical Spine.

The primary focus of this study was to assess age-related changes in the vertical distance of the estimated level of velopharyngeal closure in relation to a prominent landmark of the cervical spine: the anterior tubercle of cervical vertebra 1 (C1). Midsagittal anatomic magnetic resonance images were examined across 51 participants with normal head and neck anatomy between 4 and 17 years of age. Results indicate that age is a strong predictor (P = 0.002) of the vertical distance between the level of velopharyngeal closure relative to C1. Specifically, as age increases, the vertical distance between the palatal plane and C1 becomes greater resulting in the level of velopharyngeal closure being located higher above C1 (range 4.88-10.55 mm). Results of this study provide insights into the clinical usefulness of using C1 as a surgical landmark for placement of pharyngoplasties in children with repaired cleft palate and persistent hypernasal speech. Clinical implications and future directions are discussed.