Velopharyngeal dysfunction and articulation disorders

Overview of cleft palate speech

• Velopharyngeal dysfunction -> hypernasality

• Nasal deformations -> blocked nasal airway -> hyponasality

  • E.g. septum deviations, baby may stick tongue into nose

  • Post-surgery, hyponasality may result from blocked nasal passage

•   Dentoalvolar anomalies (missing or misaligned teeth, malocclusion) -> obligatory artic errors

• Palatal Fistulae -> obligatory artic errors

• Hypernasality and nasal air loss -> unsuccessful articulatory attempts -> obligatory artic errors

  • These become active errors after surgery

  • Hypernasality and nasal air loss -> articulatory mislearning -> compensatory/active artic errors

• Often glottal and palatal sounds are used because they have control of these

• Velopharyngeal dysfunction -> middle ear effusion -> hearing loss

  • Levator not pulling to open the Eustachian tube

• Unrelated processes -> voice and fluency disorders, phonological disorders, developmental language disorders etc.

  • If cannot prove causal relationship to cleft palate

What is the purpose for velopharyngeal valving

• Ventilation of the middle ear

• Regulation of oral-nasal airflow

• Prevention of nasal regurgitation

• Prevention of pre-deglutitive aspiration

  • Can chew forever

• Contributes to bolus propulsion during swallowing

• Oral-nasal balance for speech articulation

Overview of the Nasal Tract

• Subdivided by nasal septum

• Also meatuses

  • Turbinates divide the meatuses

• Low frequency spectrum sounds come through the nose

• 2 large anterior cartilages

  • Septal is biggest

• Also has the vomer bone (sail bone)

Overview of the normal hard palate

• Trigeminal nerve comes through the papillae

• Midline raphe

• Past the last molar = pterygoid hamulus

What are the main velopharyngeal muscles

• tensor velar palatini

• levator velar palatini

• palatoglossus

• palatopharyngeus

• superior pharyngeal constrictor

• musculi uvulae

• salpingopharyngeus

What is the tensor velar palatini

• Changes direction by 90 degrees

• Primary Function: Opens ET

• Superiorly attached to sphenoid bone and lateral cartilage of the ET

• Slings around the hamulus pterygoids, which changes its direction of pull from vertical to horizontal

• Inferiorly it fans out and forms the palatine aponeruosis

• Secondary function – lateral stretch of the velum

• Innervated by the mandibular branch of CN5

What is the levator velar palatini

• Most important muscle for closing the velopharyngeal sphincter

• Superiorly attached to temporal bone and the medial cartilage of the ET

• Inferiorly forms the levator sling

• Primary function = velar elevation

• Secondary = open ET

• Innervated by the plexus pharyngeus/pharyngeal branch of CN10, and the glossopharyngeus

What is the palatoglossus

• Pulls the velum down

  • Seals oral cavity

• 1^st palatal arch

•   Helps make nasal sounds

• Superior attachment is the oral surface of the palatine aponeurosis

• Inferior attachment is the lateral posterior dorsum of the tongue

• Function: lowering the velum, dorsal elevator of the tongue

• Innervated by the plexus pharyngeus (CN10)

What is the palatopharyngeus

• Second palatal arch

• Brings pharyngeal walls medially

• Superior attachment is the palatine aponeurosis

• Inferior attachment is the lateral pharyngeal wall and posterior thyroid cartilage

• Function: medial displacement of the lateral pharyngeal walls, lowering velum

• Innervation: plexus pharyngeus (CN10)

What is the superior pharyngeal constrictor

• Tightens pharynx

• Originates from the pterygoid plate and the lateral fringes of the velum and runs along the pharyngeal walls to the median raphe

• Function: pharyngeal narrowing (naso and upper oropharyngeal segement)

• Innervation: pharyngeal plexus (CN10)

What is the musculi Uvuli

• Muscle pair, runs parallel to the velar midline into the mucous membrane of the uvula

• Function: intrinsic flexion and shortening of the velum, forms velar eminence (helps fill space between elevated velum and Posterior pharyngeal wall)

• Commonly small or absent in cleft palate patients

• Innervation: plexus pharyngeus

What is the salpingopharyngeus

• Originates from ET and inserts into the posterior aspect of the palatopharyngeus muscle

  • Blends into palatopharyngeus

• Thought to contribute to raising of the pharynx and larynx as well as ET opening

• Innervation: plexus pharyngeus

Diagram of VP muscles

Diagram 2 of VP muscles

What is the plexus pharyngeus

• A network of intersecting nerve fibers, composed of branches of the N. vagus X (motor), N. glossopharyngeus IX (sensation)

  • Some authors argue that the accessory (XI) and facial (VII) nerves also branch into the pharyngeal muscles

If you scope someone and they gag you’ve touched it

• Can induce tacycardia and heart arrest and tachypnoe

Continuum of VP closure

•   Yawning

• Speech

  • Narrow of nasopharynx, elevated velum

  • Whistling and blowing are similar

• Swallow

  • Lower velar elevation

  • Less closure of nasopharynx, but open below

Difference between male and female nasopharynx, child vs. adult

• Male nasopharynx is larger and wider than female

  • Makes need to elevate the velum higher and more posteriorly to achieve complete closure

  • Uvula muscle can help give extra elevation

Child vs. adult

• Nasal sinus is not fully developed in a child, so the nasopharynx is quite small

• Have to do less during speech

• In adults – the distance increases between the velum and posterior pharyngeal wall

• Kids also have adenoid pads

  • These decrease the distance between the velum and PPW further

What are the closure patterns of the VP sphincter

• Coronal

  • Velum goes up and does most of the closure

• Sagittal

  • Less frequent

  • The lateral pharyngeal walls move towards the midline

• Circular

  • Velum goes up and the lateral pharyngeal walls close a bit

• Circular with Passavant’s ridge          

  • Increased activity of the superior pharyngeal constrictor muscle supports velopharyngeal closure

  • In some cleft patients see this

  • Muscular bulge on the PPW on a patient with an unrepaired cleft

    • Hypertrophic superior pharyngeal muscle

  • Mainly in cleft palate

  • Passavant’s ridge = formed by an isolated contraction of a hypertrophic segment of the superior (or medial) pharyngeal constrictor muscle

Direct Methods of VP structure, morphological and functional analyses

• Direct visual inspection

• Endoscopy

• Multiview videofluroscopy

• MRI

  • Not standard, but emerging

Indirect Methods of VP structure, morphological and functional analyses

• Tongue anchor technique

  • Stick out tongue and puff cheeks

  • Really only tests if velum can go down

• Mirror test

  • Remove quickly before they stop

• I-a test

  • Say ee/a then close nose

  • Very coarse test for hypernasality

• Aerodynamic measurements

• Electromyography

• Oral inspection

Overview of FEEs, what might you see in 22q11

• If you see a concave velum on the scope -> may be a submucous cleft

• 22q11 -> velocardiofacial syndrome

  • May see pulses

  • Due to internal carotid artery being displaced medially

  • May die during operation

    • If you cut into the PPW and accidentally cut an artery

• Can also look at anterior posterior velar displacement

  • How far is the velum from the PPW

  • How much do the lateral walls come in

Overview of MRI

• Best but not common

• Can see whole levator loop

• In the late 80s there was a call for standardization of reporting

  • Measure the distance of velar elevation

  • E.g. 60% closure

• Lateral view – measurement of velar displacement in the anterior-posterior dimension

• Anterior posterior view – measurement of the lateral wall displacement

  • Posterior lateral walls move towards the velum

  • Each side is 50%

What are the 4 categories of VPI/VPD

• VP insufficiency

  • unrepaired clefts

  • post surgical insufficiency

• VP insufficiency (non cleft)

  • mechanical interference

    • tonsils, adenoid, Post. pillar web

  • palatopharyngeal disproportion

    • cervical anomalies

  • palatal lesions (e.g. cancer)

• VP incompetency: it is there but it doesn’t function

  • stroke

  • TBI

  • Congenital (CP, distrophies)

  • dysarthrias

  • Motor Programming → AoS

• VP mislearning: have a working one but don’t make use of it

  • PSNE

  • after post-op with sufficient closure nasal emission

  • compensatory misartic

  • deafness

Oral Nasal-Balance Disorders and Associated Observations Overview (what might you see)

• hypernasality

• hyponasality

• mixed nasality

Associated Obs:

• cul-de-sac

• nasal emission

• nasal turbulance

• nasal grimance

What is Hypernasality

Can be functional or organic

• Too much air and sound escape through the nose

• Non-nasal vowels and consonants are nasalized

  • Give non nasal test sentence (e.g. pick up the book)

• Organic etiology: Velopharyngeal insufficiency

  • Typically etiology is organic

• Nerve damage, velum too short

• Functional etiology: Velopharyngeal incompetence

  • Have working velum but doesn’t know how to use

Why is Hyponasality

Can also be functional (rare) or organic

• Too little air and sound travel through the nose

• Nasal consonants (and vowels) are denasalized

  • Use nasal sentence: my mum made lemon jam

• Organic etiology: Septum deviation, hypertrophic turbinates

• Functional etiology (rare): Protective reaction to autophonia

  • Autophonia = thickening of the ET (like in a really bad cold)

  • Speaker tends to be hyponasal

  • Palatous ET

  • Can happen during pregnancy

What is mixed nasality

• Combination of velopharyngeal dysfunction and a blocked nasal passage

• May occur in uni- or bilateral cleft lip and palate (VPI and septum deviation)

What is cul-de-sac resonance

• A confusing term, describing a muffled sound quality

• Sometimes used to denote severe anterior hyponasality

• Sometimes used to denote mixed nasality (combined hyper- and hyponasality)

• Subtypes:

  • It can be related to nasal cul-de-sac

  • Can have pharyngeal cul-de-sac

    • Yoda/hot potato

  • Oral form form of cul-de-sac

• Difficult to measure

what are the two kinds of nasal emission

2 Kinds:

• Nasal emission/nasal escape

  • Everything wide open

  • Audible sound of air coming out (with noise)

  • Laminar -> flowing through a tight space

  • Steady flow but audible

    • No noticeable turbulence

• Nasal turbulence/friction

  • High pressure through small opening

  • Velopharyngeal closure almost there

What is nasal emission generally, what is obligatory vs. learned

• Inaudible nasal emission (mirror test)

• Audible nasal emission

  • Audible (non-turbulent) emission

    • Usually related to a larger VP gap

  • Nasal turbulence

    • May indicate close VP approximation

    • Often interpreted as a counter-indication for secondary velopharyngeal surgery (pharyngeal flap, pharyngoplasty)

• Obligatory nasal emission

  • Structural velopharyngeal insufficiency

  • Oro-nasal fistula

  • Velopharyngeal incompetence related to neurological damage

• Learned nasal emission

  • VP mislearning

  • Phoneme specific nasal emission

  • Persisting postoperative nasal emission

What is nasal grimace

• Some hypernasal speakers with cleft lip and palate may show a visually distracting and unfavourable flaring of the nares

• Nasal grimace is interpreted as a subconscious compensatory attempt to reduce nasal escape