Anatomy: Cleft lip / palate

External ear, Middle Ear, Inner ear

• Pinna & External auditory canal

• Tympanic membrane & ET

• Cochlea, Organ of corti & semicircular canals

Nose & nasal cavity

*lip closed by 3 months (feeding)

*palate closed by 10 months b/c of growth

Naris = nostril

• upper lip

  • philtrum

  • philtral ridges/columns

  • cupid’s bow

  • white roll

  • vermilion

  • tubercle

Nose & nasal cavity

Nasal septum

• quadrangle septal cartilage

• vomer: fits in median palatine suture groove

• perpendicular plate of the ethmoid

Turbinates (choane/bone) & meatuses (hallway)

• superior , middle, inferior turbinates (Choane)

• superior, middle, inferior nasal meatuses

• paranasal sinuses

• *MIDDLE TURB BEST FOR ENT TO SEE, informs surgical processes (VP closure)

oral cavity

• hard palate

• alveolar ridge

• velum (soft palate)

• uvula

• tongue (dorsal & ventral surface)

• faucial pillars (ant & post)

• tonsils (palatine tonsils)

• PPW

Palate & pharynx

• hard palate (maxilla)

• velum (soft palate)

• ET

• tonsils

  • adenoid (pharyngeal tonsil)

  • tonsils (palatine tonsils)

  • lingual tonsil (base of tongue)
    
    

• epiglottis

• *sleep apnea, HYPO nasality, ET dysfunction w/ enlarged tonsils

Hard palate

• separates nasal cavity & oral cavity

• serves as roof of mouth and floor of nasal cavity

• palatal vault: dome on upper part of oral cavity

• alveolar ridge (alveolus): provides bony support for teeth

• *APERTS = high narrow arch

Hard palate: mucoperiosteum

• tissue that covers the hard palate

  • mucous membrane: lining of stratified squamous epithelium & lamina propria

  • periosteum: thick, fibrous tissue that covers bone

*right side is hard palate

hard palate: rugae

• ridges that run horizontally

• incisive papilla: projection of mucosa at area of incisive foramen (just behind central incisors)

• palatine (median) raphe: line from incisive foramen to uvula

hard palate: foramen

• hole or opening in a bony structure to allow blood vessels and nerves to pass through to the mucosa

• incisive foramen: in the area of alveolar ridge behind the central incisor, starting point of embryological development

hard palate: premaxilla

• triangular-shaped bone

• bordered by incisive foramen and incisive sutures

• 4 maxillary incisors

Hard palate: palatine processes of maxilla

• forms anterior 3/4th of maxilla

• two plates separated by median (intermaxillary) palatine suture

• nasal aspect of palatine suture forms groove for lower portion of vomer (nasal septum)

Hard palate: suture lines

• incisive suture lines

• median intermaxillary palatine suture

• transverse palatine palatomaxillary suture lines

hard palate: horizontal plates of the palatine bones

• posterior portion of the hard palate

• bordered by the transverse palatine suture lines

• meet in midline at the median palatine suture

• ends with the posterior nasal spine

Hard palate: torus palatinus (palatine torus)

• seen in some caucasians of northern european descent

• prominent longitudinal ridge on oral surface along intermaxillary suture line

• normal variation and usulaly not cause of the problem

Sphenoid & temporal bones

• medial & lateral pterygoid plates: part of pterygoid process of spehnoid bone

• pterygoid hamulus: inferior end of pterygoid plate

• both provide bony attachment for VP musculature

Velum (soft palate)

• consists of muscles & mucosa (no bone)

• attaches to hard palate

• median palatine raphe continues to uvula

• uvula attaches to posterior border

Velum: palatine velar aponeurosis

• consists of fibrous, connective tissue

• anchoring point for velar muscles

• provides stiffness

Uvula

• teardrop-shaped pendulum

• consists of mucosa, glandular, and adipose tissue

• very vascular

• no known function

Pharynx (throat)

nasopharynx: above velum

oropharynx: below velum

hypopharynx

posterior pharyngeal wall (adenoid tissue located behind velum)

Adenoid pad

• mass of lymphoid tissue

• located on PPW behind velum

• more prominent in children than adults

Eustachian tube

• connects middle ear with pharynx

• at horizontal angle in children under age 6

• at 45 degree angle in adults

ET

• pharyngeal tube opening is lateral & slightly above velum

• torus tubarius - ridge located posteriorly to ET

• Salpingopharyngeal folds - originate from torus tubarius and course down to lateral pharyngeal wall

• *empties into pharynx

VP closure

• coordinated 3 dimensional closure of structures

• valve like a sphincter

• close off nasal from oral

• * coronal most common

VP function

• regulates and directs transmission of sound energy and airflow in the oral and nasal cavities

• important for production of “pressure sensitive consonant sounds & all vowels”

• MOST Difficult = fricatives

VP function requires

• coordinated movement of the following structures

velum (soft palate)

lateral pharyngeal walls

posterior pharyngeal wall

velar movement

• moves in a superior & posterior direction

• kneeing action

• moves toward the PPW

• velar dimple - point of bend in the velum during contraction

• *incompetence: neurological

• *insufficiency: structural

LPW movement

• moves medially

• usually close against the velum

• sometimes close in midline behind the velum

PPW movement

• moves anteriorly toward velum

• has very little role

• passavant’s ridge - bulge of muscle on the PPW; occurs in some normal/abnormal speakers

muscles of VP closure

• levator veli palatini (velar sling)

• superior constrictor (pharyngeal ring)

• palatopharyngeus (posterior faucial pillar)

• palatoglossus (anterior faucial pillar)

• musculus uvulae (bulge on nasal surface)

• tensor veli palatini

Motor & sensory innervation

• pharyngeal plexus: network of nerves that lies along posterior wall of the pharynx and consists of the pharyngeal branches of the glossopharyngeal nerve CN IX and the vagus nerve CN X

Cranial nerves

• trigeminal V

• facial VII

• Glossopharyngeal IX

• Vagus X

• Accessory XI

• Hypoglossal XIII

Patterns of VP closure

• coronal: velum & PPW

• Sagittal pattern: LPW’s least common

• Circular pattern: all structures, passavant’s ridge

Pneumatic vs. Nonpneumatic activities

• nonpneumatic

• swallowing, gagging, vomiting

  • velum is raised high in pharynx

  • LPW close

  • want to prevent nasal regurgitation

• Pneumatic (using air pressure)

  • positive pressure (whistling, blowing, speech)

  • negative pressure (sucking, kissing)

During NONpneumatic

• entire length of LPWs move together with exaggerated movement

• closure is higher than with speech

SPEECH: greatest movement with high-pressure consonants

closure for speech are different DONT work on blowing/sucking to improve speech

Timing & height of closure

timing: valve closes before phonation begins typically, otherwise it will sound hypernasal

closure is maintained until a nasal consonant or the utterance is ended

HEIGHT: closure contact may vary with different sounds

higher and tighter with high vowels, and high pressure consonants, voiceless!

closure affected by rate / fatigue

firmness / rate / fatigue

FIRMNESS: varies with consonant, gap of 5mm (20mm2) is the threshold for hypernasality, even small gaps cause nasal emission

RATE/FATGUE: velar movement / closure decrease with rapid rate and fatigue, affects height and firmness of closure

changes w/ growth & age

• velum increases in thickness / length (velar stretch)

• maturation results in increased oral-motor coordination

• facial skeleton (hard & soft palate too) moves down and forward

• PPW bends forward

• Adenoid tissue decreases around puberty

• age 8-12 VPI

Subsystems for speech

• respiration

• phonation

• prosody (stress, rhythm, intonation)

• resonance & velopharyngeal function

• articulation

Respiration

• air pressure is required to initiate and sustain phonation

• vocal folds close

• psub builds

• vfs break open & vibrate

• pressure is released

• soft voice syndrome (less hypernasal perception)

breathing for vegetative purposes is different than breathing for speech, control breathing for phrasing

Speech breathing

quiet breathing in 40 out 60

speech breathing in 10 out 90

respiration provides

• airflow, converts to intraoral air pressure for articulation

• important for pressure sensitive (plosives, fricatives, affricates)

Phonation

• must be able to start and stop phonation quickly throughout an utterance

• e.g., a cup

prosody

stress & intonation

VP function

oral: velopharyngeal valve is closed

acoustic energy to enter oral cavity

important for the production of most consonant sounds (plosives, fricatives, affricates, vowels)

NASAL: velopharyngeal valve is open

allows most energy to enter nasal cavity (m, n, ng)

VP function: must open and close quickly and efficiently

articulation

vowels: produced by altering oral resonance

formant frequencies affected by: position of tongue/jaw/lips, size and shape of oral cavity

acoustics and vowel perception affected by formant frequencies

consonants

produced with partial or complete obstruction of oral cavity then release

usually produced with air pressure

manner of production

plosives: close oral cavity, build up air pressure, release suddenly (p,b,t,d,k,g)

fricatives: partially close oral cavity, build up air pressure, release gradually (f, v, s, z, sh, th, th)

affricates (ch, j)

subsystems

all subsystems need to be good team players

if one is not working, affects other players