CSD 318 Craniofacial Anomalies

label a, b, c, d in order

ala base, ala rim, cupid’s bow, tubercle

label e, f, g, h in order

nasal tip, columella, philtral ridges, philtrum

label a, b, c in order

adenoid/pharyngeal tonsil, palatine tonsil, lingual tonsil

label a, b, c, d in order

hard palate, velum, uvula, palatine tonsil

label e, f, g in order

alveolar ridge, anterior faucial pillar, posterior faucial pillar

label a, b, c in order

levator veli palatine (LVP)

tensor veli palatine

musculus uvulae

label d, e

palatoglossus

palatopharyngeus

label a, b, c in order

lateral pharyngeal wall

posterior pharyngeal wall

lateral pharyngeal wall

label d, e, f, g in order

posterior pharyngeal wall

lateral pharyngeal wall

velum

lateral pharyngeal wall

label a, b, c, d, e in order

palatine process of maxilla

palatine bone

velum

uvula

premaxilla

label f, g, h, i, j in order

incisive foramen

incisive suture

median palatine suture

transverse palatine suture

posterior nasal spine

label blue, yellow, and green areas in order

nasal cavity

pharynx

oral cavity

velar aponeurosis

insertion point for velar muscles

adenoids

pharyngeal tonsils

assist with VP closure due to location on posterior pharyngeal wall

apraxia

can cause velopharyngeal incompetence because it is a neurological disorder

mixed resonance can result from this

palatine tonsil

contain lymphoid tissue and assist in fighting infection particularly from 0-2

prone to hypertrophy in young children

atrophy almost completely by age 16

teratogen

any agent that can cause birth defects or developmental abnormalities

primary palate

upper lip, premaxilla, and front of hard palate

secondary palate

hard and soft palate

obligatory errors

child is using incorrect placement, attempting VP closure, and otherwise doing things correctly but the sound is not right

an unrepaired cleft can cause hypernasality, weak oral pressure, nasal emissions, /s/ distortions

speech therapy will not help, surgery is needed

compensatory errors

due to compensation for abnormal VP oral structure

if the structure has been repaired, therapy can help. if surgery is delayed, treatment can help with placement but surgery is recommended

hypernasality

too much resonance in the nasal cavity

hyponasality

too little resonance in nasal cavity due to a nasal blockage or inability to open VP on nasal sounds

cul-de-sac resonance (oral, nasal, & pharyngeal)

a “blocked” sound, as if something is taking up too much of the oral/nasal cavity or pharynx (often related to large tonsils)

mixed resonance

a combination of two or more other types of resonances

velopharyngeal mislearning

VP has appropriate structure and ability to function typically, but speaker is using VP in an atypical way

compensatory errors become this after a repair

therapy can help

direct instrumental procedures

provide direct visualization of the structures of the velopharyngeal valve during speech

includes videofluoroscopy and nasopharyngoscopy

important to determine the cause and location of VPI

indirect instrumental procedures

give objective information regarding physical correlates of velopharyngeal function (acoustics, airflow, and air pressure)

includes nasometry and aerodynamics

important for pre and post objective measures of resonance and speech

nasometry

measures acoustic correlates of resonance and nasal emission to infer VP function

nasalance score = nasal acoustic energy/total acoustic energy

fiberoptic endoscopy evaluation of swallowing (FEES)

like a nasopharyngoscopy but instead of speech you are viewing swallowing

videofluoroscopy

radiological technique used to obtain real-time moving images of internal structures

to visualize speech and/or swallowing

can see entire length of velum and depth of pharyngeal wall

speech aerodynamics

use equipment to measure airflow and air pressure through nose during speech

infer VP opening size or obstruction (more pressure = smaller opening)

nasopharyngoscopy

direct visual observation and analysis of the velopharyngeal mechanism during speech

only view that can see the nasal surface of the velum

same thing as a laryngoscopy (light source, flexible fiberoptic endoscope)

auditory feedback/biofeedback

motor learning

acquisition of motor skills to execute complex motor movements and sequences

results in development or change or refinement of speech sound production

(playing an instrument, sport, performing dance steps)

motor memory

develops automaticity of newly learned movements

dependent on constant repetition

makes new learning relatively permanent

torus palatinus

prominent longitudinal ride on oral surface along median palatine raphe/suture

normal variation and usually does not cause problems

passavant’s ridge

bulge or ride that can form on the PPW during speech and swalloging

describe the jobs of the main muscles of velopharyngeal opening/closure as well as the tensor veli palatini

levator veli palatini: velar sling, primary muscle of velar elevation, pulls velum up and back to seal off nasopharynx

superior constrictor: constricts lateral and posterior pharyngeal walls against velum to close VP complex

palatopharyngeus: pull LPWs medially and upward for VP closure/narrowing

palatoglossus: main antagonist to LVP, depresses velum for nasal consonants and can elevate tongue

musculus uvulae: bulges to assist with closure of nasopharynx

tensor veli palatini: opens eustachian tube for middle ear drainage

describe the pneumatic vs nonpneumatic activities of the VP

pneumatic involve actions that create air pressure (blowing or whistling)

non-pneumatic activities do not create pressure (sucking or swallowing)

describe how timing, height, and firmness of VP closure varies according to activity and why

valve closes before phonation begins or sound will be hypernasal; closure is maintained until nasal consonant or utterance is ended

closure contact may vary with different sounds; closure is higher and tighter with high pressure consonants, especially voiceless consonants; closure can be affected by rate and change

varies with consonant; gap of 5 mm is threshold for hypernasality; even very small gaps can cause audible nasal air emission

describe and define resonance and articulation

sound quality is affected by changes in sizes of the pharynx and oral cavity which is caused by velopharyngeal opening/closure (vowels)

moving of the articulators to produce different speech sounds (consonants)

describe VP function for nasal vs non-nasal sounds (be able to hypothesize different speech sounds from pictures of the pharynx, oral, and nasal cavities)

closes off the nasal cavity from the oral cavity to regulate and direct transmission of sound energy and airflow in the oral and nasal cavities

oral sounds: valve is closed, allowing acoustic energy to enter oral cavity. important for most consonants and all vowels

nasal sounds: valve is open, allowing most acoustic energy to enter nasal cavity, important for n, m, and ng

main endogenous and exogenous factors that can cause clefts

endogenous: syndromes, chromosomal disorders, genetic disorders

exogenous: drugs, viruses, teratogens, nutritional deficiencies, mechanical interference

when do the primary and secondary palate begin to develop and close

primary: 6-8 weeks

secondary: 9-12 weeks

describe the pattern of closure of the primary and secondary palate

primary: forward to form the alveolar ridge and then the lip

secondary: backward to form the hard palate and the velum

state the structural and functional effects of clefts of the primary palate

gap in the lip/upper gum

can cause difficulties with feeding, speech, hearing, and dental development

compare an overt vs occult submucous cleft

overt clefts are visible, often presenting with a bifid uvula, notch, and zona pellucida

occult submucuous clefts lack readily observable signs

describe the functional consequences of a submucous cleft

underlying muscles do not fully fuse even though surface looks normal

impacts speech, feeding, and hearing

describe the prevalence of cleft lip/palate generally

about 1 in 700

describe the unique characteristics of infant feeding anatomy

tongue fills the mouth, sucking pads, smaller mandible, epiglottis and velum touch, higher larynx, narrow vertical epiglottis

indicate the importance of suck-swallow-breathe coordination in feeding

this coordination is important so they can feed continuously

disrupted coordination can cause fatigue, poor intake, airway compromise, oxygen desaturation, negative feeding experiences, and distress

how are breast and bottle feeding impacted by cleft palate and why it’s less likely to be impacted by cleft lip

cleft palate causes difficulty with creating negative pressure which is needed for sucking

cleft lip may cause difficulty creating a seal, but this is more easily remedied through angles and types of bottles

describe resonance and articulation and how they interact with airflow

resonance refers to the amplification and modification of sound waves by the vocal tract

articulation involves shaping the sound waves into specific sounds

how is resonance typically adjusted or changed

compare velopharyngeal insufficiency, dysfunction, incompetence, and mislearning

dysfunction is any abnormal function of the velum

insufficiency is an anatomical or structural defect that prevents adequate VP closure by causing the velum to be short relative to the PPW

incompetence is a neuromotor problem resulting in poor movement of VP structure

mislearning is inadequate VP closure due to faulty learning of appropriate articulation patterns

describe the effects of VPI on resonance and speech

disrupts normal speech resonance and articulation by causing an opening between the nasal and oral cavity

list and describe the types of nasal emissions

inaudible: large VP gap, short utterance length, weak or omitted consonants

audible: small VP gap, air burst through nose on unvoiced pressure consonant sounds (consistent)

nasal rustle: small/tiny VP gap, rustling sound through nose on unvoiced pressure consonant sounds (inconsistent)

phoneme specific: mislearning

justify why an orofacial examination is important to an evaluation

determine if there are structural anomalies that could indicate a craniofacial syndrome

determine the cause of what you hear (obligatory, compensatory, or mislearning)

determine whether further assessment is needed if you are unsure about the cause

describe the basic components of an orofacial examination

examine the tongue, palatine tonsils, velum/uvula, alveolar ridge, hard palate, teeth

evaluating for hypertrophic tonsils, clefting of the hard palate, fistulas, missing teeth, malocclusions, median raphe, consistent pinkish color of the velum

how does surgery for VPI differ from palate and lip repairs? when does each take place?

lip (2-6 months) and palate repair (10-12 months): goal is to optimize facial, oral, and palate structures to facilitate feeding, speech, dentition, facial profile, and aesthetics

describe VP function: velum

moves in a superior and posterior direction

has a type of “knee action”

moves toward the posterior pharyngeal wall

describe vp function: lateral pharyngeal wall

moves medially

usually close against the velum

sometimes close in midline behind velum

describe VP function: posterior pharyngeal walls

moves anteriorly toward the velum

Passavant’s ridge is a bulge of muscle seen here

describe the connection between eustachian tube and velopharynx and differences in kids vs adults

connect middle ear to pharynx and is horizontal in children under 6

(45 degree angle in adults)

Pierre Robin Sequence

caused by genetic factors, in utero constriction leads to mechanical changes to the orofacial structure, medication exposures

associated with difficulty breathing and feeding, cleft palate, hearing probelms, and orthodontic difficulties (small lower jaw and overcrowding teeth)

Treacher Collin’s Syndrome

due to gene alteration

associated with unique facial features (bones of skull join together prematurely), cleft palate, hearing loss, breathing difficulties