PMI Exam 1

Location of Nasal Bridge, Nasal Tip, and Columella

Nasal Septum Anatomy

• Quadrangle septal cartilage

• Perpendicular plate of the ethmoid

• Vomer

Vomer

perpendicular structure that fits in median palatine suture groove

Turbinates and Meatuses

• Superior, middle, inferior turbinates: sense of smell (mountains)

• Superior, middle, inferior meatuses (valleys)

• Paranasal sinuses

Lip Anatomy

• Cupid’s Bow

• Philtrum

• Vermillion Border

• Tubercles

• Oral commissures

What is the muscle that surrounds the mouth?

Orbicularis oris

Hard palate anatomy: premaxilla

Hard palate anatomy: Maxilla, palatine process

Hard palate anatomy: Horizontal plate of palatine bone

Hard palate suture anatomy: incisive

blue line

Hard palate suture anatomy: median palatine

yellow line

Hard palate suture anatomy: transverse palatine

orange line

Soft Palate anatomy: uvula

Soft Palate anatomy: palatine tonsils

Soft Palate anatomy: oropharynx

Primary Palate and Secondary Palate Locations

What are the main muscles of the VP valve?

• Levator veli palatini

• Superior constrictor

• Palatopharyngeus

• Palatoglossus

• Musculus uvulae

• Tensor veli palatini

Which muscle is the levator veli palatini?

Which muscle is the Superior constrictor?

Which muscle is the Palatopharyngeus?

Which muscle is the Palatoglossus?

Which muscle is the Musculus uvulae?

Which muscle is the Tensor veli palatini?

Which VP closure closes velum to posterior pharyngeal wall?

Coronal

Which VP closure closes using the lateral pharyngeal walls and velum?

Sagittal

Which VP closure uses all the structures to close?

Circular

Cleft

Abnormal opening or fissure

When does everything fuse together by?

12 weeks

What structures can a cleft affect?

Lips, Palate, or both

Types of Clefts include:

• Isolated vs Combination

• Incomplete vs Complete

• Unilateral vs Bilateral vs Midline only

Isolated vs Combination meaning

Isolated = cleft lip only or cleft palate only

Combination = both clef lip and palate

Incomplete vs Complete meaning

Incomplete = not full opening, Complete = all the way to incisive foramen

Unilateral vs Bilateral vs Midline only

Unilateral = one side, Bilateral = both sides, Midline = on midline

Where does a primary cleft occur in the mouth?

Front of mouth, structures anterior to incisive foramen: alveolar ridge, lip

Primary Cleft info

• Form at 7 weeks

• Types: complete/incomplete, unilateral/bilateral

Where does a secondary cleft occur in the mouth?

Back of mouth, structures posterior to incisive foramen: Hard palate, velum, uvula

Secondary Cleft info

• Form at 9 weeks

• Types: complete/incomplete, midline only

What structures are involved in a Primary cleft?

• Cleft of orbicularis oris

• Wide, flat nose with spreading nasal ala

• Short columella (tissue that divides nostrils)

• Abnormal dentition (teeth development)

How does a Primary cleft impact function?

• Specific articulation errors

• Resonance affected

• Feeding issues

What structures are involved in a Secondary cleft?

• Absent velar aponeurosis (can’t assist with VP closure)

• Altered insertion of the levator velar muscle (interferes w/ VP close)

• Abnormalities in nasal septum (breathing issues)

How does a Secondary cleft impact function?

• VP insufficiency + hypernasal speech

• Feeding problems and nasal regurge

• Eustachian tube malfunction

Cleft palate causes are described as?

Multifactorial

What are the multifactorial causes of the cleft palate?

• Teratogens: chemical agents that interfere with embryonic development

• Environment: lead, radiation, pollution

• Drugs and ingested substances

• Viruses: rubella, influenza

• Maternal nutrition: nutritional deficiencies or obesity with diabetes

• Physical interference: crowding in utero that restricts mandibular growth

Syndrome

a pattern of multiple malformations in many individuals which is genetically related

Sequence

series of anomalies that results from a single cause

Association

pattern of multiple malformations in many individuals with no known genetic cause

What causes Pierre Robin Sequence?

Micrognathia

What is micrognathia?

 A deformation as a result of physical forces that inhibit mandibular growth in utero

What is the main issue in Pierre Robin Sequence?

• mandible does not grow down and forward

• tongue remains in superior/posterior position

• palatal shelves cannot move into a horizontal position and fuse because of interference

Characteristics of Pierre Robin Sequence?

• airway obstruction

• tongue in pharyngeal space

• negative pressure -> pharyngeal collapse

• feeding issues

• hearing loss

• VP insufficiency

What syndromes/genetic disorders are associated with Pierre Robin?

Fetal Alcohol Syndrome, Stickler Syndrome, Glossoptosis

What is Fetal Alcohol Syndrome?

• short fissures

• missing philtrum

• thin upper lip

• micrognathia

• ear anomalies

What is Stickler Syndrome?

• wide, flat face

• myopia

• eye abnormalities

• hearing loss

• skeletal abnormalities

What is Glossoptosis?

Posterior displacement of the tongue in nasopharynx

Facial, Oral, Pharyngeal Anomalies impact?

• aesthetics and function

• abnormalities of the ear, nose, and throat

  • affect the quality and intelligibility of speech

Ear abnormalities/malformations include:

• External Ear (conductive HL)

  • Aural atresia

  • Microtia

• Middle Ear (conductive HL)

  • Absent, hypoplastic ossicles, tympanic membrane

• Inner Ear (sensorineural HL)

  • Malformations in the cochlea, vestibular system, auditory nerve

The external ear abnormalities are?

• Aural atresia (absence of external auditory canal)

• Microtia (under-developed pinna; small auricle)

The middle ear abnormalities are?

Absent, hypoplastic ossicles, tympanic membrane

• Affects transmission of sound

• treatment = hearing aids/surgery

The inner ear abnormalities are?

Malformations in the cochlea, vestibular system, auditory nerve

• Can be independent of other abnormalities

• treatment = hearing aids, cochlear implants

How is the Eustachian tube different in kids than adults?

• Kids are less sloped

• Tube falls into place after 6

  • prior: causes middle ear effusion, acute otitis media

Nose Abnormalities include:

• Anterior obstruction: due to stenotic nares (narrow), deviated septum, PAS

  • cause hyponasality

• Posterior obstruction: due to choanal stenosis, artesia, enlarged adenoids

  • cause hyponasality + cul-de-sac resonance

Maxilla Abnormalities include:

• Maxillary retrusion/mid-face deficiency

  • cuases crossbite (class III), air restriction, hyponasality

Upper Lip Abnormalities include:

• Short upper lip

  • caused by cleft palate repair, congenital abnormality

  • effects: difficulty with bilabials, possible chewing and swallowing

Mouth Abnormalities include:

• Macrostomia: large mouth

  • no affect on speech

• Microstomia: small mouth

  • mumbling speech

Tongue Abnormalities include:

• Macroglossia: big tongue; open-mouth posture, airway obstruction

  • Causes bilabials, labiodentals, frontal and lateral lisps, palatal-dorsal articulation for lingual-alveolar sounds.

  • Affects resonance since no room in mouth

• Microglossia: small tongue

  • issues if tongue cannot reach alveolar ridge

• Lobulated Tongue: extra lobes on tongue

  • no affect on speech

• Ankyloglossia: tongue tie; can’t protrude tongue tip past the edge of the mandibular incisors

Palate Abnormalities include:

• Palatal Fistulas: abnormal opening in line of cleft, tongue can push airflow into opening during speech

  • causes nasal emission regurge in the nostrils, speech-nasality issues, backing sounds

Tonsillar Hypertrophy/enlarged tonsils issues include:

• Palatine: causing cul-de-sac resonance, nasal emission, fronting

• Adenoid: hyponasality, nasal emission, sleep apnea, conductive HL, facial malocclusion

• Lingual: rare; cul-de-sac resonance

Laryngeal Anomalies include:

• Laryngomalacia: softening of tissues around larynx; constantly moving

• Vocal fold paralysis: unilateral/bilateral

  • breathy quiet speech

• Laryngeal web: soft tissue over VF

  • noisy speech, breathy voice, hoarsness

• Vocal fold nodules: bumps on VF

  • sound hoarsness

What is Class I occlusion?

Normal; Mesiobuccal cusp of the first maxillary molar fits in the buccal groove

What is Class I malocclusion?

• Maxillary and mandibular arch = normal, teeth are misaligned

• Speech effect: only if teeth are linguoverted (in the way of tongue tip)

What is Class II malocclusion?

• Mandible too far behind maxilla (overbite)

• Speech effect: affect anterior sounds, backing of sounds to compensate

What is Class III malocclusion?

• Mandible too far forward (underbite)

• Speech effect: lateral distortion, fronting, anterior crossbite

What type of occlusion or malocclusion is this?

Class I occlusion

What type of occlusion or malocclusion is this?

Class I malocclusion

What type of occlusion or malocclusion is this?

Class II malocclusion

What type of occlusion or malocclusion is this?

Class III malocclusion

Speech requires what 2 things?

Sound and airflow

What is sound?

generated from VF vibration

What is airflow?

generated from lungs

Sound and Airflow chart

What is resonance?

certain frequencies of sound are amplified or strengthened in the vocal tract

What are the two types of resonance?

• Oral: resonant quality of sound production in mouth

• Nasal: resonant quality of sound in nasal cavity

Normal Resonance occurs when there is?

• Balance between oral and nasal = clear, pleasant voice

• VP valve function

• Size and shape of resonating cavities

  • Length/volume of phaynx

  • Size and shape or oral cavity

    • Shorter/smaller = enhance high freq

    • Longer/larger = enhance lower freq

  • Configuration of nasal cavity

• Vowels are resonance sounds

What is hypernasality?

too much sound in nasal cavity

• usually on vowels/resonant sounds; nasalized voiced plosives, nasal phoneme sub for voiceless phonemes

Causes of hypernasality?

• abnormal coupling of oral/nasal cavities

• VP open

• thin velum

• large oronasal fistula

• phoneme-specific mislearning

What is hyponasality?

reduction in normal nasal resonance (usually on nasal sounds)

• nasal consonants sound similar to their oral cognates

Causes of hyponasality?

blockage in nasal cavity/nasopharynx, common with clefts

What is cul-de-sac resonance?

sound is trapped in nasal cavity

• muffled, low volume speech (aka mahomes)

Causes of cul-de-sac resonance?

• Oral: sound partially blocked from exiting the oral cavity - microstomia

• Nasal: sound partially blocked from exiting nasal cavity - cleft lip/palate

• Phayrngeal: sound partially blocked from exiting orophaynx - large palatine tonsils

What is mixed resonance?

any combo of nasality issues

• hyper and hypo cannot occur at same time but on certain sounds separately in same person

Causes of mixed resonance?

VPI, obstruction/enlarged tonsils

Hypernasality should be referred to?

Cleft/craniofacial team

Hyponasality and cul-de-sac should be referred to?

ENT

Velopharyngeal disorders include:

• VP incompetence

• VP insufficiency

• VP mislearning

VP incompetence involves

physiology issues / part not moving

What causes VP incompetence?

• cranial nerve damage

• velar/pharyngeal hypotonia

• neurological injury

• neuromuscular disease

VP insufficiency involves

anatomy issues

What causes VP insufficiency?

• history of cleft palate

• deep pharynx

• adenoid atrophy

• hypertonic tonsils in nasopharynx

• latrogenic conditions

Effects of VPI’s on speech?

• Hypernasality: phonated sounds in nasal cavity

• Nasal emission: leak of airflow into nasal cavity

What is Velopharyngeal mislearning?

Articulation disorder

• substitution of a nasal for oral sound