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Hyponasality vs hypernasality
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Hyponasality vs hypernasality



This is an integrated presentation about Resonance Disorders and Velopharyngeal Dysfunction. ...

This is an integrated presentation about Resonance Disorders and Velopharyngeal Dysfunction.

here I have discussed the following topics:
*What is resonance?
*What Determines Resonance?
*Resonance and Vowels
*Effect of Cavity Size on Resonance
*Structures Active in VP Closure
*Velum (Soft Palate)
*Velum: Rest
*Velum: During Speech
*Physics and Flow
*Velopharyngeal Valve and Flow
*Lateral Pharyngeal Walls (LPWs)
*Posterior Pharyngeal Wall (PPW)
*Passavant’s Ridge
*VP Valve during Speech
*Purpose of VP Valve
*Muscles of VP Closure
*Motor Nerves of VP Function
*Sensory Nerves of Velum
*Normal VP Closure (Nasopharyngoscopy)
*Patterns of VP Closure among Normal Speakers
*Variations in VP Closure
*Normal Velopharyngeal Function
*Velopharyngeal Dysfunction
*Velopharyngeal Insufficiency (VPI)
*VP Insufficiency Following Surgery or Treatment
*Hypernasality (Causes of Hypernasality, Treatments for Hypernasality )
*Pharyngeal Augmentation
*Speech Prostheses
*Palatal Lift Appliances
*Speech bulbs

*Limitations of Prosthetic Devices
*Physical Exercise to Improve Hypernasality
*Continuous Positive Airway Pressure (CPAP):

*Hyponasality (Causes of Hyponasality)
*Mixed resonance disorder



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    Hyponasality vs hypernasality Hyponasality vs hypernasality Presentation Transcript

    • HYPONASALITY VS HYPERNASALITY Under The Supervision of: Dr. Burhan Al Khatib Done By Mahmoud Amir Alagha
    • Resonance Disorders andVelopharyngeal Dysfunction
    • What is resonance?• Modification of the sound that is generated from the vocal cords• Provides the quality of perceived sound during speech
    • What Determines Resonance?• Size and shape of the resonating cavities • pharyngeal cavity • oral cavity • nasal cavity• Function of the velopharyngeal valve
    • Resonance and Vowels• Vowels are resonance sounds• They are produced by changing the size and shape of the oral(resonating) cavity
    • Effect of Cavity Size on Resonance• Smaller resonating cavity results in a ... – higher formant frequency/pitch• Larger resonating cavity results in a ... – lower formant frequency/pitch
    • Structures Active in VP Closure • Velum (Soft Palate) • Lateral Pharyngeal Walls (LPWs) • Posterior Pharyngeal Wall (PPW)
    • Velum (Soft Palate)• Moves in a superior and posterior direction• Has a type of “knee” action• Moves toward the posterior pharyngeal wall
    • Velum: Rest
    • Velum: During Speech
    • Physics and Flow• Water (and air) flow in a forward direction until something stops it.• An obstructing object will redirect the flow.
    • Velopharyngeal Valve and Flow• Due to the physics of airflow, even a small opening will be symptomaticfor speech.
    • Lateral Pharyngeal Walls (LPWs)• Move medially• Usually close against the velum• Sometimes close in midline behind the velum
    • Lateral Pharyngeal Walls
    • Posterior Pharyngeal Wall (PPW)• Moves anteriorly toward the velum• In some speakers, there’s a bulge called a Passavant’s ridge
    • Passavant’s Ridge
    • Passavant’s Ridge
    • VP Valve during Speech• Velopharyngeal valve is closed for oral sounds – Particularly important for “pressure-sensitive” consonants and all vowels• Velopharyngeal valve is open for nasal sounds (m, n, ng)
    • Purpose of VP Valve• Directs transmission of sound energy and air flow in the oral and nasalcavities during speech
    • Muscles of VP Closure• Levator veli palatini (velar “sling”)• Superior constrictor (pharyngeal ring)• Palatopharyngeus (post faucial pillar)• Musculus uvulae (bulge on nasal surface)• Palatoglossus (ant faucial pillar)
    • Motor Nerves of VP Function• Glossopharyngeal (IX)• Vagus (X)• Accessory (XI)• Trigeminal (V)• Facial (VII)
    • Sensory Nerves of Velum• Vagus (X)• Glossopharyngeal (IX)
    • Normal VP Closure(Nasopharyngoscopy)
    • Patterns of VP Closure among Normal Speakers• Coronal Pattern - velum and PPW• Sagittal Pattern - LPWs• Circular Pattern - all structures – sometimes includes Passavant’s ridge
    • Patterns of Closure
    • Variations in VP Closure• Non-Pneumatic: – gagging, vomiting, swallowing• Pneumatic: – blowing, whistling, speech (+ pressure) – sucking, kissing (- pressure)
    • Normal Velopharyngeal FunctionLearning (Articulation)Anatomy (Structure)Physiology (Movement)
    • Velopharyngeal DysfunctionArticulation/Speech Learning (Velopharyngeal Mislearning)Anatomy (Velopharyngeal Insufficiency)Physiology (Velopharyngeal Incompetence)
    • Velopharyngeal Insufficiency (VPI)
    • VP Insufficiency• History of cleft• Submucous cleft palate (overt or occult)• Short velum or deep pharynx (cranial base anomalies)• Irregular adenoids• Enlarged tonsilsFollowing Surgery or Treatment
    • VP Insufficiency Following Surgery or Treatment• Adenoidectomy• UPPP or UP3 (Uvulopalatopharyngoplasty)?• Maxillary advancement• Treatment of nasopharyngeal tumors
    • The primary subsystems of voice and speech production include:Respiration, Phonation, Resonance, and Articulation.These subsystems are highly dependent on one another for audible, aestheticand intelligible oral communication.Any disruption to one or more of these subsystems through surgical ablation,invasion or other adjuvant oncologic treatments will result in a functionalmaladaptive compensation of one or more of the remaining subsystems,creating increased labor of vocalization and speech production.
    • VPI is described by any of the following:Velopharyngeal inadequacy (includes incompitence and/or insufficiency butmay also suggest a reduction or absense pf pharyngeal wall function.Velopharyngeal insufficiency (when some or all of the soft palate is absent)Velopharyngeal incompetence (soft palate is of adequate dimensions butlacks movement because of disease or trauma affecting mucsular and/orneurological capacity.Velopharyngeal dysfunction.These terms are used interchangeably to denote any type of velopharyngeal closure problem.
    • VPI originates from a number of possible etiologiesStructural (i.e. cleft palate and post-surgical insufficiency),Neurologic (i.e. cerebral palsy, dystrophies and myotonias) andSpeech sound “mislearning” (i.e. compensatory misarticulations, hearingimpairment, and postoperative nasal emission).The specific etiology needs to be discerned in each case to provide a tailoredtreatment.
    • HypernasalitySwallowing and speaking are complex motor functions requiring thecoordination of a diverse group of muscles in the upper airway.Hypernasality is a speech disorder that occurs when the tissues of thepalate and pharynx do not close properly, and air leaks from the noseduring speech.
    • Hypernasality• Too much sound resonating in the nasal cavity• Most perceptible on vowels• Voiced oral consonants become nasalized (m/b, n/d, etc.)
    • Causes of Hypernasality• Velopharyngeal dysfunction• Open palate, thin velum or fistula• Misarticulation
    • Treatments for HypernasalityTreatments for hypernasality may include:SurgeryProsthetic appliancesTherapeutic intervention, physical therapy or a combination of thesetreatments.
    • Surgery Or Prosthetics Surgical Management Procedure chosen depends on:• Size of gap• Cause of gap• Location, location, location!
    • Surgery for VPI• Pharyngeal augmentation• Furlow Z plasty• Pharyngeal flap• Sphincter pharyngoplastyNote: These do not always work the first time.May need revision or even re-do.
    • Pharyngeal Augmentation• Injection of a substance in the posterior pharyngeal wall• Can use fat, collagen (Demalogen, Simetra) or Radiesse (hydroxyl apetit)• Good for small, localized gaps or irregularities of theposterior pharyngeal wall
    • Furlow Z Plasty• Often used as a primary palate repair• Can be used as a secondary repair to lengthen velum• Appropriate for narrow, coronal gaps
    • Pharyngeal Flap
    • Pharyngeal Flap View from nasopharyngoscopy before and after flap Pharyngeal wallVelom Pharyngeal FlapNasal surface
    • Pharyngeal Flaps Both are too low
    • Sphincter Pharyngoplasty
    • Sphincter Pharyngoplasty Too narrow and too low
    • Surgical Options 1. Repair of Fistulae (holes in the palate): If any holes remain in the palateafter cleft repair, these are surgically repaired. 2. Furlow Palatoplasty:• The Furlow palatoplasty is performed in children whose palatal muscles are cleft, whether after palate repair or in the case of submucous cleft palate.• This procedure consists of a double z-plasty which realigns the muscles of the soft palate and also lengthens the soft palate at the same time.• This additional length makes it easier for the palate to contact the back of the throat. Realigning the muscles of the palate may also facilitate improvement in middle ear disease, which is common in children with cleft palate.
    • Surgical Options3. Sphincter Pharyngoplasty:• The Sphincter pharyngoplasty is a procedure in which flaps of tissue from the back of the throat are used to build a "speed bump" in the nasopharynx, behind the soft palate.• This creates an additional ridge of tissue in the back of the throat which the soft palate can then contact.• The size of the "speed bump" is tailored to the size and shape of the velopharyngeal gap. It cannot be seen when looking into one’s mouth.
    • Surgical Options4. Pharyngeal Flap:• This is another procedure performed to correct hypernasality, and has been the standard speech surgery for many years.• It consists of sewing a flap from the back of the throat into the palate, which blocks of the back of the throat.• Two openings are left on either side of the flap for breathing and nasal drainage.• While this procedure can correct the problem, it can sometimes overcorrect the deficiency, causing obstruction of the nose.• Obstructive sleep apnea is a relatively common complication after pharyngeal flap surgery. We generally do not recommend this procedure.
    • Speech ProsthesesDental prostheses may be designed to fill the gap in the back of the throat.Such devices prevent excess air leakage from the nose during speech, and areremovable.Speech prostheses may be recommended for children who are poor surgicalcandidates, but if the device is lost or not used, speech will return to its originalstate until a new appliance can be made.Creating the removable device requires weekly or biweekly visits over thecourse of several months. Two devices that can be used by patients with VPIare palatal lift appliances and speech bulbs Palatal Lift Appliances
    • Speech ProsthesesA palatal lift device acts to lift the soft palate upwards and backwards intofull contact with the posterior and sometimes lateral pharyngeal walls. Palatal Lift AppliancesThis device is recommended ifthe soft palate does not movevery much during speech, butappears long enough to reachthe back of the throat. These devices are also useful in non-cleft patients when there is minimal movement of the velum such as neurologically impaired patients.
    • Speech ProsthesesSpeech bulbs work best when the device does not have to close a large VP gapand can be designed to close off “most” of the gap and leave a small space fornasal respiration. Speech bulbsThe device is most successful in patientsthat have adequate inward movement ofthe pharyngeal walls to improve closure.Speech bulbs are recommended when surgery is not possible because ofmedical or anesthetic risks, or sometimes when the gap is so large that surgeryis unlikely to work.
    • To occlude nasopharynx when thevelum is short (velopharyngealinsufficiency)• Can be combined with an obturator Speech bulbs
    • Speech bulbsSpeech bulbs
    • Limitations of Prosthetic Devices• Require insertion and removal• Have to redo periodically due to growth• Can be lost or damaged• May be very uncomfortable• Compliance is often poor• Don’t permanently correct the problemMany centers use only if surgery is not possible
    • Physical Exercise to Improve HypernasalityPhysical therapy principles which stressed improving muscle tone andstrength through:• Tactile stimulation• Repeated contraction of muscles• Resistance exercises.Speech pathologist’s activities included; blowing, whistling, swallowing,sucking, cheek puffing and blowing against resistance.
    • Continuous Positive Airway Pressure (CPAP)One approach to alleviate low muscle tone is to increase muscle strength orendurance using a resistance exercise regimen focused on the muscles of thesoft palate.Resistance to the muscles of the VP mechanism is delivered via artificiallyincreased nasal resistance through increased air pressure to the nasal cavities.Air pressure is delivered using a commercially available device referred togenerically as continuous positive airway pressure (CPAP).
    • HyponasalityHyponasality occurs when the nasal cavity cannot be accessed for the nasalconsonants "m", "n" and "ng".This results in the sound "b" being pronounced as an "m" and the "n" soundas a "d".Reduction in normal nasal resonanceInsufficient nasal airflow during target nasal soundsGenerally caused by blockage in the nasopharynx or obstruction in the nasalcavity particularly affects nasal phonemes (e.g., /m/=> [b]; /n/ => [d])
    • Causes of HyponasalityTemporary hyponasality is often caused by excessive mucus secretions andswollen mucus membranes, resulting from a cold, flu, or allergies.Chronic hyponasality may be caused by allergies, structural deviations ofnasopharynx, nasal septum (such as a deviated septum), or sinus cavities.Other causes include growths such as nasal polyps, or enlarged adenoids.
    • Chronic hyponasality can cause some serious health problems even if thecause of the hyponasality is comparatively benign.Mouth breathing is a common result of hyponasality, which in extreme casescan cause developmental problems affecting dental occlusion, oral health, andperhaps even the proper growth of facial bones.
    • Blockage of the Eustachian tubes commonly co-occurs with hyponasality,which can lead to chronic ear infections; chronic ear infections may causepermanent hearing loss and in severe cases may lead to meningitis.Blockage of the sinuses is also associated with a decreased sense of smell,which may lead to a decreased appetite. Theoretically lacking a sense ofsmell is also a health hazard because you can no longer detect gas leaks,smoke, and the like, but personally Id worry more about the meningitis.
    • Cul-de-sac resonanceType of hyponasalityAnterior nasal obstruction“Muffled” quality
    • Correction of hyponasality will often result in temporary hypernasality, untilthe speaker learns to adjust their speech to account for the decreased nasalblockage.Speech should return to normal within six weeks after surgery, otherwise itstime for a another consult.
    • Mixed resonance disorderHypernasality and hyponasality co-existNot uncommon in cleft palate population Hyponasality can mask hypernasality
    • Resourceshttp://www.speechpathology.com/articles/article_detail.asp?article_id=293Bridget A. Russell, Ph.D., CCC-SLP, Department of Speech Pathology & Audiology, StateUniversity of New York Fredoniahttp://www.entcolumbia.org/hypernas.htmlDepartment of Otolaryngology, Head & Neck SurgeryHypernasality – Velopharyngeal Insufficiency, Oral Cavity ReconstructionTerry A.Day Douglas A.GirodResonance Disorders and VeloPharyngeal Dysfunction: Evaluation and TreatmentAnn W. Kummer, PhD, CCC-SLP Cincinnati Children’s Hospital Medical Centerhttp://www.choa.org/default.aspx?id=760Speech Pathology, Managing Speech DisordersAn Introduction to Speech Pathology and Resonance Disorders by John E. Riski, Ph.DClinical Management of the Soft Palate DefectSteven E.Eckert, DDS,MSRonald P. Desjardins, DMD,MSDThomas D. Taylor, DDS, MSD
    • THANKS