Velopharyngeal dysfunction

1. VELOPHARYNGEAL
DYSFUNCTION
DR SAMIK SHARMA

2. INTRODUCTION
• Definition – Dysfunction of the velopharyngeal valve leading to failure of complete
closure of the sphincter between oral & nasal cavities during sound production &
swallowing (uncoupling of oral & nasal cavities)
• Results in –
1. Hypernasality
2. Nasal air emission
3. Compensatory articulation errors

4. ANATOMY
VP port boundaries –
Anterior – soft palate (velum)
Posterior – post. pharyngeal wall
Lateral – lateral pharyngeal wall
Levators – velar elevation, closure of VP
port at levator eminence at mid-third of
soft palate
Palatoglossus & palatopharyngeus – finer
positioning of velum during speech
Musculus uvulae – adds bulk, velar stretch
Sup.constrictor – medial movement of
lateral walls & anterior movement of
posterior wall of the velopharynx

5. ANATOMY
• Nerve supply –
 CN IX, X, XI  Pharyngeal plexus  all muscles (except Tensor veli palatini – trigeminal V3 division)
 Facial n. – minor role
 Speech – voluntary movement (motor cortex)
 Swallowing – involuntary movement (brainstem)

6. PHYSIOLOGY
Point of contact
– 3/4th distance
from post.nasal
spine at or just
inferior to
palatal plane
Patterns of VP closure
Coronal
(Closure by
velar
elevation)
Circular
(Closure by
medial
movement of
lateral
pharyngeal
wall & velar
elevation)
Sagittal
(closure by
medial
movement of
lateral
pharyngeal
wall)
Passavant’s ridge - localized transverse ridge of
tissue may be seen to form on the posterior
pharyngeal wall during speech d/t anterior
movement of the posterior pharyngeal wall
indicative of pathologic velopharyngeal
function

7. Definition :
oVelopharyngeal insufficiency (VPI) :
• It is known as a failure of the separation between nose
and mouth, because of an anatomical dysfunction of the
soft palate, the lateral or posterior wall of the pharynx.
oVelopharyngeal inadequacy :
• (VPI) is a malfunction of a velopharyngeal mechanism.
• The velopharyngeal mechanism is responsible for
directing the transmission of sound energy and air
pressure in both the oral cavity and the nasal cavity.
• When this mechanism is impaired in some way, the valve
does not fully close, and a condition known as
'velopharyngeal inadequacy' can develop.

8. • VP incompetence: Due to neurological
etiologies such as motor disorders (e.g
dysarthria)
• VP incorrect learning: The result of
sensory deficits (e.g.hearing impairment),
or congenital disorders (existing at birth)

9. Terms used in the study of
VPI
 Nasalization: significant communication of the nasal cavity
with the rest of the vocal tract during speech.
 Nasality: perceptual quality of nasal resonance.
 Hypernasality: excessive nasally escaping air reverberating in
the nasal cavity.
 Hyponasality: blocked nasal resonance caused by
nasal obstruction.
 Nasal emission: increased nasal instead of oral airflow
during the production of pressure consonants (not
necessarily acoustic).
 Nasal turbulence: fricative sounds caused by nasal airflow

10. SYMPTOMS:
• The two main speech symptoms of velopharyngeal insufficiency
(VPI) are hypernasality and nasal air emission.
• Hypernasality is sometimes called nasal speech. In English
the sounds "m," "n" and "ng" are the only sounds that should
resonate nasally.
• Hypernasality occurs when sounds other than these
resonate through the nose, and it varies from mild to severe.
• Some other consonants can be produced without
velopharyngeal closure, including "h," "w," "y," "l" and "r."
• The rest of the consonants are referred to as pressure
consonants because they require buildup of air pressure in the
mouth to produce normal sounds.

11. Causes:
• Any child with cleft palate is at risk for VPI.
• The most common cause of VPI is a history of cleft palate
or submucous cleft (cleft covered by the lining or mucous
membrane of the roof of the mouth).
• About 20% to 30% of children who have cleft palate with
or without cleft lip will have persisting VPI after their
palate repair.
• A small percentage of children with submucous cleft
palate will also have VPI.

12. • Sometimes VPI develops after an adenoidectomy (a
surgical procedure to remove adenoids or lymphoid
tissue in the back of the nose).
• Children who are born with weak throat muscles or
who suffer a traumatic brain injury that results in weak
throat muscles may have VPI.
• Sometimes children have VPI from an unknown cause.

13. • Velopharyngeal insufficiency (VPI) can be caused by a variety of
disorders :
 Structural
 Genetic
 Functional
 Acquired

14. DIAGNOSIS
History Examination Imaging
• Pregnancy history
• Obstetric history
• Primary medical diagnoses
(cleft palate, cardiac defects,
neuromuscular disease)
• Feeding history
• History of hearing loss or ear
disease
• History of snoring or
symptoms of sleep apnea
• Surgical history
• Family history
• Developmental history
• Speech therapy history
• Craniofacial symmetry
• Oral–facial movement and
symmetry
• Dentition and occlusion
• Presence and location of any
fistulae
• Presence of signs of
submucous cleft palate,
including bifid uvula, zona
pellucida, and palpate for
notch
• Soft palate length,
symmetry, and degree of
elevation and symmetry
during phonation
• Tonsil size and symmetry
• Perceptual speech evaluation
• Indirect measures of VP
closure for speech
• Static radiographs – lateral
cephalometry at rest & at
sustained sound production
• Multiple videofluoroscopy –
during connected speech
• Nasopharyngoscopy
• CT scans / MRI / Dynamic
MRI
•Use nasal contrast

15.  Diagnostic evaluation :
• It can be divided into two broad categories:
 perceptual
 Instrumental.

16. Perceptual :
• “Perceptual” connotes the use of the evaluator’s unaided senses.
• Listening for the production of specific phonemes (i.e., auditory perceptual
velopharyngeal evaluation) is the major form of perceptual evaluation.
Observing the face for grimacing
watching for fogging of a mirror below the nares
feeling for airflow through the nares with attempted pronunciation of
phonemes that require velopharyngeal function.

17.  Instrumental :

19. VIDEOFLUOROSCOPY:
• It is a radiographic technique, mostly used to
demonstrate the lateral and posterior wall of the
pharynx.
• This is a questionable technique considering these children
undergo radiographic examinations frequently.
• Most of the time barium is used in multiview
videofluoroscopy.
• Besides the fact that videofluoroscopy provides an
overview of the lateral and posterior walls of the pharynx,
this technique also provides information about the length
and movement of the soft palate, the posterior and the
lateral walls

21. NASOENDOSCOPY
:
• Nasoendoscopy is a non radiographic technique in
which the physician uses a scope to enter the
mouth of the patient.
• Usually the examiner uses a flexible scope, but
in certain situations a rigid scope is used.
• Nasoendoscopy provides an overview of the
anatomy of the velopharynx during phonation.
• With nasoendoscopy the vocal tract but especially
the soft palate and the lateral wall of the pharynx
can be visualized.
• Not only the location but also the movement
can be visualized with nasoendoscopy.

23. LIMITATIONS :
• It is hard to get an overview with nasoendoscopy
with a rigid scope in small kids.
• Especially when there are abnormalities or
obstructions in the nasal cavity, which are
frequently found in children with a history of cleft
palate.
• The nasoendoscope can cause irritations of the
mucosa when the child does not cooperate.

24. SPEECH
ANALYSATION:
• To come to the right diagnosis this is the gold
standard in VPI evaluation.
• The speech scientist listens to the voice, articulation,
motor speech and the velopharyngeal function of the
patient.
• The main symptom is hypernasality of the voice.
• The patient is unable to create normal resonance
because of nasal air emission.

25. NASOMETRY:
• Nasometry is a test which calculates a ratio
between the nasal and oral sound emissions.
• The ratios of the patient will be compared with a
normal ratio and standard deviation.
• These ratios will help determine whether the
operation was a success.
• Preoperative ratios will be compared with
postoperative ratios.

26. Airflow:
• Pneumotachograph:
 split mask with airflow sensors

27. Sound pressure:
• Microphones (eg. Probemic, Nasometer)
• Accelerometers or contact microphones for
tissue vibrations

28. • The scientist also examines the patient
for Obstructive Sleep Apnea Syndrome (OSAS),
when this is positive the patient will be treated
for OSAS first.
• When there is no sign of oral sleep apnea the
patient will conduct a speech analyzation.
• If is proven that the patient has an indication for
surgical treatment, the next step will be
visualization of the mouth and pharyngeal cavity.
• Often the visualization is combined with
audiometry or speech analyzation.

29. MUSCLE
ACTIVITIES:
Electromyography (EMG)
• Surface electrodes
• Intramuscular electrodes
VP study usually needs the
intramuscular one.

30. IMAGING :
• Fiberoptic endoscope
• Xray / MRI / Ultrasound

31.  Management of cleft-related velopharyngeal
insufficiency :
Once the diagnosis of VPI has been made, treatment may consist of
nonsurgical speech therapy, obturation with a speech bulb, placement of
a palatal lift, or reconstructive surgery of the airway.
Surgical treatment of VPI is indicated when the problem is related to
anatomic factors and documented to be consistent.
By surgically recruiting additional local tissue to decrease the aperture,
complete or improved closure of the velopharyngeal sphincter can occur.
Once the diagnosis is confirmed, the timing of surgical intervention should
be early to prevent long-term speech difficulties and abnormal articulatory
compensations that are difficult to correct later in life.

32. A FIRM DIAGNOSIS OF VPI MAY NOT BE POSSIBLE
BEFORE AGE 3 BECAUSE APPROPRIATE TESTING IS
DIFFICULT IN SUCH YOUNG CHILDREN.
For most children, reliable testing can be performed
somewhere between 3 and 5 years of age.
The surgeon and speech pathologist must work
together to select the procedure that might offer the
best outcome based on the specific clinical situation.

33. NONSURGICAL TREATMENT OPTIONS
Prosthetic treatment Behavioral speech therapy approaches
Indications for speech prostheses –
• diagnosis of VPD unclear
• when the comorbid speech
problems make it difficult to
determine if surgical intervention
will result in meaningful
improvement in speech
• known neuromuscular or
degenerative condition
Adequate compliance and dedication
Good dental hygiene
Palatal lift – lift up soft palate (need
good soft palate length)
Speech bulb – additional bulb of
acrylic material (for short soft
palate)
Obturators for palatal fistulae
Indications –
•Velopharyngeal mislearning
•Articulation errors
•Phoneme-specific nasal emission or phoneme-specific
nasalization of sounds
•mild or inconsistent hypernasality or nasal air emission
Ideal candidate –
• Age 6–8 years or older
• Intact cognitive skills
• Intact motor skills
• Adequate attention span and maturity.
• Normal hearing and vision
• Good self-monitoring or speech self-correction skills
• At least inconsistent velopharyngeal closure for speech
• At least some accurate articulation skills already in the
speech repertoire
• Can demonstrates measurable change within the first
few sessions of therapy
Nasopharyngoscope as biofeedback tool

34. SURGERY
• Principles –
Goal is to produce a competent velopharyngeal mechanism while
avoiding the complications of nasal airway obstruction, including
hyponasality, obligate mouth-breathing, snoring & obstructive sleep
apnea
Reduce the cross-sectional area of velopharyngeal port &/or improve
the dynamic function of the velopharyngeal valve
To address VPI – 1) lengthen palate 2) narrow the pharyngeal wall 3)
to bring posterior pharyngeal wall anteriorly

35. SURGERY
Surgery on palate Surgery on pharynx
Palatal
defect
closure
Palatal lengthening Lateral wall Posterior wall
Actual lengthening Palatal
retroposition
Static Dynamic Static Dynamic
Using intrinsic
tissues
Using
extrinsic
tissues
•Push back of
oral layer
•Cronin’s
incision on
nasal layer
via nostril
•Dorrence
flap – U
shaped
bipedicled
flap push-
back
Pharyngeal
flap
Pharyngoplasty Pharyngeal
flap
Augmentation
pharyngoplasty
•Furlow’s double
opposing Z-
plasty
•Intravelar
veloplasty
(Braithwaite,
Kriens)
•Cheek flap
•Tongue flap
•Pharyngeal
flap

37. FURLOW DOUBLE-OPPOSING Z-PALATOPLASTY
Advantages –
•Creation of levator sling without
muscle dissection
•Palatal lengthening without
velar shortening
•No lateral incision, so growth
center at maxillary tuberosity
not damaged  less midface
retrusion
Disadvantages –
•Not ideal for wide palatal
gap (>5-10mm) & short
velum
Complications –
•Bleeding
•Oronasal fistula – repair
without tension, lateral relaxing
incision (Modified Furlow)
•Nasal airway obstruction

38. INTRAVELAR VELOPLASTY
• Restoration of levator sling
• Steps –
1. Release of levator muscle from abnormal position (oral & nasal layer, cleft margin,
posterior margin of hard palate)
2. Make horizontal & midline stitch
• Advantage –
 Levator sling restored – pull velum posteriorly & upwards
 Release anomalous insertions – exclude abnormal palatal movement (widening of gap)
 Extensive release & retroposition of muscle – palatal lengthening
• Disadvantages –
 Fibrosis / scarring
 Avascular necrosis & fistulae

39. POSTERIOR PHARYNGEAL FLAP
Types –
•Inferiorly based
(Schoenborn)
•Superiorly based
(Padgett)
•Lateral port control
(Hogan)
Advantages –
•Acts as central obturator
•Suitable in central gap with
good lateral wall motion
•Donor defect closure help
narrowing pharynx
Disadvantages –
•Static procedure
•Halitosis
•Cicatricial flap
narrowing
Complications –
•Bleeding
•Dehiscence
•Nasal obstruction &
OSA

40. POSTERIOR PHARYNGEAL FLAP
Inferiorly based Superiorly based Lateral port control (LPC)
•Technically
easier
•May prevent
normal palatal
movement
•Direction of flap
is consistent
with normal
movement of
soft palate
•Modification of superiorly
based flap
•Positive port control using
“catheter technique”
•Form 2 ports, 10 sq.mm
each using 14Fr.(3.8mm)
catheters
•At rest – port size is 20
sq.mm
•At speech – port size
decrease

41. SPHINCTER PHARYNGOPLASTY Types –
•Hynes - transposition of
musculomucosal flaps
containing
salpingopharyngeus ms.
•Modified Hynes - include
palatopharyngeus ms.
•Orticochea – b/l
palatopharyngeal
myomucosal flaps inset into
an inferiorly based mucosal
flap on posterior
pharyngeal wall
•Jackson & Silverton – b/l
palatopharyngeal flaps inset
into a transverse incision
located higher on the
posterior pharyngeal wall
Advantages –
•Narrowing of VP port by
augmentation of
post.pharyngeal wall
•Dynamic sphincter created
Disadvantages –
•Failure if pharyngoplasty
placed too low on
post.pharyngeal wall
Complications –
•Bleeding
•Flap dehiscence
•Upper airway obstruction

42. POSTERIOR PHARYNGEAL WALL AUGMENTATION
Autologous tissues Alloplastic
materials
Local tissues Distant
tissues
•Fluid silastic
injection
•Teflon injection
•Proplast
•Calcium
hydroxyapatite
•Palatopharyngeus
•salpingopharyngeus
Cartilage
graft
•Cervical
approach
•Transoral
approach

43. THANK YOU