Velopharyngeal dysfunction

Content
Introduction
Anatomy and physiology
Basic science/disease process
Diagnosis/patient presentation
Treatment/surgical techniques & nonsurgical
approaches

Introduction
• Normal speech is dependent upon the functional and
structural integrity of the velopharynx, a complex and
dynamic structure that serves to uncouple the oral and
nasal cavities during sound production.
• Dysfunction of the velopharyngeal valve (referred to as
VPD) may lead to hypernasality, nasal air emission, and
compensatory articulation errors, all of which may impair
speech intelligibility.
• The goal of surgical intervention is to produce or restore
velopharyngeal competence while avoiding the
complications of upper airway obstruction.
• Successful surgical management of VPD requires precision
in diagnosis and individualization of treatment.
• Analysis best performed with close collaboration between
the surgeon, the speech pathologist, and the other
members of the cleft/craniofacial team.

Anatomy
• The velopharyngeal port is
defined anteriorly by the soft
palate, or velum, laterally by
the lateral pharyngeal walls,
and posteriorly by the posterior
pharyngeal wall.
• Closure of the velopharynx
during speech is a voluntary
action that is mediated by the
motor cortex and that requires
the coordinated action of the
velopharyngeal musculature.
The muscles of the soft palate
include the levator veli palatini,
the tensor veli palatini, the
palatoglossus, the
palatopharyngeus, and the
musculus uvulae (Fig. 28.1).

Cont...
The levator takes its origin from the
petrous portion of the temporal bone
and from the medial aspect of the
eustachian tube. Insert into the palatal
aponeurosis and decussating with the
levator fibers from the opposite side.
Contraction of the muscular sling
formed by the paired levators is the
primary mechanism for velar elevation
and closure of the velopharyngeal
port.
The musculus uvulae is a paired
intrinsic muscle that likely contributes
to velopharyngeal closure both by
adding bulk to the dorsal surface of
the velum and by contributing to velar
stretch.
It is usually absent in patients with
overt and submucosal clefts of the
palate.

Cont....
The superior pharyngeal constrictor
is a broad, thin muscle that takes
origin from the velum, the medial
pterygoid, and the pterygomandibular
raphe, inserting into the median
pharyngeal raphe along with the
constrictor muscle fibers from the
opposite side.
Contraction of the superior
constrictor may contribute to
velopharyngeal closure by effecting
medial movement of the lateral walls
and anterior movement of the
posterior wall of the velopharynx.
The anatomy of the superior
constrictor and its contribution to
velopharyngeal closure, however, are
highly variable.

Cont...
 With the exception of the tensor veli palatini, which is
innervated by the third division of the trigeminal nerve
(V3), all of the muscles of the velopharynx receive
motor innervation from the pharyngeal plexus, which is
composed of fibers from the glossopharyngeal (IX),
vagus (X), and accessory (XI) nerves.
 Velopharyngeal movements for speech are learned,
voluntary activities that are controlled by the motor
cortex, whereas similar movements for swallowing are
primarily involuntary activities that originate from the
brainstem.

Physiology
• The velopharynx is a complex, three-dimensional valve which serves
to uncouple the oropharynx and nasopharynx during speech and
swallowing.
• It is widely accepted that the levator veli palatini is the muscle that
is primarily responsible for velar motion and, hence, for
velopharyngeal closure.
• Fine motor control of velar position may also be governed by the
palatoglossus and palatopharyngeus. As noted above, the paired
musculus uvulae may play an important role in velar stretch and in
filling the gap between the velum and the posterior pharynx during
• In normal individuals, the velum lifts posteriorly and superiorly
during velopharyngeal closure.

Cont...
The normal point of contact
with the posterior pharyngeal
wall is located approximately
three-quarters of the way
back on the velum from the
posterior nasal spine (Fig.
28.3).
The site of velopharyngeal
closure is usually at or just
inferior to the palatal plane,
which is typically at or above
the level of the first cervical
vertibrae.
Maximal lateral pharyngeal
wall displacement generally
occurs at the level of
velopharyngeal contact.

Cont...
Skolnick et al. and Croft et al. have
described three basic patterns of
velopharyngeal closure observed in
normal subjects (Fig. 28.4):
(1) coronal, in which closure is
effected primarily by velar
elevation.
(2) sagittal, in which closure is
effected primarily by medial
movement of the lateral
pharyngeal walls and the velum
contacts the lateral walls rather
than the posterior wall.
(3) circular in which medial
movement of the lateral
pharyngeal walls contributes to
velopharyngeal closure in near-
equal proportion to the velum.
Of these, the coronal pattern of
closure is observed most commonly in
both normal individuals and in
patients with VPD.

Cont...
• The anterior movement of the posterior pharyngeal wall
during velopharyngeal closure was first described by
Passavant in 1863 and is therefore frequently referred to as
“Passavant’s ridge.”
• Although some have written that its appearance is always
indicative of pathologic velopharyngeal function, Croft et
al. have demonstrated that Passavant’s ridge may play a
role in velopharyngeal closure in both normal speakers and
in those with VPD.
• Electromyographic studies support the notion that normal
velopharyngeal function requires the central coordination
of velopharyngeal muscle activity with other articulatory
movements.

I. Velopharyngeal insufficiency
II. Velopharyngeal incompetence
III. Velopharyngeal mislearning
IV. Combined types
Basic science/disease process of
velopharyngeal dysfunction

Velopharyngeal insufficiency
 The term used to denote an anatomic,
or structural, defect responsible for
inadequate closure of the
velopharyngeal valve.
 congenital, as in cases of cleft palate or
congenital velopharyngeal disproportion
(i.e., a short soft palate relative to the
depth of the pharynx) (Fig.28.5), or they
may be secondary to surgical
procedures that alter velopharyngeal
anatomy, as in cases of palatoplasty,
tumor resection, or adenoidectomy.
 The most common congenital structural
defects associated with VPD are cleft
palate and submucosal cleft palate.
 Since adequacy of velopharyngeal
closure is largely a function of the ratio
of pharyngeal depth to palatal length,
patients with a proportionally short
palate or deep pharynx may
demonstrate incomplete velopharyngeal
closure

Cont....
• Cicatricial changes following palatoplasty, for example, may lead to
velopharyngeal insufficiency secondary to velar shortening.
• Congenital differences in skeletal architecture may also play a role
in postpalatoplasty VPD.
• Osborne et al. and Ross and Lindsay have shown that a higher
prevalence of upper cervical spine abnormalities in patients with
clefts may result in increased pharyngeal depth.
• Flattening of the cranial base angle, may contribute to VPD by
increasing pharyngeal depth.
• Ruotolo et al. have shown that patients with 22q11.2 deletion
syndrome, a condition associated with a high frequency of severe
noncleft VPD.

Cont...
• In young children, velopharyngeal closure is most
often velar-adenoidal.
• Postadenoidectomy velopharyngeal insufficiency
is transient, and resonance returns to normal
within 6–12 months.
• Careful assessment of velopharyngeal anatomy is
therefore essential in all patients prior to
adenoidectomy.
• Enlarged tonsils may intrude between the velum
and the posterior pharyngeal wall, resulting in
incomplete closure.

Velopharyngeal incompetence
 The second major diagnostic category of VPD is velopharyngeal
incompetence.
 Typically reserved for those cases of VPD known or suspected to be due to
congenital or acquired neurological and/or neuromuscular causes such as
cerebrovascular incidents, traumatic brain injury, brain tumor,
abnormalities in muscle tone or function, and degenerative
neuromuscular diseases.
 In velopharyngeal incompetence, there is typically no evidence of any
underlying structural abnormality and palatal length is sufficient; however,
the function of the velopharyngeal mechanism is suboptimal for speech
production and/or swallowing.
 In addition, adults with velopharyngeal incompetence, depending on the
etiology, frequently exhibit dysphagia and varying degrees of nasal
regurgitation.

Velopharyngeal mislearning
 The third, and lesser known, type of VPD involves velopharyngeal
mislearning.
 The velopharyngeal mechanism appears to be anatomically and
physiologically capable of consistent and complete velopharyngeal closure
for speech.
 In this type of VPD, the patient has mislearned how to produce certain
speech sounds accurately.
 The most common example is that of phoneme-specific nasal emission, in
which nasal airflow is produced as a complete substitution for an oral
consonant, despite adequate velopharyngeal closure ability for other
consonants.
 Velopharyngeal mislearning should be treated with behavioral speech
therapy, not surgery. It is critical that a well-trained speech pathologist
perform a thorough clinical evaluation to diagnose such conditions
differentially in order to make the most appropriate treatment
recommendations.

Combined types
 In some cases, individuals with craniofacial anomalies
and/ or clefting may exhibit a combined disorder with
evidence of both velopharyngeal insufficiency and
velopharyngeal incompetency, resulting in a challenge
for surgeons.
 Some patients with 22q11.2 deletion syndrome have
been shown to demonstrate evidence of a combined
type of VPD due to the combination of structural
clefting disorders, increased pharyngeal depth, and
hypotonia of the velopharynx.

Diagnosis/patient presentation
I. Patient history and physical exam
II. Perceptual speech evaluation
III. Indirect measures of velopharyngeal
closure for speech
IV. Imaging

Patient history and physical exam
Individuals with known or suspected VPD are best
treated in the context of an interdisciplinary cleft
palate team.
Regardless of age, the clinical examination
typically includes a brief history and physical
examination, perceptual speech evaluation,
imaging and acoustic measures, and team
discussion for treatment planning.
• The following information should be obtained
during a patient interview when undergoing
evaluation for VPD

1. Current patient/family concerns with speech
2. Pregnancy history, complications, medication use, and any exposure to
teratogens
3. Birth and delivery history and complications
4. Primary medical diagnoses (e.g., cleft palate, syndromes, cardiac defects,
neuromuscular disease)
5. History of any feeding or swallowing difficulties during infancy and any
current swallowing concerns, including nasal regurgitation and difficulty
with breastfeeding or bottlefeeding during infancy
6. History of hearing loss or ear disease, including history of frequent ear
infections or effusions
7. History of snoring or symptoms of sleep apnea
8. Surgical history, including prior tonsillectomy, adenoidectomy, and, if
appropriate, cleft-related surgical history and timing
9. History of any genetic testing and results
10. Family history of cleft lip/palate, nasal speech, speech delay, or
articulation/pronunciation difficulties; hearing loss, learning disabilities,
and medical conditions
11. Developmental history
12. Speech therapy history.

 Every patient, regardless of age, should undergo direct
craniofacial and oral examination by the surgeon and speech
pathologist with experience in clefting/craniofacial anomalies.
1. Craniofacial symmetry
2. Oral–facial movement and symmetry
3. Dentition and occlusion
4. Presence and location of any fistulae
5. Presence of signs of submucous cleft palate, including bifid
uvula, zona pellucida, and palpate for notch
6. Soft palate length, symmetry, and degree of elevation and
symmetry during phonation
7. Tonsil size and symmetry.
 The observations from the physical examination should be
interpreted together with the clinical speech evaluation
results.

Perceptual speech evaluation
• Perceptual speech assessment is considered the gold
standard in the diagnosis of speech disorders of persons
with cleft palate and VPD.
• Additional instrumental assessment and imaging are
considered adjunct to the perceptual speech findings.
• During the speech evaluation, the speech pathologist
obtains the necessary clinical information regarding the
presence and perceived severity of VPD, suspected
etiology, and makes preliminary decisions regarding
treatment recommendations to discuss with the team.
• Box 28.1 provides a list of common speech pathology
terminology used for describing the speech characteristics
associated with VPD.

Cont...
• The most common speech sequelae of VPD
include reduced speech intelligibility;
articulation disorders; reduced intraoral
pressure of oral pressure consonants; audible
nasal emission or nasal turbulence on oral
pressure consonants; hypernasal resonance;
possible hoarseness and decreased loudness.

Cont...
• Audio or video recording of the speech examination should
be completed whenever possible for clinical archiving,
comparison pre–post treatment, assessment of speech
outcome, and for potential research purposes.
• Standard speech evaluations for the cleft or VPD population
should occur on at least an annual basis, and more
frequently if there are changing needs (e.g., postsurgery,
posttherapy).
• Speech evaluations after surgical management (e.g.,
pharyngeal flap) should occur at least 3–6 months
postsurgery to allow for adequate time for healing,
decrease in postoperative edema, and an initial period in
which patients can “practice” speech with their newly
modified speech mechanism.

Indirect measures of velopharyngeal
closure for speech
• When clinical speech evaluation suggests the
presence of VPD, instrumental assessment of
speech and velopharyngeal closure may be useful
as an adjunct to perceptual judgments.
• Instrumental measures can provide confirmation
of perceptual judgments and further evidence of
the need for intervention, as well as allow for
objective pre–post treatment measurements.
• The most popular clinical tools for indirect
instrumental evaluation include acoustic
assessment of nasality and aerodynamic testing.

Cont....
• Nasometer (Kay Pentax) (Fig. 28.6),
 Nasalance is a ratio of the nasal sound
energy divided by the sum of the oral plus
nasal sound energy in the speech signal.
• The patient wears a specialized headpiece
with nasal and oral microphones that
capture the speech signal while the
patient reads or repeats a standardized
speech sample.
• Automated analysis provides a nasalance
score (expressed as a percentage), which
is then interpreted against the perceptual
speech observations.
• Nasalance can range from 0 to 100%;
higher numbers represent a higher degree
of nasality in speech.
• A variety of normative and “cutoff” scores
have been suggested, which are
dependent upon the type of speech
stimuli used for the nasalance score
calculation.

Imaging
 Imaging of the velopharynx is critical for making the
most appropriate treatment decision.
 It is important for the surgeon to visualize the
velopharyngeal mechanism in vivo during speech in
order to identify or confirm the etiology and extent of
the problem, as well as to determine which type of
surgical approach will best manage the speech
problem.
1. Static radiographs
2. Multiview videofluoroscopy
3. Nasopharyngoscopy

Multiview videofluoroscopy
 During multiview videofluoroscopy, a connected speech
sample is recorded while motion fluoroscopy records the
movement of the velopharyngeal mechanism from multiple
angles.
 The benefit of this imaging approach is that it requires a lower
degree of cooperation (as compared to nasopharyngoscopy)
and also provides information regarding palatal length,
pharyngeal depth, velopharyngeal gap size, and tonsil and
adenoid size.
 In this procedure, barium contrast is often instilled through
the nose to help highlight the nasal surface of the velum and
posterior pharyngeal wall, to aid in identification of the
velopharyngeal gap.
 Due to radiation exposure and the availability of other
imaging options, videofluoroscopy

Nasopharyngoscopy
 Nasopharyngoscopy involves the passage
of a flexible fiberoptic endoscope into the
nasal cavity. the view should allow for
complete observation of all
velopharyngeal structures during speech
and swallowing, including anteriorly, the
soft palate; posteriorly, the posterior
pharyngeal wall or adenoid pad; and
laterally, the lateral pharyngeal walls.
 Nasopharyngoscopy during speech is
usually conducted by the surgeon,
otolaryngologist, or a trained speech
pathologist.
 Regardless, a speech pathologist should
be present during the examination to
model the correct speech stimuli for the
patient to imitate during the procedure.
 A topical anesthetic and decongestant
and scope lubricant are often utilized for
increased patient comfort and
cooperation.

Cont...
Two other imaging methods, computed
tomographic scans and magnetic resonance
imaging (MRI), have been utilized for the
assessment of velopharyngeal closure for
speech, but primarily for research purposes.

Preoperative evaluation
 All patients considered candidates for surgical management
should undergo thorough preoperative evaluation.
 The surgeon should elicit a thorough history, carefully
assessing each patient for prior surgery on the palate,
velopharynx, tonsils, and adenoids.
 The presence of associated syndromes and comorbid
conditions should be noted, as should a prior history of
upper airway obstruction.
 Appropriate preoperative medical and anesthetic
consultation should be obtained.
 Patients noted to have enlarged tonsils and/or adenoids
should undergo tonsillectomy and adenoidectomy prior to
posterior pharyngeal flap surgery in order to reduce their
risk of postoperative upper airway obstruction.

Management
• Surgical treatment
1. Posterior pharyngeal flap
2. Sphincter pharyngoplasty
3. Posterior pharyngeal wall augmentation
4. Furlow double opposing Z-Palatoplasty
• Non-Surgical treatment
1. Prosthetic treatment
2. Behavioural speech therapy

Treatment/surgical techniques
• The primary goal of surgical management is to produce a competent
velopharyngeal mechanism while avoiding the complications of nasal
airway obstruction, including hyponasality, obligate mouth-breathing,
snoring, and obstructive sleep apnea.
• In all cases, surgical management should be individualized, taking into
consideration each patient’s velopharyngeal anatomy and function, as well
as any comorbid conditions that may influence surgical outcome.
• All surgical procedures for the management of VPD seek to reduce the
cross-sectional area of the velopharyngeal port and/or improve the
dynamic function of the velopharyngeal valve.
• The procedures most commonly used for the management of VPD include
Furlow double-opposing Z-palatoplasty, posterior pharyngeal flap, and
sphincter pharyngoplasty.
• Posterior pharyngeal wall augmentation has been used less frequently.

Furlow double-opposing Z-
palatoplasty
 Transposition of the posteriorly based myomucosal flaps reorients
the levator muscles from the sagittal to the horizontal position,
thereby reconstructing the levator sling. The Z-plasty design
provides for palatal lengthening while avoiding velar shortening
that may occur after straight-line closure.
 An unrepaired submucosal cleft palate and in those who have
undergone cleft palate repair without levator reconstruction.
 The design of the Furlow palatoplasty incorporates mirror image Z-
plasties on the oral and nasal aspects of the velum, such that the
posteriorly based flaps contain both mucosa and the attached fibers
of the levator veli palatini. the anteriorly based flaps contain
mucosa and submucosa alone.

Cont...
• The Z-plasty design is determined by palatal
anatomy, the incisions extending from the
hamulus to the junction of the hard and soft
palate at the cleft margin on one side and
from the base of the uvula to the hamulus on
the other.
• The posteriorly based flap is elevated in the
nasal submucosal plane, thereby creating an
oral myomucosal flap.
• The contralateral flap is elevated in the oral
submucosal plane, creating an anteriorly
based mucosal flap.
• The anteriorly based nasal mucosal flap is
then developed by incising the nasal mucosa
from the base of the uvula to a point just
medial to the orifice of the eustachian tube.
• On the opposite side, the posteriorly based
nasal myomucosal flap is incised along the
posterior edge of the hard palate, again
completely dividing the attachment of the
levator to the bone.
• The nasal flaps are then transposed and
sutured in place.
• Transposition of the oral flaps reconstructs
the levator sling and completes the repair.

Cont...
• In a series reported by Hudson et al. 66 85% of
patients with VPD after primary palatoplasty
demonstrated normal resonance after conversion
to a Furlow Z-palatoplasty.
• Chen et al. reported that the majority of patients
with a velopharyngeal gap of less than 5 mm
achieve velopharyngeal competence after Furlow
repair, whereas the repair is far less successful
when the gap size exceeds 10 mm.

Complications after Furlow Z-
palatoplasty
• Bleeding, oronasal fistula, and nasal airway obstruction.
• Fistula formation can be minimized by ensuring that the
repair is completed with minimal tension.
• Although mild obstructive apnea has been documented in
patients following Furlow Z-palatoplasty, such has been
noted to resolve in nearly all patients within 3 months of
surgery.
• When compared to patients who have undergone posterior
pharyngeal flap surgery for the management of VPD,
patients treated by Furlow repair demonstrate significantly
lower incidence and severity of upper airway obstruction 6
months or more postoperatively.

Posterior pharyngeal flap
 The creation of midline flaps from the posterior pharyngeal wall
represents the oldest surgical technique for the management of VPD.
 In 1865, Passavant published the first report describing the surgical
management of VPD by adhesion of the soft palate to the posterior
pharyngeal wall.
 Schoenborn described the use of an inferiorly based pharyngeal flap in
1875 and of a superiorly based flap a decade later.
 The superiorly based pharyngeal flap was described in the US by Padgett
in 1930, and by the middle of the 20th century, the procedure was widely
employed as the standard surgical treatment for VPD.
 The pharyngeal flap functions primarily as a central obturator of the
velopharyngeal port. Closure of the lateral side ports during speech is
dependent upon the medial movement of the lateral pharyngeal walls.
 Hence, this technique is optimally suited for patients with VPD that is
characterized by the presence of a central gap and that is associated with
good lateral pharyngeal wall motion.

Surgical Technique
• The flap is undermined and elevated with its
superior as well as inferior attachments still
intact, and the inferior attachment is then
divided.
• The soft palate is split in the midline, and
lining flaps are incised and elevated from the
nasal surface of the soft palate, based on the
posterior edge of the soft palate.

Surgical technique
The patient is intubated orally
with a midline oral RAE
endotracheal tube.
This tube is secured, and the
mouth is held open by a
Dingman retractor.
The posterior pharyngeal wall
and midline of the soft palate
are injected with 1.0% lidocaine
with epinephrine 1 : 100,000.
After a wait of 7 minutes,
parallel incisions are made in
the posterior pharyngeal wall,
approximately 2.5 cm apart.
Dissection is carried down to
the prevertebral fascia.

 The tip of the superiorly based
posterior pharyngeal flap is then
sutured into the defect on the
nasal surface of the soft palate
with absorbable horizontal
mattress sutures.
These are left untied until all
have been placed, and they are
then sequentially tied.
It can be helpful to pass a 10 or
12 French nasal catheter through
the planned lateral port on each
side to define the ports and to
prevent their obliteration.
The lateral edge of the posterior
pharyngeal flap on each side can
then be sutured to the lateral
edge of the soft palate to better
define the lateral ports.
The oral lining of the soft palate
and the nasal lining flaps of the
soft palate are then repaired in
the midline.

Cont...
• The flap donor defect in the posterior pharyngeal wall is
repaired in the midline if it can be easily closed. Otherwise,
in most cases, it is left open and will rapidly heal by
secondary intention.
• If the patient shows any significant upper airway
obstruction at the end of surgery, the oral RAE tube is
changed to a cuffed endotracheal tube, and the patient is
mechanically ventilated for the next 24 to 72 hours until
the edema has decreased.
• Even if the patient can be extubated in the operating room,
all patients who have undergone pharyngeal flap
attachment are observed in the intensive care unit for the
first night after surgery because of the risk of early
postoperative airway complications.

Sphincter pharyngoplasty
• In 1950, Wilfred Hynes first described the technique of
pharyngoplasty by transposition of musculomucosal flaps
containing the salpingopharyngeus muscles.
• He later modified the technique to include the palatopharyngeus
muscles, noting that success of the technique could be attributed to
narrowing of the velopharyngeal port and to augmentation of the
posterior pharyngeal wall with bulky, “often contractile” flaps.
• Orticochea stressed the concept of creating a true “dynamic
sphincter” in order to achieve velopharyngeal competence on
inferiorly based mucosal flap on the posterior pharyngeal wall.
• Jackson and Silverton later modified the procedure, eliminating the
posterior pharyngeal flap, instead insetting the palatopharyngeal
flaps into a transverse incision located higher on the posterior
pharyngeal wall.

Original Hynes pharyngoplasty
He used the
salpingopharyngeus muscles and
their overlying mucosa.
he dissected, based superiorly,
and transplanted into a
transverse surgical defect in the
mucosa of the posterior wall of
the nasopharynx.
His initial attempts were
performed as twostaged
procedures.
In the first stage, the soft
palate was divided and the
salpingopharyngeus muscles
were attached to the posterior
pharyngeal wall, and to each
other, in a side-to-side design
(Fig. 97-13).

A different sphincter
pharyngoplasty design was
proposed by Miguel
Orticochea of Bogotá,
Colombia.
Orticochea inset the
pharyngoplasty flaps at a
much lower level than
Hynes did, significantly
below the level of usual
Orticochea also raised a
separate, inferiorly based
flap from the posterior
pharyngeal wall and
sutured the tips of his
pharyngoplasty flaps to the
raw surface of that flap(Fig.
97-14).

Jackson and Silverton
In their technique, bilateral superiorly based
flaps from the posterior tonsillar pillars,
including the palatopharyngeus muscles, were
elevated.
These flaps were then sutured together in the
midline and also to the undersurface of a
superiorly based posterior pharyngeal flap (Fig.
97-15).
The Jackson and Silverton technique produce
a higher positioning of the pharyngoplasty flaps
than in the original Orticochea operation, thus
bringing the level of the sphincter
pharyngoplasty closer to the normal level of
Jackson and Silverton described 74 patients
who underwent their pharyngoplasty.
They found speech improvement in 67
patients (91%).

Modified Hynes
pharyngoplasty
Vertical incisions are made anterior
to both posterior tonsillar pillars, and
the palatopharyngeus muscles are
exposed.
The longitudinally oriented muscle
fibers are carefully dissected from the
posterolateral pharyngeal wall, so as
to include the entire muscle in each of
the flaps.
Vertical incisions are then made
posterior to the pillars, creating flaps
that measure approximately 1 cm in
width.
On each side, the parallel incisions
are joined by a transverse incision at
the lowest aspect of the pillar, and the
flaps are elevated.
The flaps are then rotated medially
and inset into a transverse incision
that connects the most superior
aspect of the medial palatopharyngeal
flap incisions.

Cont...
 In a retrospective review of speech outcome in 48
patients who underwent sphincter pharyngoplasty,
Shewmake et al. reported that 85.4% achieved normal
resonance. Riski et al. reported that, of 139 patients
who underwent sphincter pharyngoplasty, 78%
demonstrated resolution of hypernasality and normal
pressure–flow measurements.
 Most surgical failures were the result of the
pharyngoplasty being placed too low on the posterior
pharyngeal wall.
 In a series of 250 patients, Losken et al. noted a
revision rate of 12.8%, noting that persistent VPD after
pharyngoplasty was more common in patients with
22q11.2 deletion syndrome.

Posterior pharyngeal wall
augmentation
 Augmentation pharyngoplasty, using both autologous
tissues and alloplastic materials, has long been used by
surgeons to reduce the size of the velopharyngeal orifice in
patients with VPD.
 In 1862, Passavant became the first to describe the use of
local tissues to augment the posterior pharyngeal wall.
 In his initial description, he sutured the palatopharyngeal
muscles together in the midline.
 In 1912, Hollweg and Perthes described the use of
autologous cartilage grafts inserted through a cervical
incision. Later through a transoral approach.
 Recent reports have documented improvement in
velopharyngeal function following injection of autologous
fat into the posterior pharynx in selected patient.

Cont...
 The earliest attempts to augment the posterior
pharyngeal wall by injection of exogenous material
may have been those of Gersuny, who reported the
use of petroleum jelly in 1900.
 Various studies have shown injection of paraffin,Teflon
or using implantable blocks and injectable fluid Silastic.
 To date, no single alloplastic material has been found
to be uniformly safe, effective, and reliable, and single
type of autologous graft has demonstrated consistent
long-term stability.
 Augmentation pharyngoplasty should be considered
only as a secondary option in carefully selected
patients with VPD.

Nonsurgical treatment options
Prosthetic or behavioral speech treatment may
be appropriate for a select set of patients.
(1) when the diagnosis of VPD is unclear based on
perceptual speech and/or imaging findings.
(2) when the comorbid speech problems make it difficult
to determine if surgical intervention will result in
meaningful improvement in speech.
(3) when the patient has a known neuromuscular or
degenerative condition that has been shown to result
in suboptimal surgical outcomes.

Prosthetic treatment
• To be a good candidate for prosthetic
management, the patient and family must
demonstrate adequate compliance and
dedication to completing the prosthetic
treatment plan, which may require several
visits, and be an appropriate dental candidate
for fabrication of a speech prosthesis (i.e.,
demonstrate good dental hygiene).

The palatal lift and the speech
bulb are the most commonly
used speech prostheses116
(Fig. 28.13
A palatal lift is basically a
standard orthodontic retainer
with an extension posteriorly
to “lift” up the soft palate. It
is an appropriate treatment
option for patients with a soft
palate of sufficient length but
lacks adequate movement
during speech and/or
swallowing, such as in cases
of velopharyngeal
incompetence.
A speech bulb is more
appropriate for patients with
velopharyngeal insufficiency
in which the palate is too
short to contact the posterior
pharyngeal wall.
The speech bulb is similar to
the palatal lift, with an
addition of a “bulb” of acrylic
material to fill in the
remaining velopharyngeal gap
during speech.

Behavioral speech therapy approaches
In selected patients with borderline or
inconsistent VPD and/ or velopharyngeal
mislearning, at least a trial period of
behavioral speech therapy may be helpful
prior to proceeding with surgical
management.
Speech therapy is always the most
appropriate treatment for articulation errors.

Cont...
• The ideal patient for such a treatment trial would
have many of the following characteristics:
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.

Cont...
• Biofeedback is often a cornerstone of behavioral speech
therapy to improve velopharyngeal closure for speech.
• Biofeedback may be provided through enhanced auditory,
visual, or tactile.
• Lastly, continuous positive airway pressure (CPAP) has been
proposed as a treatment modality to improve
velopharyngeal closure by “working” the muscles against
artificially increased nasal resistance (nasal pressure)
during speech for longer durations of time.
• More research is needed to identify the most effective
behavioral speech therapy approaches for improving
velopharyngeal closure for speech.

Velopharyngeal dysfunction

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