The Diagnosis of Velopharyngeal Inadequacy

Speech and Language Issues in the Cleft Palate Population: The State of the Art

Objective

State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems.

Method

The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether.

Conclusion

Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.

The Relationship between the Characteristics of Speech and Velopharyngeal Gap Size

Objective

The purpose of this study was to examine the relationship between perceptual characteristics of hypernasality, nasal emission and nasal rustle, and size of the velopharyngeal gap.

Design

A retrospective medical chart review.

Setting

Cincinnati Children's Hospital Medical Center.

Subjects

Subjects were patients of the Craniofacial Anomaly Team. All were between ages 3 and 12 years and diagnosed with velopharyngeal dysfunction secondary to cleft palate ± cleft lip. A total of 173 charts were reviewed.

Outcome Measures

Speech characteristics were assessed perceptually by an experienced speech-language pathologist. Following that assessment, velopharyngeal closure was evaluated using videofluoroscopy, nasopharyngoscopy, or both.

Results

Based on the perceptual ratings alone, 21 subjects were diagnosed with nasal rustle only, 27 had hypernasality with nasal rustle, 89 had hypernasality with nasal emission without nasal rustle, and 36 had hypernasality with no audible nasal emission. An ordinal logit regression was conducted and showed that moderate and severe hypernasality contributed significantly to the prediction of a large gap size; nasal rustle contributed significantly to prediction of a small gap size. Perceptual characteristics of speech correctly predicted gap size for 121 of the 173 subjects (70%).

Conclusions

This investigation revealed that some information regarding velopharyngeal gap size may be predicted from the speech assessment alone. Confidence in the prediction is strongest if the patient has nasal rustle, suggesting a small gap, or if the patient has moderate to severe hypernasality, which is more commonly associated with a large opening.

Validity of test stimuli for nasalance measurement in speakers of Jordanian Arabic

OBJECTIVE

The objective of the study was to establish the validity of passages for measuring nasalance of Jordanian speakers of Arabic.

DESIGN

Two Arabic text passages were constructed; the Spring Passage is devoid of nasal consonants and the Home Passage contains both oral and nasal consonants. Nasalance was measured for participants while reciting each passage three times. Perceptual ratings of hypernasality were also obtained for each participant on each passage using a 5-point equal-appearing rating scale.

PARTICIPANTS

Forty-seven children and adults ranging in age between 9 and 26 years participated in the study. Twenty-three participants had no history of communication disorders, and 24 had repaired cleft palate.

RESULTS

Correlation coefficient between ratings of hypernasality and the nasalance scores was significant for the Spring Passage (r = 0.88, p > 0.001) and for the Home Passage (r = 0.78, p > .001). Using cutoff scores of 17% and 36% of nasalance for the Spring and the Home Passages, respectively, and a threshold score of 1.5 for hypernasality, sensitivity for the Spring Passage was 88% and the Home Passage was 78%.

CONCLUSIONS

Results showed the validity of the Spring Passage and the Home Passage in measuring nasalance scores as proved by their high sensitivity and strong correlation with perceptual rating of hypernasality.

Consonant accuracy in Mandarin-speaking children with repaired cleft palate

OBJECTIVE

To compare the consonant production of Chinese-speaking cleft palate children with perceived hypernasal resonance (PHR) after palatoplasty and those with perceived normal resonance (PNR), and to assess the possible influence of language on articulation.

SETTING

Two hospital cleft lip and palate centers in mainland China.

PARTICIPANTS

Thirty-one speakers were allocated into two groups based on perceptual judgment results of their resonance provided by three speech therapists: one group with PNR (n=20, average age=9.3 years), and another group with PHR (n=11, average age=8.3 years). All participants had no known hearing or cognitive deficits.

INTERVENTION

Articulation was evaluated using two Mandarin Chinese assessment tools, the Putonghua Segmental Phonology Test and the Deep Test for Cleft Palate Speakers in Putonghua. Speaker consonant accuracy was evaluated by two experienced speech therapists.

RESULTS

Compared to individuals with PNR, the PHR group exhibited more difficulties on production of unaspirated consonants, including/b/,/t/,/k/,/ts/,/tʂ/ and/tɕ/, than for aspirated consonants.

CONCLUSION

The distinctive feature of aspiration in Mandarin phonology brought a language specific pattern to consonant production among those speakers with PHR after primary palatal closure.

Evaluation of dynamic magnetic resonance imaging in assessing velopharyngeal insufficiency during phonation

BACKGROUND

Velopharyngeal insufficiency (VPI) expresses the structural and neuromuscular disorder of soft palate and pharyngeal walls inhibiting the normal functions of velopharyngeal (VP) sphincter mechanism. In this study, efficacy of dynamic magnetic resonance imaging in the diagnosis of VPI is investigated.

MATERIALS AND METHODS

A total of 32 cases, 16 controls and 16 cleft palates, were included in this study. T1 fast spin echo-weighted imaging during rest, dynamic investigations with True-fast imaging with steady-state precession sequence during /sss/ and /mmm/ phonations were performed.

RESULTS

During /sss/ phonation, complete closure was observed in the control group, whereas mean VP opening was 4.11 cm2 preoperatively and 0.21 cm2 postoperatively in the cleft palate group. In the postoperative period, only 3 patients did not have complete closure. In the second operations, performed 6 months later, only muscle repair was done. All 3 had complete closure.

CONCLUSIONS

In cleft palate cases with delayed diagnosis, appropriate application of muscle repair will be sufficient for anatomic repair of VPI without any extra procedures. In addition, dynamic magnetic resonance imaging is an objective, noninvasive, reliable, and effective modality that may be used in the diagnosis and treatment of VPI without any extra investigations.

Results with Furlow palatoplasty in management of velopharyngeal insufficiency

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

Long-term outcome analysis of two treatment methods for cleft palate: combined levator retropositioning and pharyngeal flap versus double-opposing Z-plasty

OBJECTIVE

Two surgical techniques for repair of a cleft palate include levator retropositioning in combination with a pharyngeal flap and the Furlow double-opposing Z-plasty. This study compared morbidity and speech results from the use of these two methods in an effort to determine which was the superior technique.

DESIGN

Patient records from 1986 to 1996 were retrospectively reviewed, and 10 patients with a cleft palate who underwent repair with a levator retropositioning and pharyngeal flap were compared to 14 patients who underwent a double-opposing Z-plasty repair. Postoperative complications including fistula formation, obstructive sleep apnea, and residual velopharyngeal insufficiency were recorded. Speech was assessed perceptually and through the use of nasometry.

RESULTS

Both surgical techniques resulted in good speech in the majority of patients. Only two patients in the study, both in the Z-plasty group, had severe postoperative hypernasality. Two patients in the levator retropositioning and pharyngeal flap group developed severe postoperative obstructive sleep apnea, requiring additional surgery.

CONCLUSION

The levator retropositioning and pharyngeal flap technique was successful in achieving good speech results, but it also caused more serious postoperative complications when compared to the double-opposing Z-plasty technique.

An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty

An audit of patients with velopharyngeal incompetence treated by the Orticochea pharyngoplasty was undertaken. 54 patients who had been treated by a single surgeon over a 10-year period were identified. All patients had pre- and postoperative speech therapy and were followed up for an average of 6 months. 49/54 patients had lessening of their nasal escape; in 40/54 it was eliminated completely. Nasal resonance was assessed as normal in 46/54 of patients postoperatively. The results are compared with those of other similar studies.

Submucous cleft palate: diagnostic methods and outcomes of surgical treatment

The following statements summarize our interpretation of the literature regarding submucous cleft palate: Incidence and Diagnosis of Submucous Cleft Palate 1. In surveys of classic stigmata of submucous cleft palate among the general population, the incidence has been reported to be 0.02 to 0.08 percent. In the larger of these series, the incidence of velopharyngeal inadequacy among patients identified to have submucous cleft palate was 1 to 9. The incidence of occult submucous cleft palate is not known, since these patients will only be detected during the evaluation of patients who present with velopharyngeal inadequacy. 2. The diagnosis of submucous cleft palate is made by identification of the classic stigmata on physical examination. The diagnosis of occult submucous cleft palate is only pursued if the patient has velopharyngeal inadequacy. 3. For consistency in evaluating and reporting data, patients with an overt cleft of the secondary palate that extends beyond the uvula should be reported as having a cleft palate, and not a submucous cleft palate, even if a submucous cleft exists in a portion of the palate anterior to the overt cleft. 4. The true incidence of otitis media with effusion in the presence of submucous cleft palate has yet to be determined using a prospective study. Surgical Treatment of Velopharyngeal Inadequacy in Patients with Submucous Cleft Palate 1. The technique that has most consistently been documented to result in a significant correction of velopharyngeal inadequacy is the pharyngeal flap. There is recent evidence from one large center supporting the efficacy of the Furlow Z-plasty in selected patients with submucous cleft palate. Both these procedures appear to be most effective in patients with good lateral pharyngeal wall motion. 2. If a pharyngeal flap is performed as the primary procedure to act as an obturator against which the lateral pharyngeal walls appose for closure, we do not see the need for adjunctive palatal procedures. The dynamic component of velopharyngeal competence following such a pharyngeal flap consists of lateral wall motion, which is not enhanced by further surgical manipulation of the palate. However, a pharyngeal flap may be performed as an adjunctive procedure to a palatal pushback in order to provide lining for the resultant defect in the nasal mucosa. 3. The present literature does not support "prophylactic" operations on patients who present with the physical stigmata of submucous cleft palate prior to reaching an age at which it can be demonstrated by perceptual speech assessment that velopharyngeal inadequacy remained refractory to speech therapy. A significant number of patients will never develop velopharyngeal inadequacy; therefore, surgery would be unnecessary. In addition, objective data regarding the outcomes of different surgical techniques cannot be gathered if patients with submucous cleft palate are operated on without having had velopharyngeal inadequacy documented prior to those operations. 4. In order to objectively compare the outcomes of different surgical techniques, any future studies should be prospective and utilize uniform means of assessment. As minimum criteria, these would include preoperative and postoperative perceptual speech assessments performed by a trained speech pathologist and preoperative nasopharyngoscopy and multiview videofluoroscopy. The latter two studies should be repeated postoperatively only in those patients who have persistent velopharyngeal inadequacy.

Comparison of velopharyngeal growth patterns between cleft lip and/or palate patients requiring or not requiring pharyngeal flap surgery

This investigation compares the patterns of velopharyngeal growth in cleft lip and/or palate patients. Those who had velopharyngeal competence and acceptable speech are compared with those who presented with velopharyngeal incompetence requiring pharyngeal flap surgery or prosthesis later. Lateral cephalograms of 30 cleft palate only (CPO), 35 unilateral cleft lip and palate (UCLP), and 20 bilateral cleft lip and palate (BCLP) children of the Lancaster Cleft Palate Clinic were studied. These records were taken at 6 month intervals during the first 2 postnatal years and annually thereafter up to 6 years of age. Soft tissue landmark points in the velopharyngeal region were digitized. Length and thickness of the soft palate and height and depth of the nasopharynx were measured. Evaluation of the growth curves of these four cephalometric variables indicated only two significant differences between children who later required pharyngeal flap surgery and those who did not. These differences were found in the growth in length of the soft palate of the CPO group and in the growth in depth of the nasopharynx of the BCLP group. Based on the present cephalometric data, it is impossible to predict at an early age those cleft lip and/or palate patients who will later require pharyngeal flaps.

[High-frequency videocinematograpphy for the objective imaging of the velopharyngeal closure mechanism in cleft palate patients]

The use of high-frequency video cineradiography makes possible an objective and dynamic rendering of the individual velopharyngeal closer pattern. The high resolution and the depiction of the finest mucosal structures while in motion achieved by this technique opens up the possibility of exact and objective 3-dimensional evaluation of the velopharyngeal gap. Following secondary velopharyngoplasty on 80 cleft palate patients, the velopharyngeal closure was studied by means of high-frequency video cineradiography and this rendering was then compared to results obtained by nasoendoscopy and to the clinical findings. It became definitely apparent that the radiological technique is markedly superior in relation to clearness of depiction and ease of use, especially in young children. This imaging technique can be recommended without reservation for pre- and postoperative control of speech-improving procedures.

Perceptual assessment of resonance distortion in unoperated clefts of the secondary palate

The purpose of this study was to examine the frequency with which five speech-language pathologists made judgments of hypernasality during the clinical assessment of young children with unoperated and repaired clefts of the secondary palate. Among the 293 nonsyndromic patients with secondary palate clefts included in this study, 219 were between 1 and 2 years of age. Of those, 83 had undergone primary palatoplasty whereas 136 had not. The remaining 74 children were between the ages of 4 and 5 years and presented with repaired secondary palatal clefts. The results showed that the clinicians were unable or unwilling to assess hypernasality in 31% of the 1 to 2 year old children with unoperated clefts. The same clinicians failed to evaluate oral-nasal resonance balance in only 12% of the children in the 1- to 2-year age group who had undergone palate repair. Only 1 of the 74 older children (1.4%) was not evaluated for hypernasality. Possible explanations for these findings are presented and discussed.

Successful nasoendoscopic and aerodynamic examinations of children with speech/voice disorders

An 8-year retrospective analysis of aerodynamic and nasoendoscopic examinations of children with a variety of speech and voice disorders shows that these examinations can be completed with a high rate of success. Moreover, the examinations were achieved with relative ease in children as young as 2 years old. Several clinicians were involved in the examinations, illustrating the viability of the methods. It is suspected that the failures to complete the examinations relate more to the examiners' methods and skills than to the child's tolerance of the instrumentation.

Results of a survey of cleft palate teams concerning the use of nasendoscopy

A national survey was conducted concerning methods used for the evaluation of velopharyngeal function with emphasis on the role of nasendoscopy. Forty-five percent of questionnaires were returned. Ninety percent of the responding teams indicated that nasendoscopy was available. Sixty-one percent agreed that endoscopy was an important clinical tool and not solely a research tool. The majority (59%) considered 3 to 5 years of age to be the youngest, appropriate age for referral. Ninety percent agreed that nasendoscopy was indicated for difficult diagnostic problems and 41% reported endoscopic studies were appropriate for all patients for whom secondary palatal management is planned. The results of this survey suggest that endoscopic assessment of velopharyngeal function is used routinely as an adjunct to the perceptual evaluation of speech and has become the standard of care among cleft palate teams for difficult diagnostic cases. However, the data also indicate that increased availability does not necessarily assure optimal use.

Primary palatorraphy in the adult cleft palate patient. Surgical, prosthetic and logopaedic aspects

The treatment of 8 adults with untreated cleft palates is retrospectively discussed. A palatorraphy, consisting of a palatoplasty with pedicled palatal mucoperiosteal flaps and an intravelar veloplasty, is performed. A rib graft between the nasal and oral layer and a partial vestibuloplasty are used in a few patients to create a more favourable anatomical situation for the prosthetic appliance. The palatorraphy contributes to improved speech intelligibility however, combined with a pharyngeal flap as performed in 5 patients, an even better result can be achieved. According to the results, a surgical procedure in the adult still seems to be worthwhile.