This seminar gives brief description about introduction, normal anatomy of velopharyngeal structure, different closure pattern of velopharynx, diagnostic aids used, VPI in cleft patients

1. Velopharyngeal
insufficiency
Presented by - Dr Parag S. Deshmukh

2.  Contents :
• Introduction
• Causes
• Normal anatomy
• Different closure patterns of velopharynx
• Diagnostic tools
• Treatment
• Related article
• Conclusion

3.  Introduction:
• The terms velopharyngeal "incompetence",
"inadequacy" and "insufficiency" historically have
been used interchangeably
• Velopharyngeal insufficiency includes any
structural defect of the velum or pharyngeal walls
at the level of the nasopharynx with insufficient
tissue to accomplish closure, or there is some kind
of mechanical interference with closure.

4. 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.
Definition :

5. • 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)

6. • Velopharyngeal insufficiency (VPI) is a disorder
resulting in the improper closing of the velopharyngeal
sphincter (soft palate muscle in the mouth) during
speech, allowing air to escape through the nose instead
of the mouth.
• During speech, the velopharyngeal sphincter must
close off the nose to properly pronounce strong
consonants such as "p," "b," "g," "t" and "d.“
• To close off the nose from the mouth during speech,
several structures come together to achieve
velopharyngeal closure.

7. • These include the velum (soft palate or roof of the mouth),
the lateral pharyngeal walls (side walls of the throat) and the
posterior pharyngeal wall (the back wall of the throat).
• If the velopharynx is not closed, snort sounds may be
produced through the nose or you may hear air coming out of
the nose during speech.
• Improper function of this structure also produces a nasal tone
in the voice.

8. 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.

9. • Nasal air emission occurs when air escapes through the nose
on pressure consonants, and it can sound like puffs, squeaks or
snorts, or it might make speech sound muffled.
• Children sometimes develop unusual speech sounds to
compensate for their VPI. A common one is a glottal stop,
produced by stopping air with the vocal cords (as one would do
when saying "uh oh").
• Some other sounds are made by awkward stopping or
restricting air with the tongue in the throat or mouth in
unusual ways.

10. 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.

11. • 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.

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

13. Terms used in the study of VP
function/dysfunction :
 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

14. Normal anatomy :

16. • The muscles that control its movement can be grouped based on their
respective actions on the soft palate. They include elevators, depressors, and
tensors.
Elevators Depressors Tensor
Levator veli palatini palatopharyngeus Tensar veli palatini
Musculus uvulae palatoglossus
• In addition to the five soft palate muscles, there are two other pharyngeal
muscles that also arise in pairs and assist in the functional mechanism of
velopharyngeal closure: pulling the soft palate to the sides and thereby opening
the pharyngotympanic tube during swallowing and yawning

17. Levator Veli Palatini :
• Bilaterally, the muscle is superiorly
attached to the cartilage of the
pharyngotympanic tube and the
temporal bone and inferiorly
attached to the palatine
aponeurosis.
• Since 1953, it has been
acknowledged that the principal
function of the LVP is to elevate
the soft palate. (Bosma J: A correlated study of the anatomy and motor activity of theupper pharynx and by
cinematic study of patients after maxillo-facial surgery. Ann Otol Rhinol Laryngol 1953; 62:51-
72.)

18. The action of the LVP is the principal velar component to
velopharyngeal closure and is important in maintaining
closure, particularly for expiration at high intraoral
pressures.
The LVP is the primary muscle involved in velopharyngeal
closure, which is important for normal speech and in the
production of oral sounds, and is also active in non-speech
activities, such as blowing or sucking.

19. Palatopharyngeus :
• palatopharyngeus has two components: the
velar component consisting of two heads
that clasp round and insert into the levator,
and the pharyngeal component which
inserts into the superior constrictor in the
lateral and posterior pharyngeal walls.
• The function of the palatopharyngeus is
primarily to lower the palate, which assists
the swallowing of food.
• It may elevate the larynx, which assists in
the phonation of high pitched sounds.
• palatopharyngeus is active in the
production of oral sounds as well as nasal
speech sounds.

20. Palatoglossus :
• The palatoglossus is attached superiorly to the palatine aponeurosis and
inferiorly to the sides of the tongue.
• The function of this muscle is to
elevate the posterior part of the
tongue and assist in depressing the
soft palate onto the tongue.
• The palatoglossus coordinates with
the TVP to lower the soft palate to
produce nasal sounds.
• The palatoglossus raises the tongue against the soft palate to pronounce the
consonant k or g.

21. Musculus Uvulae :
This muscle is found bilaterally, attaching to the
posterior nasal spine and the palatine
aponeurosis superiorly and inserting into the
mucosa of the uvula inferiorly.
The main action of this muscle is to shorten the
uvula and add bulk to the soft palate, thereby
assisting the levator veli palatini in
velopharyngeal closure.
There have been differing opinions as to whether
the musculus uvulae is single or paired and
whether or not the muscle has a passive or active
role in contributing to velopharyngeal closure
during normal speech.

22.  Superior Constrictor :
• The superior pharyngeal constrictor is superiorly attached to the
pterygoid hamulus, the pterygomandibular raphe, the posterior end of
the mylohyoid, and the side of the tongue.

23. The muscle on either side sweeps around
superiorly and medially to form the lateral
and posterior walls of the pharynx and inserts
at the midline into the pharyngeal ligament,
thus encircling the nasopharynx and upper
oropharynx.
The action of the superior constrictor is to
elevate the pharyngeal wall and draw the
pharyngeal walls inward, assisting the action
of palatopharyngeus in the pharyngeal
component of velopharyngeal closure by
reducing the pharyngeal diameter.

24. • The uppermost fibres of this muscle originate from the medial pterygoid plate, it is
known as Passavant’s pad, named after Gustav Passavant (1860s) who first observed a
ridge on the posterior pharyngeal wall in cleft palate patients.
• Prominence on posterior wall of nasopharynx formed by contraction of superior const
rictor muscle of pharynx during swallowing Also called
Passavant bar, cushion, pad, and ridge.
• When present, this pad may assist in
effecting a seal with the soft palate as it
moves anteriorly with contraction of the
superior constrictor muscle.
• Passavant’s pad has been reported to be
more marked in individuals with palatal
insufficiency, suggesting that this ridge may
develop further when acting to compensate
for ineffective velopharyngeal closure

25.  Salpingopharyngeus :
• Attached superiorly to the
cartilaginous part of the
pharyngotympanic tube and
inferiorly to the
palatopharyngeal muscle.
• It was first believed that the
muscle elevates the larynx and
shortens the pharynx during
swallowing and speaking.
• Some of the fibres of the salpingopharyngeus blend with the
fibres of the superior constrictor, which may indicate that the
salpingopharyngeus assists the superior constrictor in elevating
the pharyngeal wall

26. VELOPHARYNGEAL CLOSURE :
• The soft palate (or velum) separates the nasopharynx from the
oropharynx.
• During quiet breathing the soft palate suspends between the
nasal and oral cavities, allowing air to freely move through the
mouth or through the nose.
• During active breathing in and out through only the mouth, the
soft palate will elevate to touch the posterior pharyngeal wall,
thus closing the opening between the oropharynx and
nasopharynx.
• This velar closure is known as velopharyngeal or
palatopharyngeal closure and is important for swallowing,
speech, and blowing.

27. Functional Anatomy of the Soft Palate Applied to Wind Playing
Alison Evans, MMus, Bronwen Ackermann, PhD, Medical Problems of Performing Artists, December 2010.
 Velopharyngeal mechanism :

28.  Sphincteric mechanism:
• Firstly, the velar component involves the elevation
and posterior movement of the velum.
• Secondly, the pharyngeal component involves the
movement of the pharyngeal walls encompassing
the oropharynx and nasopharynx.

29. • Croft et al. (1981) observed four main types of closure patterns
4. Circular
closure with
Passavant’s
pad is a
combination
of the circular
closure with
the anterior
movement
of the
posterior
pharyngeal
wall.
3. Circular
closure
requires an
equal
movement
from both
the velum
and the
lateral
pharyngeal
walls.
Sagittal
closure
involves the
medial
movement of
the lateral
pharyngeal
walls to meet
the velum
Coronal
closure is
achieved by
the elevation
of the velum
to touch the
posterior
pharyngeal
wall;

30. Variations in VP Closure
• Non-Pneumatic Closure - swallowing, gagging, and
vomiting
• Closure is high in the nasopharynx and is exaggerated.
• Pneumatic Closure - sucking, whistling, blowing, speech
• Closure may be complete for non-pneumatic activities, but
may be insufficient for speech and other pneumatic
activities.

31.  Evaluation of Velopharyngeal Function :
• Modulation of the pressurized air stream that emerges from the
lungs during expiration produces an auditory phenomenon that
is called “speech”.
• The tissues comprising the velopharyngeal sphincter are one of
several articulators capable of modification of the air stream.
• Dysfunction of that sphincter impairs the normalcy of speech to
varying degrees.
• There is a lack of consensus on the preferred terminology to
describe such dysfunction: velopharyngeal incompetency,
velopharyngeal insufficiency, and velopharyngeal inadequacy
have all been abbreviated as VPI.

32. • It is a physiological impairment without attempting to denote etiology.
 Diagnostic evaluation :
• It can be divided into two broad categories:
 perceptual
 Instrumental.
• “instrumental” includes all evaluations that use some type of
instrumentation.

33. 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.

34.  Instrumental : [Krakow & Huffman, Baken & Orlikoff ]

35. Muscle activities:
Electromyography (EMG)
• Surface electrodes
• Intramuscular electrodes
VP study usually needs
the intramuscular one.

36. Imaging :
• Fiberoptic endoscope
• Xray / MRI / Ultrasound

37. 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

39. 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.

40. 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.

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

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

43. • 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.

44. 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.

45. 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.

46. • A third grouping can be based on whether the
technique provides “visualization” of the
functioning velopharyngeal port or more indirect
assessment by recording changes in airflow, air
pressures, or sound or light transmission across
the velopharyngeal port, usually by means of
oronasal discrimination.

47.  Differential Diagnosis of Velopharyngeal Dysfunction
1. Anatomical deficiency
2. Myoneural deficiency
3. Anatomical and myoneural deficiency
4. Neither anatomical nor myoneural deficiency

48. Anatomical deficiency means a structural problem such
as an unrepaired cleft palate, a palatal fistula, a short
velum, a deep velopharynx, or ablated velopharyngeal
tissue.
Myoneural deficiency means adequate palatal and
velopharyngeal structural anatomy but inadequate or
absent function of one or more components of the
velopharyngeal port.
Combined anatomical and myoneural deficiency may
occur with repaired cleft palate, unoperated submucous
cleft palate, or postablative surgery and/or radiotherapy
for oronasopharyngeal malignancy.

49.  Velopharyngeal insufficiency in patients
with cleft palate:
Patients born with cleft palate have, by definition, a malformation that
involves critical anatomic components of the velopharyngeal mechanism.
Normally, the soft palate, or velum, is part of the complex coupling and
decoupling of the oral and nasal cavities to produce orally based or nasally
based speech sounds.
When a cleft of the soft palate is present, abnormal muscle insertions are
located at the posterior edge of the hard palate.
Surgery must not be aimed simply at closing the physical palatal defect, but
rather at the release of abnormal muscle insertions, establishment of muscle
continuity, and correct orientation so that the velum may serve as a dynamic
sling-like structure.

50. Despite successful closure of the soft and hard palate, the velopharyngeal
valving mechanism may not work adequately to allow for appropriate closure of
the nasopharynx from the oropharynx.
Most commonly, this insufficiency of the velopharyngeal valving mechanism
results in hypernasality, the audible nasal emission of air, which also may be
associated with abnormal compensatory articulation problems.
Most children who have cleft palate repairs performed at the appropriate time
in a successful manner have speech that is normal or speech that displays minor
abnormalities that can be treated successfully with speech therapy.
Approximately 20% of children with palates repaired appropriately develop VPI,
that may require additional surgical treatment using one of several surgical
options

51. A second clinical situation in which cleft palate patients may develop VPI is
after orthognathic surgical procedures.
Depending on the degree of skeletal movement, the soft palate structures
may be advanced to the point at which adequate velopharyngeal closure is
no longer possible.
VPI in cleft palate patients after Le Fort I midfacial advancement usually
resolves within 6 months of the procedure, but there is a small subgroup of
patients who benefit from an additional surgical procedure to help with
adequate closure of the velopharyngeal mechanism.

52.  Speech abnormalities in the cleft patient :
One of the complexities of the cleft palate malformation is the
function of the velopharyngeal sphincter.
In patients with a repaired cleft palate, the apparatus is altered and
the patient has learned to overcome a short or scarred palate that
does not move well by recruiting extra efforts from the adjacent
structures.
Activation of Passavant’s ridge (hypertrophy of tissue in the posterior
pharyngeal wall) is an example of a compensatory effort that many
cleft patients have developed to overcome the insufficiency of velar
movement and stretch.

53.  Warren’s aerodynamic demands theory :
severe velopharyngeal closure impairments cause the patient to
attempt to articulate pressure consonants at the larynx or pharynx
level instead of within the oral cavity.
This attempt causes abnormal compensatory articulation sounds.

54. Nasal air emission :
During the production of consonants, the creation of relatively
high oral pressure is critical to produce the appropriate sound.
If nasal escape occurs because of incomplete velopharyngeal
closure or fistula presence, consonants do not sound as they
should because of excessive nasal air emission.
It occurs with hypernasality, which is a resonance problem
associated with vowel production, not consonant production.

55. Resonance :
Hypernasal perturbations occur during the production of vowel sounds
that require the appropriate closure of the nasal spacefrom the oral
space.
Of the 20% of patients who have speech disturbances related to cleft palate, most
speech issues present as hypernasality. (Hall C, Golding-Kushner KJ. Long-term follow-up of 500 patients
after palate repair performed prior to 18 months of age. Presented at the Sixth International Congress on Cleft Palate and
Related Craniofacial Anomalies. Jerusalem)
Hyponasality is a reduction in nasal resonance that occurs because of abnormal
obstruction (a pharyngeal flap that is too wide).

56.  Articulation :
Articulation problems may be related to difficulties with creating the
adequate amount of oral pressure necessary to create fricative,
affricative, oral stop, lateral, and glide sounds (/f/,/th/, /v/, /s/, /z/,
/sh/, /zh/, /ch/, /j/, /p/, /b/, /d/, /k/, /g/, /t/, /l/, /r/, /y/, and /w/,).
When the velopharyngeal mechanism does function appropriately to
close off the nasal cavity, airstream escape makes it challenging to
produce these sounds.
Compensatory articulation occurs when the patient tries to
pathologically shape the airstream more posteriorly in the vocal tract
rather than at the normal locations of the anterior palate, teeth, and
tongue.

57.  Speech evaluations :
VPI is only one element of speech problems that can be seen in patients with cleft
palate.
A standardized speech assessment should be used at each center that evaluates
these patients
The same clinical evaluation and measurements should be obtained for each visit
and ideally should be performed by the same speech pathologist.
Specialized testing such as nasometry, videofluoroscopy, and nasopharyngoscopy
usually is warranted in addition to standard screening and evaluation tools.

58.  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.

59. 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.

60. • When the pharyngeal flap is used, a flap of the posterior wall is attached to the
posterior border of the soft palate.
• The flap consists of mucosa and the superior pharyngeal constrictor muscle.
• The muscle stays attached to the pharyngeal wall at the upper side (superior
flap) or at the lower side (inferior flap).
• The function of the muscle is to obstruct the pharyngeal port at the moment that
the pharyngeal lateral walls move towards each other.]
• It is important that the width and the level of insertion of the flap are properly
constructed, because if the flap is too wide, the patient can have problems with
breathing through the nose what can result in sleep apnea.
• Or a postoperative situation can be created with the same symptoms as before
surgery. Although there are complications such as the flaps width can change
because of contraction of the flap.
• This results in a situation with the same symptoms of hypernasality after a few weeks
of surgery.

61. superiorly based pharyngeal flap:

63. Inferior based pharyngeal flap :

64. When the sphincter pharyngoplasty is used, both sides of the superior-based
palatopharyngeal mucosa and muscle flaps are elevated.
Because the distal parts (posterior tonsillar pillars, which the palatopharyngeal
muscles are attached to) are sutured to the other side of the posterior wall the
pharyngeal port will become smaller.
As a result the tissue flaps cross each other, leading to a smaller port in the
middle and a shorter distance between the palate and posterior pharyngeal wall.
The procedure is relatively easy to execute. This makes the operation cheaper,
also because of a reduced anesthesia time.
The dynamic sphincter can be moved as result of a remaining neuromuscular
innervation, what gives a better function of the velopharyngeal port.
At last there is a lower complication rate, although obstructive sleep apnoea
syndrome(OSAS) is associated.
Sphinctoroplasty:

66. Posterior wall Augmentation :
• This technique can only be used for small gaps.
• When this operation is performed there are a several
advantages.
• It is possible to narrow down the velopharyngeal port
without modifying the function of the velum or lateral
walls.
• Furthermore the chance of obstructing the airway is
less, because the port can be closed more precisely.
• Many materials have been used for this
closure: petroleum jelly, paraffin, cartilage, adjacent
soft tissue, silastic, fat, Teflon and proplast.

68.  Complications of surgery for velopharyngeal
insufficiency :
Long-term postoperative complications are frequently seen as part of a
continuum of pathologic resistance in the airway that may result after
pharyngeal flap surgery.
Patients who have undergone pharyngeal surgery to decrease the aperture of
the sphincter to allow for closure during the formation of certain speech sounds
may present with problems related to snoring, upper airway resistance
sequence, or obstructive sleep apnea.
These pathologic conditions are each a progressive form of increased resistance
within the upper airway.

69. • Snoring is the audible sound produced when airflow is inefficient through
the upper airway.
• This may not be significant pathophysiologically but may be bothersome to
the significant other if the snoring prevents the other’s normal and restful
sleep.
• Upper airway resistance syndrome develops when more significant
resistance occurs without clear obstruction and a decrease in effective
oxygenation.
• Obstructive sleep apnea is the clear cessation of breathing during sleep that
causes an arousal from the normal sleep cycle.
• This condition contributes to daytime hypersomnolence and is associated
with increased risks for hypertension, cardiovascular disease, and stroke.

70. Non operation techniques :
•Prosthesis :
• Prosthesis are used for nonsurgical closure
in a situation of velopharyngeal
dysfunction.
• There are two types of prostheses. One
called the speech bulb and the other one
the palatal lift prosthesis.
• The speech bulb is an acrylic body that
can be placed in the velopharyngeal port
and can achieve obstruction.

71. • The palatal lift prosthesis is comparable with the speech bulb,
but with a metal skeleton attached to the acrylic body.
• This will also obstruct the velopharyngeal port.
• It is a good option for patients that have enough tissue but a
poor control of the coordination and timing of velopharyngeal
movement.
• It is also used in patients with contraindications for surgery.
• It has also been used as a reversible test to confirm if a surgical
intervention would help.

72. Related article:
• Association between velopharyngeal function and
dental-consonant misarticulations in children with
cleft lip/palate
J. Pulkkinen, M.-L. Haapanen, J. Laitinen, M. Paaso and R. Ranta
(British Journal of Plastic Surgery (2001), 54, 290–293)

73.  Introduction :
• The prevalence of dental-consonant articulatory
errors is higher in cleft patients than in non-cleft
patients.
• earlier studies have shown that, at the age of 6
years, 44% of cleft patients misarticulate at least
one of the sounds /r/, /s/ and /l/; 41% distorted
and 5% substituted (2% both distorted and
substituted) at least one sound.
• Speech aerodynamics and breathing may be
distorted in cleft patients.

74. • Dentoalveolar dysmorphology, in terms of the severity of the cleft, results in
atypical cephalometric dimensions.
• This is associated with abnormalities in vocal-tract anatomy and may cause
abnormal functioning and physiology during breathing and phonation.
• Alveolar fistulae, and the presence or absence of incisors, may also interfere
with the ability to articulate.
• Aim of this study was to examine the relationship between velopharyngeal
function and articulation of the Finnish dental consonants /r/, /s/ and /l/,
normally produced by linguoalveolar contact.
• To control for possible misleading variables, the effects of sex, cleft type,
method and timing of primary palatoplasty, palatal fistulae, earlier
velopharyngoplasty and speech therapy were also studied.

75. Patients and methods :
They assessed 278 6-year-old Finnish-speaking non-syndromic children (115 girls, 163
boys) with isolated cleft palate, cleft lip/alveolus or unilateral or bilateral cleft lip and
palate.
Auditory analysis of speech and velopharyngeal function, the presence of fistulae,
previous velopharyngoplasty and speech therapy, as well as surgical technique and timing
of primary palatal surgery were obtained from the hospital records.
The misarticulations of the sounds /r/, /s/ and /l/ were evaluated in spontaneous speech
by two experienced speech pathologists from the cleft team.
Velopharyngeal function was categorised, on the basis of the effect on speech, into
competent, marginal incompetent and obvious incompetent.
Nasal grimace and distortions due to palatal fistulae were registered.

76. • Number of patients with each type of cleft by sex, misarticulations of /r/,
/s/, /l/ or their combinations, obvious or marginal velopharyngeal
incompetence (VPI), previous velopharyngoplasty, previous speech
therapy and fistulae

77. • Specific signs of velopharyngeal incompetence (VPI) were not
included in the misarticulations studied.
• Speech characteristics associated with VPI were registered for all of
the sounds. Those were:
• 1:nasal air emissions;
• 2: hypernasality;
• 3: weakness of pressure consonants; and
• 4: compensatory articulations (glottal, lingual, pharyngeal
stops and nasal and laryngeal fricatives).

78. • The inter-judge agreement in the assessment of
speech characteristics of velopharyngeal function and
psychomotor development ranged from 91.3% to
94.2%.
• The data for each patient’s /r/, /s/ and /l/ sounds were
evaluated simultaneously by the two speech
pathologists; the categorizing of distortions and
substitutions was based on a 100% consensus
between them.

79. Results :
• The occurrences of misarticulation of /r/, /s/ or /l/ or
their combinations were statistically compared to
velopharyngeal competence, marginal velopharyngeal
competence and obvious VPI.
• No significant differences were observed.

80. • There was no significant difference in velopharyngeal function between boys
and girls in any cleft group.
• Thus, boys and girls were combined in later comparisons
• only significant difference was observed in the bilateral-cleft-lipand- palate
group, where all /s/ disorders were in the velopharyngeal competence
group.

81. Conclusion:
• Dental-consonant errors in cleft patients are a
separate error category.
• The treatment of dental-consonant errors could be
planned independently of the treatment of VPI.
• Some features specific to VPI may, of course, also
occur in association with dental-consonant
misarticulations, but according to our results
dental-consonant misarticulations are not
significantly related to velopharyngeal function,
whether competent or not.

82. Conclusion :
• The factors that may prevent VPI are not well understood and further
research is therefore needed.
• The function of the soft palate is essential for maintaining upper
respiratory tract structure and function under pressure and hence for
allowing optimal airflow.
• It is crucial for patients with cleft palate, some repaired cleft patients, wind
and brass players to be able to maintain firm velopharyngeal closure for
optimum performance.
• It is important to increase understanding of the functional anatomy of the
soft palate to help better manage injuries that may arise from overuse or
misuse of the soft palate muscles.

83. References:
• Cleft Palate & Craniofacial Anomalies Effects on Speech and
Resonance - Ann Kummer.
• Functional Anatomy of the Soft Palate Applied to Wind
Playing (Alison Evans, MM us, Bronwen Ackermann, PhD, and Tim Driscoll, PhD)
• Management of Velopharyngeal Dysfunction: Differential
Diagnosis for Differential Management (Jeffrey L. Marsh, MD St. Louis,
Missouri)
• Resonance Disorders and Velopharyngeal Dysfunction: Part
I. Types, Causes and Characteristics. Ann W. Kummer, PhD, CCC-SLP
• Wikipedia, the free encyclopedia

84. THANK YOU