Speech Telepractice and Treatment Intensity in a Cantonese-Speaking Case with 22q11.2 Deletion Syndrome Following Late Diagnosis and Management of Velopharyngeal Dysfunction.

This case report explores clinical treatment efficacy in a Cantonese-speaking child with 22q11.2 Deletion Syndrome where diagnosis and management of velopharyngeal dysfunction can be considered late. All treatment sessions were undertaken via telepractice during the peak of the COVID-19 pandemic in Hong Kong. A hybrid of specialized cleft palate speech treatment techniques and traditional treatment approaches in Speech Sound Disorders were utilized. Treatment intensity components including dose, dose form, session duration, and total intervention duration were documented.

Prognosis of Continuous Positive Airway Pressure Treatment to Velopharyngeal Insufficiency: Preliminary Study.

BACKGROUND: Cleft palate is a congenital malformation that causes hypernasality and decreases the intelligibility of pronunciation and leads to velopharyngeal insufficiency. It causes difficulty in language development. Many studies and treatments have been conducted to reduce this problem, but there are limitations. In this study, the effect obtained through continuous positive airway pressure (CPAP) treatment was analyzed by statistical methods. METHODS: From May 2012 to December 2018, using patient demographics, computed tomography (CT) scan, and nasalance test was performed on 25 patient groups treated with CPAP devices for 8 weeks to confirm the effect after 6 months. RESULTS: After CPAP treatment in a total of 25 patients, 13 patients had a therapeutic effect. The average age of the patient group with treatment effect (effective group [EG]) was 51.2months, and the patient group with no treatment effect (ineffective group [iG]) was 73.6 months. ( P < 0.05). In CT data analysis, the highest palatal arch point was 6.31 mm in EG and 7.36 mm in IG, which was lower in EG ( P < 0.01), and the distance from incisive foramen to posterior pharyngeal wall was 41.39 mm in EG and 49.07 mm in IG ( P < 0.05). CONCLUSIONS: Through the statistical analysis, the group of patients who were effective in treatment had a low age at the beginning of treatment, the height of highest palatal arch point was low on CT data, and the length of distance from incisive foramen to posterior pharyngeal wall was short. It will be helpful to set the CPAP treatment patient group with respect to the results and age and CT data when treating VPI patients.

Velopharyngeal Insufficiency in Craniofacial Microsomia: Prevalence, Diagnosis, and Treatment.

ABSTRACT: The purpose of this study was to analyze the prevalence, diagnosis, and management of velopharyngeal insufficiency (VPI) in patients with craniofacial microsomia (CFM).Craniofacial microsomia patients 13 years of age and above treated at 2 centers from 1997 to 2019 were reviewed retrospectively for demographics, prevalence of VPI, and management of VPI. Patients with isolated microtia were excluded. Comparisons were made between patients with and without VPI using chi-square and independent samples t tests.Among 68 patients with CFM (63.2% male, mean 20.7 years of age), VPI was diagnosed in 19 patients (27.9%) at an average age of 7.2 years old. Among the total cohort, 61 patients had isolated CFM, of which 12 (19.6%) were diagnosed with VPI. Of the patients with isolated CFM and VPI, 8 patients (66.7%) were recommended for nasoendoscopy, of which only 2 patients completed. Seven isolated CFM patients (58.3%) underwent speech therapy, whereas none received VPI surgery. In contrast, 7 patients were diagnosed with both CFM and cleft lip and/or palate (CL/P), all of whom had VPI and were recommended for nasoendoscopy, with 5 (71.4%) completing nasoendoscopy, 6 (85.7%) undergoing speech therapy, and 6 (85.7%) undergoing corrective VPI surgery. Overall, we demonstrated that VPI was present in 27.9% of all CFM patients. On subset analysis, VPI was diagnosed in 20% of patients with isolated CFM and 100% of patients with CFM and CL/P. In addition, despite clinical diagnosis of VPI, a sizeable proportion of isolated CFM patients did not undergo therapy or surgical interventions.

Patient With Cleft Maxillary Hypoplasia Who Underwent Distraction Osteogenesis and Conservative Therapies to Postoperative Velopharyngeal Insufficiency.

The authors performed distraction osteogenesis using The Maxillary Distractor System (SYNTHES) to maxillary hypoplasia patient with cleft lip palate, and consequently improved the aesthetic complexion of the patient. Velopharyngeal insufficiency developed after bone elongation; the authors improved the insufficiency with conservative therapies such as articulatory training using the bulb attached palatal lift prosthesis. The authors were successful and accepted postoperative speech outcome.

[Velopharyngeal insufficiency in children]. / Insuffisance vélo-pharyngée chez l'enfant.

Velopharyngeal insufficiency (VPI) represents an incomplete closure between the soft palate and the posterior pharyngeal wall. Its etiology can be anatomical (cleft palate), neurologic, or iatrogenic (after adenoidectomy). The evaluation of a VPI begins with a through speech and language assessment and can be complemented by instrumental investigations. VPI treatment relies on its early identification, followed by a specific speech therapy management. Surgery is performed in case of no improvement with speech therapy or in case of an anatomical defect not allowing the child to improve. IVP management requires a multidisciplinary team.

L'insuffisance vélo-pharyngée (IVP) désigne un défaut d'occlusion entre le voile du palais et la paroi postérieure du pharynx. Son étiologie peut être d'ordres anatomique (fente palatine), neurologique ou iatrogène (adénoïdectomie). L'évaluation de l'IVP débute par un bilan phoniatrique et orthophonique détaillé et peut être complétée par des explorations instrumentales. Son traitement repose sur une identification précoce puis une prise en charge et un suivi orthophonique spécifiques. Une chirurgie est réalisée en cas d'absence d'amélioration ou de défaut anatomique ne permettant pas à l'enfant de progresser. L'IVP est une pathologie intéressant plus particulièrement l'enfant et sa prise en charge se fait par une équipe multidisciplinaire.

State of the Art in Treating Velopharyngeal Dysfunction.

Velopharyngeal dysfunction (VPD) is a condition that can greatly impact a child's quality of life. The initial evaluation and workup of patients presenting with VPD is generally straightforward, consisting of history taking and physical examination, perceptual speech analysis, and objective techniques such as nasometry and speech endoscopy. However, there is no standardized treatment option. Multiple surgical and nonsurgical techniques have been described, all with varying approaches to correction of the defect and similarly, with varying risks and outcomes. We aim to provide an overview of this condition and available treatment options, as well as highlight recent updates in management, including the use of cine magnetic resonance imaging, new injectable options for pharyngeal augmentation, and the evolving role of robotic surgery. We also discuss techniques to facilitate teaching during oropharyngeal surgery and our approach to revision surgical planning.

Calcium Hydroxylapatite Injection for Persistent Velopharyngeal Insufficiency after Sphincter Pharyngoplasty.

BACKGROUND: The role of calcium hydroxylapatite injection pharyngoplasty after failed sphincter pharyngoplasty surgery has not previously been described. We report our technique of injecting calcium hydroxylapatite into the pharyngoplasty site to add bulk to specific areas of the velopharyngeal port. METHODS: A retrospective review of children undergoing calcium hydroxylapatite injection pharyngoplasty for persistent velopharyngeal insufficiency after sphincter pharyngoplasty was performed. Our surgical technique is described. Outcome measures included postoperative perceptual assessment of resonance, improvement in phoneme-specific nasometry scores, and rate of revision surgery. RESULTS: Fourteen patients were included in the study. Improvement in hypernasality on perceptual assessment was noted in the majority of children (85.7%). The rate of achievement of normal resonance on perceptual analysis was 35.7%. A significant decrease in nasometry scores was noted for the following phonemes: /pa/, /sa/, /sha/, and /pi/. There were no intraoperative complications or immediate postoperative complications associated with calcium hydroxylapatite injection. CONCLUSIONS: Our early experience suggests that calcium hydroxylapatite injection after failed sphincter pharyngoplasty is a safe, minimally invasive technique with favorable short-term results.

A novel patient-controlled bidirectional palatal lift appliance.

OBJECTIVE: Palatal lift appliances have a role in management of velopharyngeal dysfunction for immobile palates of adequate length where surgery is contraindicated. Conventional appliances involve acrylic/wire work adjustment over successive appointments until they can be tolerated without gagging. A novel appliance has been developed where the lifting plate is incrementally distalized by the patient and vertically adjusted to optimize soft palate positioning. METHOD: The design, construction, and utility of the appliance, which was developed in Dundee Dental Hospital, are described. PARTICIPANTS: The subject was a 12-year-old boy with a variant of Moebius syndrome and velopharyngeal dysfunction. Previous pharyngoplasty had been carried out and further surgery was contraindicated. INTERVENTIONS: The appliance is constructed and fitted and the flexible spring arm is vertically adjusted to lift the soft palate. The screw is turned incrementally at home, extending the lifting plate posteriorly. Videofluoroscopy allows visualization of the appliance and soft palate positioning. MAIN OUTCOME MEASURES/RESULTS: The procedure improved soft palate positioning, as demonstrated by videofluoroscopy, and objective speech outcomes. CONCLUSIONS: The appliance was well tolerated and led to improved speech outcomes for the patient. Adjustments were quick and easy for both clinician and patient. Further studies are needed to definitively determine the efficacy of the appliance.

The Effect of Loudness Variation on Velopharyngeal Function in Children with 22q11.2 Deletion Syndrome: A Pilot Study.

OBJECTIVE: Children with 22q11.2 deletion syndrome (22qDS) often require surgical intervention to treat velopharyngeal dysfunction (VPD). Although some studies have documented improved velopharyngeal (VP) closure under increased speaking effort, currently no studies have examined the effect of similar behavioral speech modifications on VP closure in children with 22qDS. The purpose of this pilot study was to explore the effect of loudness on VP closure during speech in children with 22qDS and persisting VPD. PATIENTS AND METHODS: Four children with 22qDS, posterior pharyngeal flap, and persisting mild VPD underwent pressure-flow testing while repeating words at habitual and increased loudness levels. Using a single-subject A-B design, descriptive statistics and graphical measures were used to examine differences in VP orifice area (VPA) and timing of closure in the habitual versus loud condition. RESULTS: Results were mixed. Median VPA decreased during some stimuli for 3 participants, but increased for 1 subject when speaking louder. Median duration of nasal airflow decreased for 3 participants in the loud condition. CONCLUSION: This study presents preliminary aerodynamic data regarding the plasticity of VP physiology in the 22qDS group. Further research is needed to determine how loudness impacts VP function in children with 22qDS.

Management of velopharyngeal disorder with a pharyngeal obturator: a case report.

Patients with acquired defects or congenital malformations of the palate reveal disturbances in speech, including hypernasality, nasal emission, and decreased intelligibility of speech. Deglutition is also affected. All of these side effects have a negative impact on the psychological and social status of the patient. Maxillofacial prosthetic treatment can restore the palatopharyngeal integrity and offer the potential for acceptable speech using a pharyngeal obturator, also known as a speech aid prosthesis. This article describes the prosthodontic management of a patient with a palatopharyngeal defect using a pharyngeal obturator.

Articulating the issues: speech assessment and intervention in cleft lip and palate.

This paper describes the impact of cleft lip and palate on speech. It provides an overview for the dental clinician of the key issues affecting speech development and clarity. The paper summarises the complex speech mechanism and cleft-related factors that affect speech, including palatal, dental and occlusal anomalies. It outlines the framework for speech assessment throughout the cleft pathway and provides a description of cleft speech disorder, as well as describing treatment approaches for cleft speech and velopharyngeal dysfunction.This is followed by a spotlight on speech prosthetics for treating nasal speech, with an emphasis on joint management by the Speech and Language Therapist and Consultant in Restorative Dentistry. This includes the core multidisciplinary approach, clinician and patient-reported outcome measures, and brief discussion of national developments in this area.The importance of multidisciplinary cleft care is highlighted and, within this, the essential interaction between speech and dental clinicians in providing routine care, as well as in delivering a highly specialist speech prosthetics service.

Prosthodontic rehabilitation for edentulous patients with palatal defect: report of two cases.

Cancer resection is the most common cause of acquired palatal defects, whereas cleft palate is the main cause of congenital defects. Palatal defect can be repaired by reconstructive surgery and/or a dental prosthesis. We present prosthodontic rehabilitation of two maxillary edentulous patients, one with a surgically induced palatal defect and the other with congenital cleft palate. In case 1, an 86-year-old man underwent surgical removal of soft-palate squamous cell carcinoma. The acquired palatal defect was repaired by a maxillary complete denture with a posteriorly extended speech bulb. The final prostheses provided good chewing and speech functions. In case 2, a congenital cleft palate in a 65-year-old man was repaired by a maxillary complete denture with superior extension of the obturator, which was designed to improve retention and stability of the upper single denture. He was satisfied with the upper denture after prosthesis placement. Conventional maxillary complete denture with a posteriorly extended speech bulb or modified obturator provides a good chance to restore oral functions in patients with palatal defects. The patients' skill and previous experience of denture wearing might have been important in their successful treatment. However, different patients present with unique problems and need to be treated individually.

Types and causes of velopharyngeal dysfunction.

The velopharyngeal valve is responsible for production of oral speech sounds. There are three components to normal velopharyngeal function: anatomy, physiology, and learning. velopharyngeal dysfunction (VPD) is a condition where the velopharyngeal valve does not close consistently and completely during the production of oral sounds. Velopharyngeal dysfunction can be caused by abnormal anatomy (velopharyngeal insufficiency), abnormal neurophysiology (velopharyngeal incompetence), or particular articulation errors (velopharyngeal mislearning). The purpose of this article is to acquaint the reader with what is required for normal velopharyngeal function. In addition, there will be a discussion of the types of velopharyngeal dysfunction and various causes of each. Implications for treatment and prognosis will be discussed.

Instrumental assessment of velopharyngeal closure for speech.

The presence of a palatal cleft at birth should not prevent good speech production in most children provided they have (1) appropriate surgical intervention to close the palate at or around the child's first birthday, (2) careful monitoring of speech development throughout childhood, (3) speech therapy when needed, and (4) secondary surgical or speech-prosthetic intervention when needed. When managed carefully by an experienced, well-prepared multidisciplinary team that applies the criteria listed above, ~70% of children with nonsyndromic palatal clefts will have no significant difficulties with speech intelligibility or speech quality due to velopharyngeal insufficiency by the time they enter elementary school. Speech assessment is the first step toward comprehensive team management of children with cleft palate. The purpose of this chapter is to describe the use of instrumentation in the evaluation of speech of children with palatal clefts, within the context of a multidisciplinary team. The focus of this article is on instruments that are used to supplement the perceptual assessment to document current speech status and plan management strategies.

Disorders of resonance and airflow secondary to cleft palate and/or velopharyngeal dysfunction.

The purpose of this article is to help the reader understand what contributes to normal resonance for speech production. In addition, the reader will learn about the types of resonance disorders and their characteristics. The causes of resonance disorders will be described with a guideline on how they should be treated. This article also includes a discussion of normal airflow for speech and the perceptual speech characteristics that often occur when there is abnormal nasal airflow. Secondary characteristics of nasal airflow, including weak or omitted consonants, short utterance length, nasal grimace, and compensatory articulation productions, are also described.

Prosthetic treatment combined with speech therapy improved pronunciation problems caused by palatal incompetence: A case report.

This is a case report of a patient with soft palate muscle weakness that caused difficulties with phonation. A provisional palatal lift prosthesis (PLP) was developed, and the patient underwent simultaneous speech therapy. The elevation level of the palatal lift was subjectively assessed along with nasalance analysis and the Urimal Test of Articulation and Phonation results. The final PLP was applied to improve comfort and efficiency, and the patient continually underwent regular speech therapy. The patient showed satisfactory improvement in speech and pronunciation. PLP development combined with speech therapy can improve the accuracy of pronunciation in patients with palatal incompetence, thereby improving quality of life.

Management of velopharyngeal disorders. A case series.

Patients with acquired defects or congenital malformations of the palate exhibit disturbances in speech, including hypernasality, nasal emission, and decreased intelligibility of speech. Maxillofacial prosthetic treatment can reestablish the palatopharyngeal integrity to provide the potential for acceptable speech. This article describes a case series of patients with palatopharyngeal disorders and their treatment approaches.

Publishing trends in velopharyngeal insufficiency.

OBJECTIVE: This study seeks to describe publishing trends for VPI over a 33-year span with regard to treating specialty, methods of assessment, related diagnoses, and methods of treatment for each specialty. METHODS: A PubMed search was performed on "velopharyngeal insufficiency" using medical subject headings terms from 1985 to 2017. Publisher specialty, method(s) of VPI assessment, associated diagnosis/diagnoses, and method(s) of VPI treatment per specialty and combined across specialties were analyzed. Respective publications were totaled in 11-year intervals and two-way analysis of variance was used to compare change over time within specialties and across specialties. RESULTS: 763 publications were included for analysis. The total number of publications on VPI increased from a total of 6 in 1985 to a peak of 67 in 2015. The specialties that showed the largest increase in relative frequency of publication were Otolaryngology (p < 0.001), Plastic Surgery (p < 0.001), and Multidisciplinary (p < 0.001). Publications on endoscopic (p < 0.001) evaluation of VPI have significantly increased over time relative to magnetic resonance imaging and lateral cephalometry. Across all specialties, publications that feature pharyngoplasty (p < 0.001), palatoplasty (p < 0.001), and pharyngeal flap (p < 0.001) as methods of VPI treatment have significantly increased over time. CONCLUSION: There is a trend towards endoscopy for diagnostics and a multidisciplinary approach when managing patients with VPI. The specialty that showed the largest increase in the relative frequency of publication was Otolaryngology. Surgical methods of treatment continue to be described at increasing frequency relative to more conservative treatments.

Evaluation of sites of velopharyngeal structure augmentation in dogs for improvement of velopharyngeal insufficiency.

BACKGROUND: Velopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI). METHODS: Velopharyngeal structure augmentation was performed on 10 beagles (age range: 20-24 months; weight range: 9-12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage. RESULTS: Pre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls. CONCLUSIONS: During VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients.