Modification of velopharyngeal closure pressures during phonation by neuromuscular electrical stimulation in healthy individuals.

Introduction: Rhinophonia aperta may result from velopharyngeal insufficiency. Neuromuscular electrical stimulation (NMES) has been discussed in the context of muscle strengthening. The aim of this study was to evaluate in healthy subjects whether NMES can change the velopharyngeal closure pattern during phonation and increase muscle strength. Method: Eleven healthy adult volunteers (21-57 years) were included. Pressure profiles were measured by high resolution manometry (HRM): isolated sustained articulation of /a/ over 5 s (protocol 1), isolated NMES applied to soft palate above motor threshold (protocol 2) and combined articulation with NMES (protocol 3). Mean activation pressures (MeanAct), maximum pressures (Max), Area under curve (AUC) and type of velum reactions were compared. A statistical comparison of mean values of protocol 1 versus protocol 3 was carried out using the Wilcoxon signed rank test. Ordinally scaled parameters were analyzed by cross table. Results: MeanAct values measured: 17.15±20.69 mmHg (protocol 1), 34.59±25.75 mmHg (protocol 3) on average, Max: 37.86±49.17 mmHg (protocol 1), 87.24±59.53 mmHg (protocol 3) and AUC: 17.06±20.70 mmHg.s (protocol 1), 33.76±23.81 mmHg.s (protocol 3). Protocol 2 produced velum reactions on 32 occasions. These presented with MeanAct values of 13.58±12.40 mmHg, Max values of 56.14±53.14 mmHg and AUC values of 13.84±12.78 mmHg.s on average. Statistical analysis comparing protocol 1 and 3 showed more positive ranks for MeanAct, Max and AUC. This difference reached statistical significance (p=0.026) for maximum pressure values. Conclusions: NMES in combination with articulation results in a change of the velopharyngeal closure pattern with a pressure increase of around 200% in healthy individuals. This might be of therapeutic benefit for patients with velopharyngeal insufficiency.

A new training method for velopharyngeal dysfunction: Self-inhalation for hypernasality.

OBJECTIVE: There are various methods to treat velopharyngeal dysfunction including　surgery and rehabilitation therapy. Even if a rehabilitation program is effective, the evaluation of its efficacy remains subjective. In this paper, we propose a new method of rehabilitation training for velopharyngeal dysfunction focusing on the objective peak inspiratory flow (PIF) rate. METHODS: Four patients, who were diagnosed with velopharyngeal dysfunction without cleft palate at ENT clinic of the National Hospital Organization, Tokyo Medical Center, participated in this study. All patients underwent our original rehabilitation program for velopharyngeal dysfunction, a method using the In-Check Dial, Turbohaler model. As a self-training rehabilitation program, we asked them to inhale forcefully 10 times daily at home using the In-Check Dial to increase the value of PIF rate for 3 months. We measured the patients' PIF rates with the In-Check Dial at the ENT clinic at the initial visit and after the 3-month training. RESULTS: The PIF rates of the four patients without nasal clips were higher than the rates with nasal clips at the initial visit. After the training, PIF rate without a nasal clip of all patients increased than the rate at the initial visit, which represented significant difference (P < 0.05). Also, after 3 months, PIF rate without a nasal clip was higher or equal than the rates with a nasal clip at the initial visit except one case. Naso-pharyngo-laryngeal fiberscopy did not detect salivary pooling around larynx and mirror fogging test did not show nasal escape in the three of four patients after 3 months of training. All reported improvement in dysphagia and dysarthria. CONCLUSION: This new method can be used not only to evaluate velopharyngeal function but also as an effective self-training treatment.

Effectiveness of nasopharyngoscopic biofeedback in clients with cleft palate speech: a systematic review.

OBJECTIVE: To conduct a systematic review analyzing the effectiveness of nasopharyngoscopic biofeedback in clients with cleft lip and palate and velopharyngeal dysfunction. METHOD: Extensive electronic search and analysis of the databases of Cochrane Library, MEDLINE, EMBASE, ERIC, PsycInfo, CINAHL, AMED, Journals@Ovid, and German Databases, including all papers published since 1970 plus a manual search of the Cleft Palate-Craniofacial Journal (1970-3/2010). RESULTS: Six studies met the inclusion criteria. Their analysis reflects a low level of evidence and a broad heterogeneity concerning age range, intervention methods, and outcome measurement. CONCLUSION: The analyzed studies show that nasopharyngoscopy may be effective only in combination with traditional speech therapy in helping patients with cleft palate speech optimize their velopharyngeal closure in articulation, but the quantity and quality of studies are limited.

The effect of nasal speaking valve on the speech under experimental velopharyngeal incompetence condition.

Velopharyngeal incompetence (VPI) is a contributing factor to speech disorders, frequently accompanying disorders, such as cleft palate, congenital paralysis of the soft palate, and cerebrovascular disease. For the treatment of these types of dysarthria, a Nasal Speaking Valve (NSV), which regulates nasal emission utilizing one-way valve, has been reported to be effective. As the unpleasantness while wearing the NSV was less than that with the conventional Palatal Lift Prosthesis, the NSV could be worn for a longer period of time. As NSV is inserted into the nostrils, this device could easily be provided for edentulous patients. This study aimed to evaluate the effect of NSV on experimentally induced VPI condition. Intelligibility of monosyllabic speech, intelligibility of conversational speech, nasalance score and acoustic analysis were used to evaluate the effect of NSV. Local infiltration anaesthesia was achieved to the area of levator veli palatini muscle and tensor veli palatine muscle of seven adult male subjects. In all subjects, remarkable suppression of the soft palate movement could be observed after the local infiltration anesthesia. Although the utterance supported by NSV under the experimentally induced VPI condition was less natural than the normal utterance, the intelligibility was markedly improved by the device. From the results of this study, the acoustic properties of NSV on the pure VPI condition, which was enabled by the newly established experimental induction, were revealed. This experimental model was also proved to provide a basis for the improvement in the treatment modalities for VPI.

The dental prosthesis used for intraoral muscle therapy in the rehabilitation of the stroke patient. A preliminary research study.

The dentist can maximize the oral rehabilitation of the stroke patient's weak or paralyzed oral musculature, resulting in dysfunctional speech, swallowing and deglutition, with the use of palatal lift and palatal augmentation prostheses. The study described here evaluates functional changes using these prostheses for three post-stroke patients with left hemiparesis. Clinical tests indicated decreased nasal emission and hypernasality, and improved speech articulation. Videofluoroscopy evaluation showed improvement in the oral phase of swallowing. Patient self-assessment indicated improved satisfaction with treatment.

Speech sample effects on pressure and flow measures in children with normal or abnormal velopharyngeal function.

OBJECTIVE: This study examined the effect of certain test phoneme contexts on oral pressure and nasal flow values in young children with normal velopharyngeal (VP) function. Comparison was made with responses from children with abnormal function. SPEAKERS: Ten children judged to have normal VP function (mean age = 5.2 years) and five children with VP incompetence (mean age = 7.8 years) were evaluated. Both groups were able to produce the speech sample with standard articulatory postures. Subjects were from the local community and a university cleft palate clinic. DESIGN: Simultaneous oral pressure and nasal flow recordings were obtained from the speakers as they produced /p/ in speech stimuli that varied in terms of test phoneme position in the syllable (releasing and arresting), adjacent vowel height (high, middle, and low), or adjacent consonant characteristics (voicing, placement, and manner). Within-subject differences in pressure and flow were examined to evaluate specific stimulus contrasts in each speaker group. SETTING: Data were collected in the Speech Physiology Laboratory in the Hearing and Speech Department at the University of Kansas Medical Center. RESULTS: There were few speech sample effects on oral pressure for children with VP competence. Nasal flow for this group occurred infrequently but was present at least once in 80% of the subjects. The speakers with VP incompetence demonstrated predictable phoneme context effects (higher flow and lower pressure for a nasal context; higher flow for a high vowel context). CONCLUSION: The finding of no significant stimulus effects for the normal speakers suggests the need for little concern when choosing stimuli for normative study of oral pressure. However, certain stimulus contexts should be considered for data collection if results are to be applied to children with abnormal velopharyngeal function.

Surgical correction of submucous cleft palate with Furlow palatoplasty.

Many surgeons have favored using the pharyngeal flap as the primary treatment for the velopharyngeal insufficiency associated with submucous cleft palate. However, the increasing number of reports of sleep apnea and airway compromise as a result pharyngeal flap surgery support the need to eliminate any unnecessary pharyngeal flap surgery. From 1988 to 1993, 35 Chinese submucous cleft palate patients with velopharyngeal insufficiency received surgery. A Furlow palatoplasty was used in 30 patients (3 to 26 years old). The follow-up duration was 9 months to 5 1/2 years. These patients were selected after a thorough study for velopharyngeal insufficiency including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, intraoral finding of an obviously anterior inserted levator palatine muscle, size of velopharyngeal gap, pattern of velopharyngeal closure, degree of lateral pharyngeal wall movement, and response to biofeedback speech therapy. In general, younger patients with circular or sagittal pattern closure, a velopharyngeal gap less than 5 mm, or good response to biofeedback speech therapy were considered to be the best candidates for a Furlow palatoplasty. The 5 patients who did not fulfill these criteria and whose velopharyngeal function failed to improve on preoperative biofeedback therapy were treated by pharyngeal flap operation. Twenty-nine patients (96.7 percent) achieved competent velopharyngeal function after the Furlow palatoplasty. The procedure corrected the velopharyngeal insufficiency in 3 patients older than 20 years with a velopharyngeal gap of less than 2 mm. The only patient with an unsatisfactory result was a 26-year old woman who had very prominent action of the musculus uvulae before the surgery. The results show that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected submucous cleft palate patients and thus avoid the serious complications of pharyngeal flap surgery.

Survey of services and practices of cleft palate-craniofacial teams.

Questionnaire data about services and practices of cleft palate-craniofacial teams were obtained from 63 teams in 35 states. Findings indicate the following: (1) research was the least frequently conducted activity, although 73 percent of the teams indicated that they conducted research; and (2) the majority of those responding regarded cinefluoroscopy, endoscopy, perceptual assessment, oral examination, and videoendoscopy as important procedures, yet most patients (90%) seen by these teams did not receive instrumental assessment of velopharyngeal function.

Issues in speech motor control and their relation to the speech of individuals with cleft palate.

A view of speech motor control is presented that is different from conventional coarticulation models. Rather than assuming that phonetic units specify targets for peripheral events, this view is based on holistic behavioral goals. The importance of discovering strategies that organize interactions among physiologic processes of the speech motor system is stressed. The concepts of motor flexibility and plasticity are developed. These motor control issues are used as the basis for discussing the relations among speech motor processes, critical minimum velopharyngeal port size, and speech adequacy in speakers with cleft palate. Different meanings of velopharyngeal incompetency are considered, and a potential misuse of the concept is explained. Finally, the developmental character of motor plasticity is discussed, and the implications of critical periods in speech motor learning are raised for children with cleft palate.

Dysarthria in adults: physiologic approach to rehabilitation.

A case study is used to illustrate a physical approach to the speech rehabilitation of adults with dysarthria. The approach emphasizes the component-by-component analysis of the peripheral speech mechanism, where the selection and sequencing of treatment procedures follow directly from the physiologic nature and severity of involvement in each component. The selection and sequencing of procedures also are conditioned by the inherent physical interdependencies of these component parts. Several biofeedback procedures of our own are incorporated that have not been reported previously. The case illustration is of a young man injured in an auto accident whose speech intelligibility improves from approximately 5-10% to 95% during the rehabilitation period. Effects of treatment upon individual components of the speech mechanism are illustrated.