03 VPI/VPD Flashcards
How does a cleft palate impact speech?
Where is the air going? if the velopharyngeal port isn’t working the air will come out of your nose
You have to impound air in order to:
- To do plosives
- Get frication
- And make the air turbulent
- Blocking air with your tongue
What is VPI? what two things can it be due to?
Velopharyngeal Inadequacy (it does not have to be cleft, it’s an umbrella term)
Two things:
1. Velopharyngeal Insufficiency
2. Velopharyngeal Incompetency
Velopharyngeal insufficiency is what?
Structural etiology
Due to anatomical mismatch
-the soft palate isn’t long enough to contact the posterior pharyngeal wall–even though the muscles work
Velopharyngeal Incompetancy is what?
-neurogenic etiology
-the muscles of the velum are not capable of lifting the velum to close the velopharyngeal port
ex. stroke, disease process, apraxia
(This is the opposite of insufficiency because the muscular swing does NOT work)
T/F Velopharyngeal Mislearningcan take place of VPI?
True, the velum is completely capable of closure, the child has simply learned to make the phoneme wrong
- so they have manner right but place is wrong
- ex. /s/ /sh/ learn to put it through the nose and do /f/
Velopharyngeal dysfunction
covers the same etiology as VPI just a different name
In VPD when does hypernasality occur?
on vowels
-it is a descriptor of vowel quality
In VPD when does Nasal Air Emission occur?
on consonants
-there’s air coming through the nose when there shouldn’t be
To test NAE what pressure consonants should you use?
p/b, t/d, k/g, s/z etc. but NOT liquids or glides because those naturally have airflow
-have the child say puppy, paper, this horse eats grass, I like chocolate cake
Why do children develop compensatory articulation errors?
it is a deliberate cognitive attempt to produce some of the distinctive features correctly
-they have manner and voice
What is an example of compensatory artic errors?
if it’s a plosive they’ll try to stop but they’ll do it at the level of the glottis
or they’ll do a nasal snort
What is an obligatory error?
the child cannot help it, they can’t close the velopharyngeal port therefore, there’s nasal emission AND hypernasality
You should always assess the cause because
they always have the potential to have normal anatomy and the cleft will not be obvious.
ex. submucous cleft
How can you assess VPI/VPD?
- Radiographic study/x-ray
- Endoscopic eval of VP
- Video fluoroscopy
- your ear!
you can give a _____ by doing an endoscopic eval
prognosis
-you can look at contact and how strong the contact is
What can you find for an endoscopic eval?
- normal speech and resonance with normal VP function
- Consistent VPD
- Task-specific VPD
- Irregular VPD
- Abnormal resonance with VPD
Explain consistent VPD
If it’s consistent there’s nothing therapy can do!
- a surgical fix is required because the structures are not capable of closure
- however you may want to do a couple weeks of therapy if you think you can increase muscle activity
Explain task-specific VPD
Inconsistent VPD
- it closes for some sounds, not for others
- may be a timing issue
- VPD therapy is more likely to work
- your cut off time is 6 weeks, if you have no progress it’s time for surgery
Explain irregular VPD
there’s no predictable pattern
- you can never tell when there will be closure and when their won’t
- you can have abnormal resonance
Explain abnormal resonance without VPD
- you see closure but your person still sounds hypernasal
- you can never tell when the velopharyngeal closure will happen and when it won’t
- abnormal resonance, hypernasality
What can cause abnormal resonance without VPD if there is closure?
there is closure but something extra is vibrating
- there are other resonating structures
- some nueromuscular disorder ex. spastic dysarthria after a stroke
- ex. the velum is slow and weak, it may vibrate which vibrates the air in the nasal cavity but still makes the sound hypernasal
Degree of patency is also known as what?
Describe it relative to breathing
- how open the velopharyngeal port is (small, medium or large)
- is it left or right
- symmetrical or asymmetrical
What are the patterns of closure?
Coronal
Sagittal
Circular
Circular with passavants ridge
T/f the velopharyngeal port is a sphincter
True
Describe coronal closure
- it is the most common closure
- Horizontal
- the velum coming up to contact the velopharyngeal wall
- (the velum does all the moving)
Describe Sagittal closure
- the pharyngeal walls do all the moving
- vertical plane
- the pharynx closes towards the velum
- 5% of the population
Describe circular closure
The velum, velopharyngeal walls contract, everything comes together
3% closure
Describe circular with passavants ridge closure
really rare 1-2%
100% patency means
when you look at the open velopharyngeal port when the patient is breathing through the nose (it’s completely open)
you describe patency in terms of degree and location. But, what should you always remember?
- individuality changes the affects on speech
- ex. a client may have 30% patent and have no hyper nasality OR a client may have 10% patent and have hyper nasality
You can do a complete closure test using what consonants and vowels
- So you have them do /s, z, sh/ and describe the closure (70% patency means they have very little complete closure)
- test with vowel /i/
Normal closure can still include about _____ patency (open) and 95% closure
5% to 8% patency
“Left asymmetric medium patency” is describing _______ and _______
location and degree
these are interpreted differently reliability of judges is fair—medium
T/F The velopharyngeal port may close for suck and swallow
-Although the nerves and muscles are the same there’s a different neurological pathway that is different
-Remember: Speech is voluntary action
while biological functions = suck and swallow
What is the key when doing an evaluation?
Intelligibility!
Listen to errors
- are they consistent?
- Is it task-specific?
- You try therapy because you expect a difference?
- look at the mechanism and schedule surgery ?
- remember 6 weeks is the rule
What are the surgical managements of VPI/VPD?
Pharyngoplasty (augmentation, sphincter, flap) Speech appliance (retainers, obturators, lifts) Behavioral management (speech therapy)
What are the positive and negative of surgery?
negative: exposed to radiation for x ray before surgery and anesthesia
positive: Surgical fix for VPD requires no cooperation there’s anesthesia, it’s almost always successful, and parents don’t need to do anything
What is a pharyngoplasty?
Surgery on the velopharynx
- also known as a pharyngeal flap
- literally cutting a piece of tissue off the posterior pharyngeal wall
What are 3 types of pharyngoplasties
The Inferior Flap (inferiorly based)
the Superior Flap
Midline pharyngeal flaps
What is a superiorly based pharyngeal flap
- slice the velum so you can lay the tissue into the velum
- you have to have raw edges to add the tissue to a blood supply
- you put a bridge of tissue across the velopharyngeal port
if the tissue does not survive it __________
-dehisces
-it has not been truly transplanted and it dies
(also can happen on the hard palate)
What is a Inferior based pharyngeal flap
it pulls velum down
research has shown not to be acceptable anymore!
T/F Most pharyngeal flaps are midline
True!
Flaps can have negative outcomes
- You have to leave some room for nasal drainage, if it’s too big = hypo nasal!
- patients tend to have sleep apnea
Success of surgery is measured by what?
speech
How is Heinz/Ortocochea (Sphincter or lateral) Pharyngoplasty different from a a normal pharyngoplasty approach?
It creates a circular sphincteric closure instead of the flap
-The surgeon feathers the muscles out of the posterior faucial pillars
-the palatopharyngeus in the posterior faucial pillar
a circular channel is made in the lateral and pharyngeal walls
-palatal movement includes movement of that posterior faucial pillar
-you are essentially creating a passavants ridge
A pharyngoplasty will complicate what type of occlusion?
- a Class III malocclusion as facial growth occurs a flap can become an anchor
- because it is usually done around 7-9 years old, but that’s way late for speech
- (remember if the kids not syndromic it’s NOT language, it’s speech)
- Compensatory arctic strategies are SO hard to get rid of after 7 years of practice
What is a fistula?
- the tissue dehiscence and a hole is created
- they open because some sort of physical pressure against that tissue that caused tissue not to stay there in the first place
- It is already present as the jaw grows, especially if they put in a spreader
Appliances can be used to manage NAE and air leakage. Name the 4 types
- Palate obturator
- Palatal lift
- Retainer
- Obturator with a speech bulb
What is a palate obturator?
- added to the back of retainer
- Beaver tail, you shape it to fit this person’s particulate patent velopharyngeal port
- plug velopharyngeal port
- inexpensive to make them
- allows for facial growth
- it can be changed as they grow
What is the issue of a palate obturator
Issue:
- you have to wait until their 3 because you need stable molars to hook the obturator
- some orthodontist refer to this as long term tooth extrators
- The pressure is transferred to those molars
- Instead you put a post on the roof of the mouth, the retainer obturator can be hooked on after you drill a hole in the hard palate
What is a palatal lift?
-Regular retainer, but the lift goes over the entire velum, so it’s a much bigger material
-for a velum that is long enough but not strong enough
-helps pick up the velum and put it closer to the posterior pharyngeal wall SO the velum doesn’t have to work so hard and any movement will complete closure
-neuromuscular issue rather than tissue issue
sleep apnea is not a issue because the kid can remove it at night
How can the retainer help?
- covers hard palate and fistula if one is present
- you can put a retainer over the fistula over the hard palate
How can a Obturator with a speech bulb help?
- retainer goes into the velopharyngeal port
- it takes the place of the hard palate
What are the advantages of the appliances?
- no risk
- Earlier management is possible you can use earlier to stop or manage the compensatory strategies like glottal stops
- Revisions can be done as necessary.
- May stimulate growth
- Facial growth
- Younger children - 3, 4, 5 yrs. old
Management is a good option if you want to wait on surgery because?
Unknown etiology
Severe paralysis
Severe articulation disorder-delay
Mild resonance imbalance
describe what the hearing issues and the effects on language
disfunction in eustachian tube
talk about adding tubes when talking about surgery
what are the eustacian tubes 3 functions?
- Ventilation: equalization of air pressure
- Protection: when you blow your nose, the tubes need to be closed so snot does not come out of your ears
- Clearance: fluid in your ears has to drain—cleaning out middle ear cavity
