Lecture 5

Question 1

List the three types of therapy for velopharyngeal dysfunction:

Answer 1

1) Surgical therapy
2) Prosthetic therapy
3) Conservative (SLP) Therapy

Question 2

T or F: Proprioceptive control of the Velum is good. SLP’s can easily intervene and teach this.

Answer 2

False

Question 3

Describe pharyngeal flap surgery:

Answer 3

Inferior and superior (preferred) sewing of velum to pharyngeal wall. There is space on either side of the stitch for air to pass. The patient still needs to learn to use velum.

Question 4

Describe Pharyngoplasty surgery:

Answer 4

Augmentation pharyngoplasty - brings pharynx to velum using soft tissue, cartilage or synthetic material
Sphincter pharyngoplasty - moves vertical flap of skin horizontal

Question 5

Describe double opposing Z-plasty:

Answer 5

used to restraighten elevator muscles of the velum

Question 6

List indications for pharyngeal flap or pharyngoplasty:

Answer 6

• marked hypernasality with laminar nasal air emission

- A sufficient course of Speech therapy has not improved the problem

Question 7

List counter-indications for pharyngeal flap or pharyngoplasty:

Answer 7

• velopharyngeal frication/ turbulance (almost but not quite closed velum) - may have difficulty with breathing if the surgery is done
• hyponasality/ mixed nasality

Question 8

List preoperative indicators of postoperative treatment success:

Answer 8

• Normal articulation (ie. cul de sac/ pluggin nose improves speech)
• Circular closure pattern or active pharyngeal walls / passavant’s ridge
• No cognitive and socio-behavioural impairments

Question 9

_______ require coronal velar activity.

Answer 9

pharyngoplasties

Question 10

______ require sagittal or circular velopharyngeal activity.

Answer 10

pharyngeal flaps

Question 11

Pharyngeal flaps and pharyngoplasties should be the exception rather than the norm. Both ______ and _____ criteria are important in making the decision.

Answer 11

inclusion and exclusion

Question 12

T or F: Surgery will automatically improve speech

Answer 12

False

- It will only provide the structural prerequisites for improved speech.

Question 13

List options for Prosthetic Therapy:

Answer 13

1) Obturator
2) Speech bulb
3) Palatal lift prosthesis

Question 14

Describe how and when the obturator palatal prosthesis is used:

Answer 14

Fills a hard palate deficit.

- Can be used for fistulas.

Question 15

Describe how and when the speech bulb palatal prosthesis is used:

Answer 15

Fills a VP defect.

• Made over time to fill nasopharynx and to allow them to get used to it.
• They will feel it when swallowing. It needs lots of clasps so you don’t swallow it

Question 16

Describe how and when the palatal lift prosthesis is used:

Answer 16

Elevates a sufficiently long velum

- goes under the velum and lifts it

Question 17

T or F: A speech bulb can have the opposite of the desired effect of causing pharyngeal walls to move apart.

Answer 17

True

Question 18

Describe obturator reduction therapy:

Answer 18

The incremental reduction off a speech bulb can supposedly lead to improved velopharyngeal activity.

Question 19

Four things to consider when selecting candidates for Speech therapy:

Answer 19

1) mild hypernasality (some closure) and stimulability
2) Inconsistent hypernasality
3) Faulty articulation and stimulability
4) Behaviour modification after VP surgery

Question 20

T or F: Demonstrating VP closure is a prerequisite for successful therapy

Answer 20

True

- will not help in cases with structural inadequacies

Question 21

When would you treat someone who does not have VP closure?

Answer 21

• If they refuse physical management or if it isn’t available (ie. due to health). The goal of this therapy is to help patients do as well as possible

Question 22

Continuation of therapy in the absence of improvement is ____________

Answer 22

Irresponsible

Question 23

T or F: Non-speech exercise work

Answer 23

False

• no evidence
• may be used as warm up but not as focus or goal

Question 24

List VP techniques that don’t work:

Answer 24

1) Non speech exercises
2) Decreased speech rate
3) Electrical stimulation of gag reflex (hypertrophic musculature but no speech transfer)
4) Palatal exerciser (claims but no evidence)

Question 25

A caveat of VP speech therapy is ______

Answer 25

vocal hyperfunction

Question 26

List conservative therapy techniques that kinda/ might work: ???

Answer 26

???

1) Voice therapy strategies
2) Management/ functional techniques
3) Cul de Sac therapy
4) Auditory discrimination
5) Max nasalization with pull out
6) Therapy for nasal emission
7) Therapy of secondary behaviours

Question 27

What are 3 voice therapy strategies (Boone &McFarland) for hypernasal resonance disorders?

Answer 27

1) lowering habitual pitch (proposed masking effect)
2) increasing habitual loudness (proposed masking effect)
3) Increased oral opening to facilitate oral redirection of the airstream and sound

Question 28

Stemple (2000) advised that one possible management technique for functional hypernasality was ______

Answer 28

do the obvious . . . “speak like you have a cold”

Question 29

List 4 therapy management strategies (Stemple) for hypernasal resonance disorders?

Answer 29

1) articulation therapy
2) Pitch and loudness modification (low pitch, louder)
3) Nonspeech vocal play
4) Negative practice

Question 30

Golding-Kushner showed the benefits of articulation therapy. ________ were shown to increase VP activity

Answer 30

overarticulation / strong articulatory

Question 31

Do pitch and loudness modifications influence hypernasality?

Answer 31

no

Question 32

Morley proposed cul-de-sac therapy which involves plugging the nose. What are the pros and cons?

Answer 32

Pro - cul de sac resonance

con - may have the effect of complete velar imobility (velum doesn’t need to move)

Question 33

Fisher proposed _________ and ________for VP therapy.

Answer 33

Auditory discrimination training

Maximum nasalization with subsequent gradual ‘pull out’

Question 34

List kummer’s speech therapy for nasal emission:

Answer 34

• auditory discrimination training
• visual feedback
• tactile feedback
• cul-de-sac technique
• light, quick contacts

Question 35

How should you provide therapy for secondary behaviours such as nasal grimace/ flaring?

Answer 35

• Create awareness
• use visual and tactile monitoring
• for patients who have undergone surgery only begin therapy if the grimace persists 3 months post-op

Question 36

In terms of voice, normal speakers were shown to have higher nasalance in the ________ vs ________. In a hypernasal speaker forward focus (_________) had ______ nasalance scores.

Answer 36

forward voice focus vs backwards voice focus
“baby voice”
lower nasalance scores

Question 37

List techniques for biofeedback:

Answer 37

• with air paddle (flutters)
• See Scape
• nasal tube (to nose and ear)
• cul de sac
• tactile feedback
• nasalance biofeedback

Question 38

Describe CPAP treatment for hypernasality:

Answer 38

Resistance training using CPAP masks to strengthen VP sphincter. The pressure lvl and duration of exercises are gradually increased. VNCV targets require quick movement of velum. This is not an oral-motor exercise because speech is used.

Question 39

What are the Pros and Cons of CPAP:

Answer 39

Pros: Non invasive, salf administered, increased levator EMG activity
Cons: Carry over to conversational speech is critical step

Question 40

CPAP works best for patients with ______

Answer 40

mild hypernasality due to VP incompetence

Question 41

Who might have stress velopharyngeal dysfunction:

Answer 41

wind instrument players

• with extremely long/ intense practice sessions
• anatomical factors ie. oddly shaped adenoids

Question 42

What is stress velopharyngeal dysfunction?

Answer 42

VP dysfunction affects music but not usually speech

Question 43

Describe management of stress VP dysfunction?

Answer 43

1) Revision of practice schedule
2) Surgical therapy
3) Endurance training