Management of Velopharyngeal Dysfunction Flashcards
Sphincter pharyngoplasty closed the central port
F obliterate the lateral ports of the velopharyngeal mechanism and decrease the diameter of the
central port while still maintaining the centric opening
the incidence of VPD In patients with a
history of cleft palate surgery
the incidence ofVPD is approximately
20% to 30 %
Cause of Velopharyngeal Incompetence
results from
neurologic or neuromuscular dysfunction, for example, myotonic
dystrophy or amyotrophic lateral sclerosis
velocardiofacial
syndrome patient som of them present with Velopharyngeal Insufficiency
F Velopharyngeal Incompetence
Patients with
history of cleft palate surgery may have a short velum resulting in
anatomic defect associated with Velopharyngeal Incompetence
F Velopharyngeal Insufficiency
deep
pharynx resulting from cervical spine or cranial base abnormalities,
for example, in patients with Klippel-Feil syndrome present with Velopharyngeal Insufficiency
T
The percentage of patients with submucous cleft who has VPI ?
15%
The muscle that work to antagonist to LVP muscle
Palatoglossus and Palatopharyngeus Muscles that work to depress the soft palate
Tensor Veli Palatini form the middle 25% of the soft palate
F anterior 25 % of the soft palate
Musculus uvulae is the only intrinsic muscle of the soft palate and
takes origin from the palatal aponeurosis
T
There is no benefit from the reconstruction of Musculus uvulae
F reconstruction may improve VP port closure
and assists in the production of plosive sounds
The only e TVP muscle,
innervated by the mandibular branch of trigeminal nerve (CN V
T
The origin of tenso villa palatine
Tensor veli palatini (TVP) originates from the Eustachian tube and
from the scaphoid fossa of the sphenoid bone,
What is the Passavant Ridge?
In some
patients, the anterior motion of the posterior pharyngeal wall forms a
distinct bulge called the Passavant ridge
type of velopharyngeal closure?
coronal patterns, which are caused by posterior movement of velum with less contribution from the lateral pharyngeal wall
Sagittal closure is predominantly attributed to medial
movement of the lateral pharyngeal wall.
Circular closure is seen when there is good motion of velum as well as lateral pharyngeal wall
Bowtie
closure is seen primarily with movement of velum and posterior
pharyngeal wall causing poor or minimal motion of the lateral pharyngeal wall
Passavant ridge is also seen to contribute to the sagittal closure pattern
Passavant ridge contribute to circular closure
pattern, resulting in circular Passavant ridge closure pattern.
females demonstrate more circular
closure patterns and males demonstrating more coronal closure patterns
T
Patients with history of cleft palate
repair often present with class III malocclusion
T
What is the most important modality in the evaluation of a patient with VPD
formal perceptual speech evaluation by a speech and language
pathologist (SLP)
The Pittsburgh scale rates five aspects of speech including…..
nasality, phonation, articulation, nasal air emission, and facial grimace
the ear of the listener is
considered to be the standard in evaluation the VPI patients
T
speech sample of a patient with VPD often includes what?
poor intelligibility, hypernasality, nasal substitution and glottal compensations, and
weak pressure consonants.
Information
can be obtained by Videofluoroscopy
velopharyngeal gap size, palatal length
and stretch, pharyngeal depth, as well as the size oftonsil and adenoids.
At which age we can do Videofluoroscopy
can
be performed as early as 2 or 3 years of age
VFS seems to be better
tolerated by patients compared with nasopharyngoscopy (NPS)
T
VFS does expose the patient to radiation,
which is a downside ofthis test
T
Nasopharyngoscopy indications of ?
NPS is especially useful for small and asymmetric gaps, submucous
cleft, and VPD persisting post-pharyngeal flap
At which age we can perform Nasoendoscope
The patient ideally should be at least 4 to 5 years of age for this test, although it may be possible to successfully perform NPS on a very mature three-year-old patient
The advantage of MRI over NPS and VFS
The advantage of MRI over NPS and VFS is that it is noninvasive and avoids the
exposure to ionizing radiation
Draw back of the MRI
the poor image quality, when images are obtained during active phonation
Nasometry uesd to measure …….
measurement of oral and nasal air pressure and flow and calculation of velopharyngeal port size
Nasometry is one of the few tools that indirectly provide objective assessment of velopharyngeal mechanism
T
The drawback of nasometers
the criticism of its use is its oversimplification of the VPD mechanism and its inability to predict the location of gap size
An orifice of
>10 mm’ has been shown to correlate with hypernasality in nasometer
T
What are important anatomic factors that should be considered in selecting
an optimal surgical procedure for the treatment of VPI?
Size of the defect, closure pattern, and lateral wall motion
functional repairs of VPI add tissue from the adjacent area
F functional repairs yield a more anatomic local tissue rearrangement of structures in the soft palate, without adding tissue from neighboring areas
Risk of OSA. increase with functional repair of VPI
F. functional repairs inherently have less risk of obstructive sleep apnea (OSA) and should be attempted whenever possible to reduce the risk of long-term airway complications as the patient ages
Sommerlad et al. advocated that radical intervelar veloplasty should be considered as the first-line option in patients with
VPI
T
Functional Palatal Lengthening Objectives?
To achieve lengthening of the soft palate with retro positioning of levator muscle in the velum and closure of a small gap in
the VP port
The outcome of furlow surgery in VPI?
Furlow resulted
in significant velar elongation, increased acuity ofthe genu angle, and
retropositioning of the levator sling
tightening of the genu angle can improve the speech
T
The advantage of functional repair is that reduce the risk of future Obstructive sleep apnea
T at the cost of up to 30% risk of failure (or the incomplete resolution of VPI)
Other methods of palatal lengthening rather than Furlow or intervelar velplasty
include interpositional buccal flap and V-Y pushback palatoplasty
Posterioir pharngeal flap is original design for the pharyngeal flap was
superiorly based
F
inferiorly based
Difference between the superior and inferior-based pharyngeal flap
inferiorly based flaps
are considered easier to attach, and superiorly based flaps have the
advantage of giving a larger flap
The drawback of the inferior-based flap
limitation of its length and possible inferiorly directed pull onto the velum, which is in contradiction to the
goals of the effective velopharyngeal closure mechanism.
Pharngeai flap is suitable for which type of pharyngeal closure
patients with sagittal or circularly oriented closure patterns
factors that may play a role in the success of pharyngeal flap
are flap
width and level of attachment. Flaps that are too wide may be counterproductive by causing symptoms of hyponasality and sleep apnea;
on the other hand, flaps that are not wide enough may be ineffective
Pharyngeal
flap is ideally inserted at the level of C 2 to allow adequate elevation
of the velum.
F Pharyngeal
flap is ideally inserted at the level of Cl to allow adequate elevation
of the velum.
Sphincter Pharyngoplasty Hynes in
1950 utilized which muscle
bilateral salpingopharyngeus muscles
Recently the most commonly used muscle
the most commonly used design
of this procedure entails 90° transposition of the superiorly based
palatopharyngeal muscles
Sphincter Pharyngoplasty best suited for saggital closure pattern
F It is best suited for a large
the posterior gap with coronal, circular, or bowtie closure pattern and/
or poor lateral wall motion
Advantage of Pharyngoplasty?
An advantage of sphincter pharyngoplasty procedure is the ability to adjust the port size postoperatively,
if needed by tightening or loosening the muscles.
There is not enough evidence to suggest the superiority of sphincter pharyngoplasty or pharyngeal flap for the treatment ofVPl
T
overall complication rate was reported to be 6% in VPI
T
incidence of OSA following sphincter pharyngoplasty.
13%
the most common syndrome associated with cleft
palate and VPI
velocardiofacial or Shprintzen syndrome
present always with complete cleft palate
F Submucous cleft palate
Other contributing factors to VPI in syndromic case?
increase in the width of space between the velum and posterior pharyngeal wall, asymmetric displacement of lateral pharyngeal wall reduced adenoid size, and intellectual disabilities
The importan of nasendoscopy in syndromic VPI ?
During nasal endoscopy, attention
should also be paid to the presence of pulsations in the posterior or
lateral pharyngeal wall which may suggest medialization of internal carotid arteries
routine superiorly based pharyngoplasty can don safely with syndromic vpi may be safe in 52%
T
All patients with submucous cleft develop VPI
F submucous cleft, only
49.8 % were noted to have VPD
wait
on the surgical intervention till the patient is old enough to provide
an adequate speech sample for a perceptual speech evaluation. in submucous cleft
T
VPI can be associated with
superior pole tonsillar hypertrophy
T
If tonsillectomy is indicated, then it may be best to
perform it after performing surgical intervention for VPI
F If tonsillectomy is indicated, then it may be best to
perform it prior to the performance of surgical intervention for VPI
during tonsillectomy procedure, the posterior tonsillar pillar should be protected, in case sphincter pharyngoplasty is indicated
T
Once the patient undergoes surgery,
speech therapy becomes important in the postoperative period
T
no difference was noted in terms of speech outcomes,
sleep apnea, or need for further surgery, for patients treated with pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior
pharyngeal wall augmentation
T
Most common closure patterns in normal subjects is sagittal pattern
F. Coronal patterns
Pharyngeal flap used for large defect
T
Pharyngeal fat graft can lead to sleep
apnea
T
Palatoglossus muscles
lie in the anterior tonsillar pillars, where the palatopharyngeus
muscle is found in the posterior tonsillar pillar
T
