Structural Flashcards
Most common palate repair surgeries
V-Y veau Walder Kilner
Von Langenbeck
Furlow… Double opposing z plasty
Vomer flap
What age do we repair cleft palate with surgery?
9-12 mos
The V-Y helps VP closure by
Elongating palate
Elevation of soft palate
Secondary surgery, only for severe VPI
Pharyngeal flap
Pharyngeal flap requires
Lateral wall movement
Pharyngeal flap risks
Stunted facial growth
Sleep apnea
Hyponasality
Prosthesis devices
Speech bulb/obdurator
Palatal obdurator
Palatal lift
What % cleft palate have conductive hearing loss?
96%
Therapy for cleft patient is appropriate if… (5)
Compensatory artic problems Inconsistent or mild nasal rustle (small gap) Phoneme specific nasality Nasality is due to dysarthria or apraxia Improves with trial therapy
Muscle for velum raising and vp closure
Levator veli palatini
Muscle for auditory canal tube opening
Tensor veli palatini
What does the uvulus muscle do?
Shortens velum
Lifts and pulls velum back
Helps with VP closure
What does the palatoglossus do?
Aids in velar lowering
And/or
Tongue elevation
What does the palatopharyngeus do?
Constricts and elevates pharynx. Helps with swallowing
Babbling and clefts…
Less babbling
Delayed reduplicated babbling
Cleft and consonant inventories
Avoid pressure consonants
Avoid anterior sounds
Fewer overall
Compensatory artic patterns
Glottal stops and glottal fricatives
Common phonological processes with cleft
Backing
Nasal assimilation
Improve with artic faster if cleft is repaired prior to age
10
Hypernasality most noticeable on …
Vowels
Decreased utterance length due to…
Air leaks, poor pressure… Causes more respiratory effort, resulting in more frequent breaths
Face is developing in what week?
4-10th
Combo of genetic and environmental factors called…
Multifactorial inheritance
Incidence cleft lip with or without palate
1 in 1000 live births
Delayed dentition leads to
Delayed chewing
Pharyngeal swallow develops at…
10th to 11th week gestation
Palate fuses at what week gestation?
10-11th
Suckling ability (anterior to posterior motion) at what week
18-24 weeks gestation
Most can suckle and swallow enough to maintain nutrition by age…
8-8.5 months gestation
Mix of suckle and suck can be seen in infants as young as…
6-9 months
Feeding concerns include…
Weak suck Not enough nutrition taken Nasal regurgitation Long feeding over 20-30 mins Fatigue Poor weight gain Parental anxiety affects bonding
SLP roles
Counsel parent, education
Swallowing
Artic and language
Cleft team coordinator
Best feeding position
Upright with chin tuck
Tips on feeding…
Weigh infant daily
In/out diary
Frequent burping
When to do cleft lip surgery?
Rule of 10s… 10 g Hgb?, 10 weeks, 10 lbs
As early as 6-8 weeks
2-3 months
Most common cleft lip surgery
Millard technique…
Cut as you go
Preserves philtral dimple and cupids bow
Scar is along philtral
Post cleft lip surgery feelings…
By syringe for 10 days
Velcro arm restraints
Avoid nipples which might damage sutures
Suture line care and cleaning
Speech problems persist after palate surgery in what percent of cases?
25%
If speech problems persist, secondary physical management (prosthesis) is usually needed by what age?
4 to 8 years
Post-op concerns for palate surgery
Swelling obstructs airway
Pain management and over sedation.. Meds given 7-10 days
Change in oral nasal airway dynamics
Feeding post palate surgery
Liquid diet
Soft foods 3 weeks post op
Bottles avoided
Arm restraints
We may help VP ——- but not VP ———-
Incompetence, but not insufficiency
Feedback used in therapy
Biofeedback
Nasometer
CPAP therapy
Compensations in glottis and strain may lead to
Voice disorders… Dysphonia, nodules
Hypo nasality may be seen on…
Vowels, nasal consonants
Soft voice syndrome, due to
Large nasal resonance absorbs acoustic energy - quiet vowels
Loss of pressure through VP port, hard to get loud
As a compensatory strategy for hyper nasality
In compensatory artic
Manner usually maintained
Placement is moved back
Create pharyngeal rather than oral pressure
Nasal sniff may be used for phoneme…
/s/
3 syndromes
Pierre robin sequence
Velocardiofacial syndrome
Stickler syndrome
Apert syndrome
Cleft classifications
Lip, palate
Unilateral, bilateral
Complete, incomplete
Primary, secondary palate
What is the ratio of left, right, bilateral cleft incidence
6 left - 3 right - 1 both
Where pink part of lip meets skin
Vermillion- cutaneous border
Hard and soft palates are part of the —- palate
Secondary
Layers of flat broad tendons…
Aponeusosis
Nasal cavity roof
Ethmoid bone
Nasal floor
Maxilla
Nasal lateral walls
Nasal bone
Nasal Conchae
Maxilla
Palatine bone
Nasal septum boundaries
Vomer
Ethmoid … Perpendicular plate
Cartilage
Name for nose hairs
Vibrissae
Fx of nasal conchae
Increase surface area
Increase turbulence
Reclaim heat from exhaled air
Hard palate
Anterior 2/3
Mucosa covered bone
Press food against in chewing
Soft palate
Posterior 1/3
Muscle covered by mucosa
Ends in uvula
Closes VP port in swallow
Name for bony hard palate growth
Torus palatinus/mandibulus
3 phases prenatal development, basic
1 and 2 are embryonic
3 is fetal
1st embryonic stage
Weeks 0-4
Cellular proliferation and migration
Some differentiation
2nd embryonic stage
Weeks 5-8
Differentiation of all organs… Morphogenesis
Very vulnerable stage
3rd, fetal stage
Growth and maturation
How many face primordia?
5
Face primordia develop in week — and fuse in weeks —-
Develop in week 4
Fuse in weeks 5-8
Ectodermal swellings filled with mesodermal and neural crest cells
Primordia
Name the facial primordia
1 Frontonasal prominence
2 mandibular prominences… From branchial arch 1
2 maxillary prominences… From branchial arch 1
Primitive mouth
Stomodeum
Ruptures to form oral opening
Oral plate lining
Thickened plate in ectoderm where sensory organ will develop, ie nose
Placode
Nasal placode
Lens placode
Start out laterally located
At 4 weeks in utero
Stomodeum, lining ruptures to be mouth
Nasal placodes laterally
Frontal prominence centrally above
At 5 weeks in utero
All major primordia can be distinguished
Mandible forms lower arch
Maxillary arch is lateral
At 5.5 wks, nasomedial and nasolateral processes that form nose
Paired arches like gills
Branchial arches and grooves
1st branchial arch
Mandibular arch below Stomodeum
Lower lip, mandible, muscles of chewing, front of tongue
Incus and malleus of middle ear (form meckels cartilage)
2nd branchial arch
Hyoid arch Side and front of neck Styloid process Upper part ... Lesser Cornu... Of hyoid bone Stapes of middle ear
3rd branchial arch
Greater Cornu of hyoid bone , bottom part
Part combines w 2nd arch to make hyoid and posterior tongue
4th branchial arch
Thyroid cartilage
5th branchial arch
Cricoid and arytenoid cartilages
At 6 weeks in utero
Maxillary process more prominent
Growth of nasal processes
Formation of primary palate
Fusion of median, lateral nasal processes and paired maxillary prominences
7th week in utero
Inferior tips of medial nasal processes expand laterally to form inter maxillary process
Tips of maxillary swellings meet the inter maxillary process and fuse
Cleft lip is a failure of fusion between…
Maxillary swellings and inter maxillary process
8th and 9th week in utero
Medial walls of maxillary process produce palatine shelves
Shelves grow down, parallel to lateral surface of tongue
End of week 9… Rotate up to horizontal position
Fuse w each other and primary palate to form secondary palate
Earliest ultrasound ID of clefting at…
13 weeks
Nares developed by week
Anterior nasal choane, 6th week
Tongue moves down, allowing
Palatal shelves to move up and tilt
Back to front
Toward midline
Palatal shelves are free of tongue by week…
8
Palatal shelves contact anteriorly by end of week…
8
Fusion of Palatal shelves moves from
Contact of Palatal shelves moves from
Font to back
Back to front
Uvula merges to soft palate by week
12, 1st trimester
Also this is the end of Palatal fusion
3 components of VP mechanism
Lateral pharyngeal wall
Posterior pharyngeal wall
Velum
Muscle that medializes lateral pharyngeal walls
Superior constrictor
For nasals, velum is…
Lowered
Swallowing muscles
Tensor veli palatini
Levator veli palatini
Respiration muscles
Palatoglossus
Palatopharyngeus
Innervated by cranial nerve…
10, vagus
Front 1/4 of velum is…
Tensor veli palatini
Back 3/4 of velum is the
Levator veli palatini
Is the uvulus paired?
Yes
Antagonist to levator veli palatini, covers mid 50% of velum
Palatopharyngeus
3 pharyngeal constrictors
Superior … Smallest
Middle
Inferior… Largest
Saingopharyngeus muscle
Not always present, little relevance, weak muscle
Motor nerves of velum
5, 7, 9, 10, 11
Sensory nerves of velum
10, 11
VP especially important for pressure sensitive sounds, like…
Stops, fricatives, africates
Not in all ppl, posterior wall movement during speech…
Passavant’s ridge
Coronal closure
Movement of velum and posterior pharyngeal wall
Not lateral
Sagittal closure
Movement of lateral pharyngeal walls
Little front,back
Circular closure pattern
All sides
Often Passavant’s ridge
VP insufficiency caused by
Anatomical defects…
Cleft history, short velum, deep pharynx, irregular adenoids, big tonsils
After surgery…
Maxillary advancement, Adenoids tony, treatment of tumor there, spine surgery through mouth
VP incompetence caused by
Poor muscle fx after cleft repair Hypotonia Velar paresis due to cranial nerve injury Dysarthria Myasthenia gravis Apraxia
Both VP incompetence and insufficiency are types of
VP inadequacy
PSNAE
Phoneme specific nasal air emissions
When Sound resonates in pharynx or nasal cavity and is not released due to obstruction
Cul de sac resonance
Nasal rustle is due to
Turbulence
Accompanied by nasal grimace often
How does nasal air emission affect consonants
Weakens them
Striped Y
1, 5 floor of nose 2,6 lip 3,7 alveolar ridges 4,8 premaxilla to incisive foramen 9, 10 hard palate 11 soft palate 12 congenital incompetence wo clefts 13 protruding premaxilla
Very mild incomplete lip cleft, looks like a scar
Forme fruste
Incidence cleft palate only
1 in 2000 births
Race and clefts
Gender
Asian, white, black
Male, female … Except isolated cp
% of cleft types
50 cl and cp…… More unilateral
30 cp alone
20 cl alone, most unilateral
Viral risk that causes cleft
Rubella
Risk increases with
Dad’s age
Separates primary and secondary clefts
Incisive foramen
Lip abnormality, not really a cleft
Microform
Thin bridge of soft tissue across cleft lip
Simonart’s band
Sub mucosal cleft signs
Bifid uvula
Bony notch into the hard palate
Zona pellucida… Velum mucosa looks thin
Fusion of bone sutures is called
Ossification
Inter frontal suture timeline
Starts closing after 1 year, usually done by age 7
Premature fusion of sutures
Craniosynostosis
Craniosynostosis syndromes
Apert syndrome…. Coronal
Crouzon syndrome… Coronal and saggital
Pfeiffer syndrome….all sutures
Speech concern outweighs
Maxillary growth constriction
Cheiloplasty
Cleft lip repair
Which palate surgery elongates the palate?
V-Y repair
Orthodontics to prep for surgery
Nasoalveolar molding
Bone grafting
From iliac crest of pelvic girdle
Primary… Infancy
Secondary… 8-11 years
Because it doesn’t grow
Furlow z plasty
Length at expense of width
Thickens velum
May be secondary surgery
More likely to be syndromic if
Cleft palate only
Ratio of nasal sound energy to total sound energy
Nasalance
Red flags, post surgery
Lack of consonant inventory growth
No oral stops 3 months post
Compensatory errors continue
