Week 3 Flashcards
VPI & VPI Surgery
1
Q
Optiz-G Syndrome
A
- Autosomal dominant form - X-linked form
- Wide set eyes - may need surgery - laryngeal cleft, etc.
2
Q
Turner Syndrome
A
Non-inherited chromosomal syndrome - affects females - One x is partially/completely missing - prevents body growth & sexual development -
3
Q
Anatomy of the anterior 2/3 of the hard palate
A
Premaxilla, palatine processes of maxilla, palatine bones
4
Q
Anatomy of the posterior 1/3 of the palate (soft palate)
A
Muscle, soft tissue, mucosa
5
Q
Veolpharyngeal port
A
Space surround the velum, lateral & posterior pharyngeal walls
6
Q
Muscles of the soft palate: Tensor Veli Palatini Origin
A
Medial pterygoid plate of the sphenoid & lateral Eustachian tube - hook around hamulus of pterygoid plate
7
Q
Muscles of the soft palate: Tensor Veli Palatini Insertion
A
Ant. to post. - hard palate & opp. aponeurosis in the lateral palate
8
Q
Muscles of the soft palate: Tensor Veli Palatini Innervation
A
CN V (trigeminal)
9
Q
Muscles of the soft palate: Tensor Veli Palatini Function
A
Hinge between hard and soft palate - opens Eustachian tube to improve the ventilation & drainage of the auditory tubes
10
Q
Muscles of the soft palate: Levator Veli Palatini Origin
A
Lower temporal bone and medial Eustachian tube
11
Q
Muscles of the soft palate: Levator Veli Palatini Insertion
A
Palatal aponeurosis & opposite fibers
12
Q
Muscles of the soft palate: Levator Veli Palatini Innervation
A
Pharyngeal Plexus (CN IX, X, and XI)
13
Q
Muscles of the soft palate: Levator Veli Palatini Function
A
Sling action (up & back) - interacts w/faucial pillars
14
Q
Muscles of the soft palate: Musculous Uvulae Origin
A
Near midline of palatal aponeurosis and travels over levator muscle
15
Q
Muscles of the soft palate: Musculous Uvulae Insertion
A
Mucosa of uvula
16
Q
Muscles of the soft palate: Musculous Uvulae Innervation
A
Pharyngeal Plexus (CN IX, X, and XI)
17
Q
Muscles of the soft palate: Musculous Uvulae Function
A
Adds bulk & length to the velum (extra tissue that helps to close the velopharyngeal port)
18
Q
Muscles of the soft palate: Palatopharyngeus Origin
A
Lateral pharyngeal wall
19
Q
Muscles of the soft palate: Palatopharyngeus Insertion
A
Midline of velum
20
Q
Muscles of the soft palate: Palatopharyngeus Innervation
A
Pharyngeal plexus (CN IX, X, and XI)
21
Q
Muscles of the soft palate: Palatopharyngeus Function
A
Narrowing of VP port - pulling down on the velum from the lateral pharyngeal wall
22
Q
Muscles of the soft palate: Palatopharyngeus AKA
A
Posterior faucial pillar
23
Q
What are the FIVE muscles of the soft palate?
A
Tensor veli palatini Levator veli palatini Musculous Uvulae Palatopharyngeus (posterior faucial pillar) Palatoglossus (anterior faucial pillar)
24
Q
From all of the muscles of the soft palate, which is the ONLY one not innervated by the pharyngeal plexus?
A
Tensor Veli Palatini (innervated by CN V)
25
Muscles of the soft palate: Palatoglossus Origin
Oral surface of the velum
26
Muscles of the soft palate: Palatoglossus Insertion
Posterior, lateral tongue
27
Muscles of the soft palate: Palatoglossus Innervation
Pharyngeal plexus (CN IX, X, XI)
28
Muscles of the soft palate: Palatoglossus Function
Pull tongue up / keep palate down
29
Muscles of the soft palate: Palatoglossus AKA
Anterior faucial pillar
30
Superior pharyngeal constrictors origin
Broad - velum, portions of sphenoid, mandible and lateral tongue
31
Superior pharyngeal constrictors insertion
Median pharyngeal raphe
32
Superior pharyngeal constrictors innervation
Pharygneal Plexus (CN IX X XI)
33
Superior pharyngeal constrictors function
Lateral and posterior closure of VP port, velar movement, formation of passavant's ridge (bulking of muscle on the posterior pharyngeal wall)
34
Causes of VPI (12)
- Velopharygenal incompetence / insufficiency
- Abnormal muscle insertion following surgery
- Poor lateral/posterior pharyngeal wall movement
- Small oral cavity (s/p surgery)
- s/p adenoidectomy, adenoid atrophy
- s/p orthognathic surgery (LeFort 1)
- Phoneme specific faulty articulation
- Habituated patterns continuing s/p surgery
- Hearing loss
- Dysarthria (UMN, LMN - cerebral, cerebellar, brainstem, muscular)
- Apraxia of speech (inconsistence, increased severity w/increased length/complexity, HYPO)
- LMN damage (paralysis/paresis - common w/hemifacial microsomia)
35
Velopharyngeal incompetence / insufficiency
NOT synonyms
- Incompetence: WEAKNESS - everything is there, it just doesn't work well
- Insufficiency: Insufficient muscle / tissue bulk
36
Flaccid Dysarthria
Hypernasality - decreased consonants - nasal emission - velum pulls to non-damaged side
37
Spastic Dysarthria
Hypernasality - decreased pressure consonants - increased gag
38
Hypokinetic Dysarthria
Increased nasal airflow on consonants, slow VP movement - GENERAL SLOWNESS
39
Submucous cleft
Zona pelucida, bifid uvula, notching of posterior border of hard palate (V notch) - V-shaped elevation - reduced movement of the velum
40
Occult submucous cleft
Muscular deficiency on the upper surface of the velum (must visualize from the top - you don't hear / see it)
41
VPI effects on speech (6)
- Hypernasality (resonance issue - NOT airflow)
- Nasal air emission (HEAR air coming out the nose)
- Weak/omitted consonants
- Short utterance length
- Compensatory articulation productions
- Dysphonia
42
During nasal articulation...
-The velum is DOWN and the VP port is OPEN - the air is coming out of the nose AND the mouth
43
During oral articulation...
When you make an oral sound, the velum is UP and the VP port is CLOSED - the air comes out of the mouth ONLY
44
VPI effects on speech - Hypernasality
Resonance disorder that results form fault coupling of oral and nasal cavities - muffled/nasal - predominant use of nasal sounds (basically no plosives) - moderate to large opening of VP port
45
VPI effects on speech - Nasal Air Emission
Inappropriate release of air pressure through the nasal cavity during speech - audible only on consonants - associated w/air pressure and airflow and affects articulation vs. hyper nasality that is just resonance
46
Nasal air emission - Nasal rustle/turbulance
Bubblying in the back of the nose - small VP opening
47
Nasal air emission - Nasal snort
Forcible emission during consonant production - usually with sibilant sounds
48
VPI effects on speech - Weak / omitted consonants
Leakage through VP port or oronasal fistula, decreased air pressure for oral consents - there greater the nasal air emission, the weaker the consonants - pressure consonants greatly affected (stops. sibilant sounds) - not getting the pressure build up so they turn to nasal sounds
49
VPI effects on speech - Short Utterance Length
*Real indicator that air is being lost!
Nasal leakage shortens the supply of oral air pressure for speech - increased respiratory effort needed - speech becomes physically difficult - fatigue - short, choppy utterances
50
VPI effects on speech - Compensatory Productions
Airflow and utterance length changes are considered passive speech characteristics or "obligatory errors" - articulation changes are the reaction to the VP dysfunction - compensatory articulation productions - Maintain MANNER - BACK place of artic to get behind the cleft (glottal stops, pharyngeal stops, pharyngeal fricatives) - nasalization of oral phonemes
51
Compensatory Productions - Glottal stop
Rapid voice onset - pressure built up below the level of the glottis - plosive substitution
52
Compensatory Productions - Pharyngeal plosive
Back of the tongue against posterior pharyngeal wall - difficult to produce - used for k/g
53
Compensatory Productions - Pharyngeal fricative / Affricate
Back of the tongue against the posterior pharyngeal wall - with small opening left - substituted for sibilants
54
Compensatory Productions - Velar fricative
Tongue in position for /j/ sound w/frication - used for sibilant sounds
55
Compensatory Productions - Posterior nasal fricative
Incomplete closure of VP port- using nasal air emission / friction - typically for /s/
56
Compensatory Productions - What is substituted for voiceless plosives?
/h/
57
Compensatory Productions - Nasal sniff
Phoneme is produced through forced nasal inhalation - for /s/ in final position
58
Compensatory Productions - General backing of phonemes
Using back of the tongue and velum - assists w/ VP closure - prevents later loss through fistulae
59
VPI effects on speech - Dysphonia
Alteration of normal vocal quality - characterized by breathiness, hoarseness, low intensity, and glottal fry - typically causes vocal nodules - breathiness as a compensatory strategy
60
CP population has an increased risk for...
- Congenital abnormality of larynx
- Hyperfunction w/compensatory strategies (glottal stops)
- Careful monitoring of therapy so as not to increase tension/explore surgical option
61
Other resonance disorders - Hyponasality / Denasality
- Blockage in nasopharynx or nasal cavity (swelling of nasal passages, adenoid/tonsil hypertrophy, aprxia)
- In CP population: deviated septum, chaonal atresia, stenotic naris, maxillary retrusion (Crouzon / Aperts)
62
Other resonance disorders - Cul de Sac Resonance
-Only an entrance to but no outlet from the nasal cavity - "potato in the mouth" speech - combination of VPI and anterior blockage in nasal cavity
63
Instrumentation for assessment of VPI (6)
- Human ear
- Oral mech examination (nasal emission mirror)
- Radiography (VFSS)
- Nasendoscopy (GOLD STANDARD)
- Acoustic Analysis
- Aerodynamics
64
Radiography options
VFSS: lateral plane, AP view, oblique views, base view - contrast - not perfect b/c you won't be able to see if there is a GAP in closure, you'll just see that it's closed.
CT Scan
65
Videonasendoscopy
Optical instrument: viewing lens, fiberoptic tubing, eyepiece attached to camera - assess the contribution of all parts of VP sphincter, images *w/in our scope of practice
66
Nasendoscopy is used to...
- Determine presence / extent of VPI (size of gap, consistency of VPC, timing, movement of individual structures)
- Visualize the mechanism during speech (before, during, after development of prosthesis, determine location/size of additions)
67
Endoscopic Examination
Speech sample (Iowa Pressure articulation test) - Templin-Darley articulation test - oral / nasal consonants, oral only sentence, sustained fricatives, mixed contexts, words - phrases - sentences - swallow
68
VP closure patterns
Coronal, sagittal, circular, circular w/passavant's ridge
69
VP closure patterns: Coronal
Most common (55% of people) - most of closure is from soft palate; little medial motion is required - velum goes up and back
70
VP closure patterns: Sagittal
Majority of closure is from medial motion of lateral pharyngeal walls (10-15% of people) - some lateral wall movement is typical, but not when most of the closure is due to lateral walls
71
VP closure patterns: Circular
When both the lateral walls and soft palate provide closure (10-20% of people)
72
VP closure patterns: Circular w/Passavant's Ridge
Has posterior wall motion as well as lateral walls and soft palate - uses all 4 walls to close port (15-20%)
73
Acoustic Analysis: Nasometer
-Computer based equipment - computes ratio of acoustic energy between the microphones at nose & mouth (called nasalance) - dividing the intensity of nasal acoustic energy by the total of nasal + oral acoustic energy (score of 0-100)
74
Nasometery typical scores
Nasal sounds should be >50
| Oral sounds you want a score to be <30 is fine)
75
Aerodynamic Study
Area of opening can be measured by fluid flow amount through opening & accompanying pressure change - production of stop consonants, pressure sensing tubes placed in mouth and one nasal passage to determine difference - nasal airflow measured through other nasal passage
76
What is a mean oral air pressure and nasal flow for aerodynamic study?
A mean oral air pressure 300mL/sec is ABNORMAL
77
VPI management - Large gap or Flaccid/paretic palate
Palatal lift prosthesis - tight sphincter pharyngoplasty - superior based pharyngeal flap
78
VPI management - Moderate gap (2-10 mm) / good palatal lift
Sphincter pharyngoplasty
79
VPI management - Small (1-2 mm) central gap / irregular posterior wall
Loose sphincter pharyngoplasty - folded flap paryngoplasty - revision adenoidectomy
80
VPI management - Submucous cleft palate
Palatoplasty - double opposing Z-plasty
81
VPI management - Tonsil something causing VPI
Tonsillectomy
82
Prosthodontics for VPI
- Provide optimal VPC for speech production
- Training approach to increase VP closure capability (when they've mislearned sounds)
- Increase probability of successful surgical outcome
- Assist swallowing/articulation gestures (limited tongue mobility / coordination)
83
What are two prostheses that ASSIST in VP closure
Speech bulb
Palatal lift
84
Speech bulb
When the soft palate is too short to contact the posterior pharyngeal wall - the bulb contacts the posterior pharyngeal wall - maintains some opening on the sides of the bulb for nasal breathing - need lateral wall movement to close
*used in cases of INSUFFICIENCY - there is just not enough tissue
85
Palatal lift
Soft palate of sufficient length, but lacks sufficient mobility - soft palate contacts posterior pharyngeal wall - maintains some opening on the sides of the elevated palate for nasal breathing - again, need lateral wall movement to completely close
*used in cases of INCOMPETENCE - there is enough tissue, it just doesn't function well
86
Criteria for patient selection
Based on diagnostic information, including:
- speech characteristics, oral-pharyngeal examination, nasendoscopy, & VFSS assessment during speech
* VP closure is NOT accomplished & further function efforts are contraindicated
87
Patient selection criteria: Issue 1: Surgical approach may be contraindicated due to: (3)
- Significant surgical risk
- Patient and/or family's choice
- Cultural / religious concerns/issues
88
Patient selection criteria: Issue 2: Surgical prognosis may be guarded or poor because: (3)
- Concern that lack of palatal or pharyngeal wall movement will prevent successful surgical outcome
- Extent of movement
- Timing & coordination
89
Patient selection criteria: Issue 3: Will an improved VP mechanism help?
Further diagnostic information may be needed to determine the effect of improved velopharyngeal closure on speech production
90
Patient selection criteria: Issue 4: What is the status of oral hygiene?
Oral hygiene may need to improve so that the prosthesis will not worsen dental health
91
Patient selection criteria: Issue 5: What is dental & occlusal status?
- Tooth eruption / health / shape
- Occlusal structure / function (mandibular / maxillary alignment, limited mouth opening, other orthodontic appliances)
* All factors are important to allow satisfactory retention
92
Patient selection criteria: Issue 6: Patient & family cooperation, tolerance, and support are essential
- Multiple visits to construct prosthesis
- Multiple visits to modify / adjust / repair
- Prosthesis must be worn consistently
- Prosthesis must be cleaned consistently
- Easy to lose & expensive to replace
93
Patient selection criteria: Issue 7: Patient education
Patient, family, and support systems MUST understand what the prosthesis CAN and CANNOT accomplish
94
Patient selection criteria: Issue 8: Train out
The patient may be able to "train out" of the prosthesis, following systematic reductions of size, resulting in acceptable speech production
95
What percent of kids suffer from VPI following cleft palate repair?
10-36%
96
It's important to keep in mind the causes of the VP dysfunction
- Anatomical (mechanical)
- Neurogenic
- Behavioral
- Combination
97
It's important to keep in mind the characteristics of the VP dysfunction
VP gap size - VP closure pattern
98
What are 3 signs of a sub mucous cleft palate?
- Bifid uvula
- Zona pellucidum (velar muscle diastasis)
- Palatal notch at junction of hard/soft palate
99
Management of velopharygenal dysfunction
- Speech therapy
- Surgical options
- Prosthetic Devices
100
What are the surgical options for velopharyngeal dysfunction? (3)
- Pharyngeal flap*
- Sphincter pharygnoplasty*
- Palatal lengthening and/or re-repair
* = two main surgical options
101
Goals of VPI Surgery
-Partial obstruction of the VP port
1- reduction of opening between the nasal & oral pharynges
2- Lengthening the palate by retro-positioning the velum
102
What surgeries are used for reduction of opening between the nasal & oral pharynges?
- Pharyngeal flap
| - Sphincter pharyngoplasty
103
What surgeries are used for lengthening the palate by retro-positioning the velum
- V-Y Pushback
- Intravelar veloplasty
- Double-opposing z-plasty
104
When is diagnosis of VPI usually established?
Diagnosis of VPI usually not established until around 4 years old - need to let them develop their articulation systems & functional speech before you can evaluate
105
When is VPI surgery usually performed?
VPI surgery is usually performed ~5 years
106
Pharyngeal Flap Surgery
- Creates a central static obstruction & leaves 2 lateral ports
* MOST COMMON for VPI
- Most efficient in patients w/satisfactory lateral pharyngeal wall movement
- Sagittal or circular VP closure patterns
107
Where is the donor site for a pharyngeal flap?
-Posterior pharyngeal flap as donor site -unscarred, well vascularized, expendable tissue -minimal long-term donor site morbidity
Boundaries: adenoid pads superiorly, 3rd cervical body inferiorly, lateral pharyngeal walls
108
What do musculomucosal flaps incorporate?
Musculomucosal flaps incorporate segments of the superior pharyngeal constrictor muscles and palatopharyngeus
109
Posterior pharyngeal flaps can be based...
- superiorly (preferred)
| - inferiorly (length is limited by adenoid pad)
110
Inferiorly based posterior pharyngeal flap
- May had advantages as far as vascularity
- Limitations w/length, ability to inset the flap secondary to incorporated adenoid tissue at tip
- Low position of base in pharynx - tethers velum inferiorly
111
Superiorly based posterior pharyngeal flap
- May be lengthened and inset at the level of the soft palate
- May be lacking as a robust vasculature
112
Average pharyngeal flap width:
2-3 cm (depends on lateral wall movement)
113
Length of pharyngeal flap is dependent on what?
Length of flap dependent on access and requirement for tension-free insetting - average 2.5-3cm
114
Pharyngeal flap success rate:
63-98% success rate
115
Results if the pharyngeal flap is too wide:
HYPOnasality, mouth breathing, obstructive sleep apnea - sometimes transient and resolves ~6 months
116
Results if the pharyngeal flap is too narrow:
Continued VPI symptoms
117
Sphincter Pharyngoplasty
- Provides a static & possibly dynamic lateral & posterior obstruction, creating smaller central orifice
- Patients who demonstrate good velar elevation bout poor lateral wall motion may be good candidates
118
Where is the mucosal incision for a sphincter pharyngoplasty?
Over the posterior tonsillar pillar - pillar flaps rotated 90 degrees and inset into posterior pharyngeal wall mucosa
119
Hynes: Sphincter Pharyngoplasty
Elevated lateral pharyngeal flaps 3-4 cm long with salpingopharyngeus muscle, sutured anterior to Passavant's ridge
120
Orticochea modification: Sphincter Pharyngoplasty
Incorporated posterior tonsillar pillar with palatopharyngeus muscle
121
Jackson modification: Sphincter Pharyngoplasty
Added small superior pharyngeal flap
122
Post-Op Course
- Admitted to PICU to monitor airway (liquid/soft diet after 24 hours
- Continued multidisciplinary team approach
* Go home when pain is controlled, no signs of bleeding, no longer nauseated, breathing easily
123
Early complications of VPI surgery
-Airway compromise (usually w/in 1st 24hours, <1% require reintubation), hemorrhage, infection, aspiration/pneumonia, flap dehiscence, cervical subluxation
124
When do you usually see a flap dehiscence in a VPI surgery?
Usually when the flap sutured to the friable tonsillar tissue
125
Late complications of VPI surgery
- Sleep apnea
- Hyponasality
- Residual VPI
126
Contraindications to surgery
-Patient declines surgical management by choice, has known/suspected risk for airway obstruction, has intermittent/inconsistent closure that responds well to speech therapy, has incomplete diagnostic results, visible pulsations on the posterior pharyngeal wall
127
Velocardiofacial Syndrome (VCFS) characteristics
- long face w/prominent upper jaw
- Flattening of cheeks
- Underdeveloped lower jaw
- Bluish color below eyes
- Prominent nose w/narrow nasal passages
- Long thin upper lip
- Down-slanting mouth
- Cleft palate
- Cardiac defects
128
Furlow Palatoplasty
-Double-opposing Z-plasty is a method of primary repair of cleft palate - has been used secondary for VPI - reposition the palatal muscles transversely, creating a functional muscle sling by overlapping them - adds velar length
129
Who is the Furlow Palatoplasty reserved for?
Patients w/submucous cleft palates with VPI and patients with small VP gaps (<8-10mm)
130
Which VPI surgery is more likely to cause nasal airway obstruction and obstructive sleep apnea?
The furrow palataoplasty
131
What are two types of VPI prosthetics?
- Obturator prosthesis
| - Palatal lift prosthesis
132
What is an obturator prosthesis?
Fills residual gaps when tissue is deficient
133
What is a palatal lift prosthesis?
Used when there is adequate tissue but poor coordination and movement
134
When would you use a prosthetic for VPI?
May be used when surgery is contraindicated or not desired or as a temporary trial to test the expected effectiveness of surgery
135
Poor candidates for prosthetics for VPI
Patients w/reduced mental capacity, uncooperative patients/parents, poor oral hygiene/uncontrolled dental caries
