University of Montana ScholarWorks at University of Montana Graduate Student Theses, Dissertations, & Professional Papers Graduate School 1985 Speech results and associated findings following pharyngeal flap surgery in an established state craniofacial disorders program Maureen Patricia McMahon The University of Montana Follow this and additional works at: https://scholarworks.umt.edu/etd Let us know how access to this document benefits ou.y Recommended Citation McMahon, Maureen Patricia, "Speech results and associated findings following pharyngeal flap surgery in an established state craniofacial disorders program" (1985). Graduate Student Theses, Dissertations, & Professional Papers. 3639. https://scholarworks.umt.edu/etd/3639 This Professional Paper is brought to you for free and open access by the Graduate School at ScholarWorks at University of Montana. It has been accepted for inclusion in Graduate Student Theses, Dissertations, & Professional Papers by an authorized administrator of ScholarWorks at University of Montana. For more information, please contact [email protected]. COPYRIGHT ACT OF 1976 THIS IS AN UNPUBLISHED MANUSCRIPT IN WHICH COPYRIGHT SUB­ SISTS. ANY FURTHER REPRINTING OF ITS CONTENTS MUST BE APPROVED BY THE AUTHOR. MANSFIELD LIBRARY UNIVERSITY OF MONTANA DATE : 19 8 5 Speech Results and Associated Findings Following Pharyngeal Flap Surgery in an Established State Craniofacial Disorders Program by Maureen Patricia McMahon B.A., Carroll College, 1982 Presented in Partial Fulfillment of the Requirements for the Degree of Master of Communication Sciences and Disorders UNIVERSITY OF MONTANA 1985 Approved by: ^ Chairman, fioard ot''examiners Dean, Graduate School / Date UMI Number: EP34664 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent on the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. JMT_ Dimitfltfan Piutifahlng UMI EP34664 Copyright 2012 by ProQuest LLC. All rights reserved. This edition of the work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 ACKNOWLEDGEMENTS The undertaking of this professional paper was made possible by the generous assistance of Dr. Robert Blakeley, Professor and Director, Craniofacial Disorders Program, at the Crippled Children's Division of The Oregon Health Sciences University (OHSU). Dr. Blakeley took time to locate cases to review, made suggestions for gathering data and directed me towards a better appreciation of the rehabilitation process for velopharyngeal insufficiency. I wish to express sincere appreciation to my roommate, Maureen Pohlen, for her critical review and suggestions, but most especially for friendship and support during the writing of this project. Thank also to Dad and Mom. Their pep talks always worked wonders! Finally, I wish to thank Dr. Charles Parker for his efforts to coordinate my externship program between the University of Montana and the OHSU as well as his guidance during the last three years. TABLE OF CONTENTS PAGE I. Introduction II. Chapter One: Nature of Velopharyngeal Competence. ... 1 A. Definition of the Velopharyngeal Sphinctor B. Four Requirements of Effective Velopharyngeal Function C. Velopharyngeal Insufficiency 1. Etiology 2. Effects on Speech III. Chapter Two: Management Consideration for Correction of Velopharyangeal Insufficiency 8 A. Pharyngeal Flap Surgery 1. Purpose and Description 2. Historical Perspective 3. Complications B. Determining the Effectiveness of Flap Surgery C. Surgical Obturation and Mechanical Obturation D. Diagnostic Considerations 1. Need for Careful Assessment 2. Diagnostic Tools IV. Chapter Three: Medical Record Review- 21 A. Procedures and Problems 1. Categories for Data Collection a. Client Identification b. Pre-Operative Assessment c. Post-Operative Assessment B. Client Identification Data C. Comparison by Surgeon Between Pre- and Post-Operative Findings D. Results V. Chapter Four: Discussion 37 VI. Bibliography 39 iii LIST OF TABLES PAGE Table 1: Surgeon One - (Elimination of Hypernasality and. 27 Nasal Emission following Pharyngeal Flap Surgery) Table 2: Surgeon Two - (Elimination of Hypernasality and. 28 Nasal Emission Following Pharyngeal Flap Surgery) Table 3: Surgeon Three-(Elimination of Hypernasality and. 29 Nasal Emission following Pharyngeal Flap Surgery) Table 4: Surgeons Four-Ten-(Elimination of Hypernasality. 30 and Nasal Emission Following Pharyngeal Flap Surgery) Table 5: All cases Combined - (Elimination of Hypernasality.. 31 and Nasal Emission Following Pharyngeal Flap Surgery) Table 6: Complications Following Pharyngeal Flap Surgery. 32 Table 7: Surgical Revisions 33 iv INTRODUCTION This paper focuses on insufficiency of the velopharyn­ geal mechanism for speech. Through exploration of literature explaining the nature of velopharyngeal insufficiency (VPI), the diagnostic procedures utilized to determine its presence and the effectiveness of surgical or prosthetic management alternatives available, one discovers important variables which require careful consideration in order for successful rehabilitation to occur. A literature review is presented in Chapters One and Two with special emphasis on a surgical management procedure, the pharyngeal flap operation. This background information was necessary and helpful to the writer as she collected pre- and post-surgical information from medical records of 33 pharyngeal flap surgery cases followed in the State of Oregon Craniofacial Disorders (CFD) Program. The CFD Program has been in existence since 1953. Dr. Robert Blakeley, a speech pathologist affiliated with the program, described it as a "small but representative program" (personal communication, January, 1985). He explained that the "northern" Oregon program has approxi­ mately 20 consultants from plastic surgery to select from to perform pharyngeal flap operations. Reportedly, the CFD team attempts to refer patients to surgeons consid­ ered successful in eliminating VPI according to their previous history of success. v The purpose of this study was to determine the speech results after pharyngeal flap surgery. A secondary purpose was to report side effects and to discuss variations of results among surgeons as noted in the charts available for study. This was determined from reviewing comparisons of measures of excessive nasalization of speech. Additional data were collected on complications following surgery, on nasal breathing problems noted as well as on the need for further surgery to revise the flap. This paper concluded with a discussion section addressing difficulties encountered during the data collection from pharyngeal flap patient records. vi CHAPTER ONE NATURE OF VELOPHARYNGEAL COMPETENCY Velopharyngeal Sphincter To better understand the purpose and the success of pharyngeal flap surgery, an explanation of requirements for effective palatopharyngeal function is necessary. Bernthal and Bankson (1981) explain that velopharyngeal competence is "valving that takes place to separate the nasal cavity from the oral cavity during non-nasal speech production" (p. 150). The valving results through a sphincter-like action of the velum and the pharyngeal wall musculature which closes and opens the orifice between the oral and nasal pharynx. In simplistic terms, there are two motions closing the velopharyngeal port. First, through combined contrac­ tions of the tensor veli palatini, the levator veli pala­ tini, and the palatopharyngeus muscles, the thick midportion of the velum (soft palate) is tensed, elevated and moved posteriorly to approximate the mid - posterior pharyngeal wall (Fried, 1980 and Hogan, 1973). The second closing is performed by the superior pharyngeal constrictor muscles. The lateral aspects of the velopharyngeal port are closed by a medial motion of localized regions of both lateral pharyngeal walls against the velum (Curtin, 1973; Hogan, 1973 and Zemlin, 1981). These closure patterns have been explained further by Osberg and Witzel (1981). They found that velopharyngeal 1 2 closure was achieved primarily by action of the velum in concert with the posterior pharyngeal wall with little lateral wall movement; yet, in patients with hypernasal speech, the approximated closure resulted primarily from action of the lateral pharyngeal walls. McWilliams (1985) concluded then that "closure obtained by the lateral pharyngeal walls is often not effective for adequate speech production" (p. 30). In conclusion it should also be noted that although the integrity of the closing motion provides for normal vocal resonance, the valving does not occur precisely the same in all speakers. Skolnick (1975) demonstrated that a variety of closure patterns exist in both normal and cleft speakers. The velopharyngeal sphincter is a valuable structure during sound production. Morris and Smith (1962) have referred to it as "the single most important requirement for impounding adequate breath pressure" (p.218). In connected speech, the sphincter must be closed frequently in order to impound adequate oral air pressure for the normal production of many sounds. When the velopharyngeal sphincter does not adequately function, there are numerous unacceptable changes in voice quality resulting from the acoustic coupling of the oral and nasal pharynx. Perceptual