Review Article Velo-Pharyngeal Dysfunction
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Published online: 2020-01-15 Free full text on www.ijps.org DOI: 10.4103/0970-0358.57201 Review Article Velo-pharyngeal dysfunction: Evaluation and management Jeffrey L. Marsh Department of Plastic Surgery, St. Louis University School of Medicine, St. Louis MO, USA Address for Corrsepondence: Dr. Jeffrey L. Marsh, Kids Plastic Surgery, 621 S. New Ballas Road, Suite 260A, St. Louis MO-631 41, USA. E-mail: [email protected] ABSTRACT Separation of the nasal and oral cavities by dynamic closure of the velo-pharyngeal port is necessary for normal speech and swallowing. Velo-pharyngeal dysfunction (VPD) may either follow repair of a cleft palate or be independent of clefting. While the diagnosis of VPD is made by audiologic perceptual evaluation of speech, identiÞ cation of the mechanism of the dysfunction requires instrumental visualization of the velo-pharyngeal port during speciÞ c speech tasks. Matching the speciÞ c intervention for management of VPD with the type of dysfunction, i.e. differential management for differential diagnosis, maximizes the result while minimizing the morbidity of the intervention. KEY WORDS Velo-pharyngeal dysfunction; Velo-pharyngeal insufÞ ciency; Velo-pharyngeal incompetency INTRODUCTION due to the ambiguity of the acronym VPI and association of the various “I “nouns with etiologic specificity. The ynamic separation of the nasal cavity from the oral acronym VP is used both for the noun, velopharynx, and cavity is a necessary component in the production the adjective, velopharyngeal. This article discusses the Dof normal speech. This separation occurs in the normal function and dysfunction of the velo-pharynx with anatomic space between the nasal and oral cavities known respect to evaluation as well as management and outcome as the velo-pharynx. Failure to achieve this separation not of the dysfunction. The unifying theme is differential only directly impairs speech with inappropriate escape of management for differential diagnosis. air and/or sound into the nose and inability to properly produce specific phonemes, but also indirectly by inducing FUNCTIONAL ANATOMY OF VELO- PHARYNX abnormal compensatory articulations as well as abnormal facial movements. This anatomic locus, the velopharynx, The velo-pharynx is the space that connects the nasal and becomes a modifying adjective for the several terms oral pharynges. This space is delineated by myomucosal used to describe its dysfunction in literature: velo- structures: anteriorly – the velum (soft palate), posteriorly pharyngeal insufficiency, velo-pharyngeal incompetency, – the posterior pharyngeal wall, and laterally – the right velo-pharyngeal inadequacy and velo-pharyngeal and left lateral pharyngeal walls. In a child, the VP space dysfunction. Velo-pharyngeal dysfunction (VPD) is the may be statically encroached upon by hypertrophic preferred nomenclature of this author, and others[1-3] adenoids, on the posterior pharyngeal wall, and/or S129 Indian J Plast Surg Supplement 1 2009 Vol 42 Marsh hypertrophic tonsils, on the lateral pharyngeal walls. Instrumental assessment of velo-pharyngeal function While swallowing and during the production of specific is of two basic types: visualization[12,13] and effect on speech phonemes, the muscles surrounding the VP space physical parameters[14-16] Visualization may be done with contract, thereby, moving their overlying mucosa three- optics (nasendoscopy) or medical imaging (fluoroscopy dimensionally to separate the nasal and oral cavities by or dynamic MRI)[17] Change in physical parameters of closing the space. Because this motion resembles that sound, airflow, air pressure, and transmitted light have of digestive tract sphincters, the zone of dynamic action all been reported. Each type of instrumental assessment is often referred to as the velo-pharyngeal sphincter even has assets and limitations. Visualization alone can though it lacks discrete, circularly enclosing muscle(s). document the anatomic locus of the dysfunction; The space that is dynamically opened and closed is however, quantification is difficult and the techniques referred to as the velo-pharyngeal port. Normal function of are cumbersome and expensive. Physical parameters the velo-pharynx requires not only closure of the port but are usually recorded quantitatively and for some can also proper coordination and speed of closure as well as be obtained with minimal disturbance of the subject re-opening appropriate for the specific task. Incomplete and at low cost.[18] It is impossible to match a specific closure, lack of coordination between movement and task, VPD management with the anatomic dysfunction and and impaired velocity of closure and/or opening alone to know the functional outcome of that intervention or in combination produce velo-pharyngeal dysfunction without pre- and post-intervention visualization. For (VPD). Clinical signs and symptoms of VPD can be direct this reason, functional velo-pharyngeal visualization or indirect. Direct manifestations include: rustling sound prior to velo-pharyngeal management has become the during speech (nasal turbulence), inappropriate nasal standard of care.[19] The most commonly clinically used resonance during speech (hypernasality), and nasal visualizations are nasendoscopy and video fluoroscopy. regurgitation during swallowing; indirect manifestations These examinations should be conducted by individuals include: abnormal facial movements (grimacing), skilled not only in instrumentation (endoscopy, radiology) abnormal phoneme production (compensatory or but also in eliciting standard speech samples designed mal-articulations), and voice disorders (harsh voice ≡ to assess velo-pharyngeal function in both spontaneous hoarseness, low volume).[4] While in common usage the and provocative speech. While both the imaging and term VPD connotes a failure of velo-pharyngeal closure speech sampling functions can be performed by the for normal physiological tasks, a stenotic velo-pharynx same individuals, the majority of velo-pharyngeal centres also can produce dysfunction. The clinical signs and utilize two professionals to optimize each aspect of the symptoms of a non- or minimally patent velo-pharynx examination: An instrumental visualizer (endoscopist or include nasal airway obstruction affecting breathing radiologist) and a speech pathologist. as well as secretions, mouth breathing with chronic open-mouth posture, diminished nasal resonance for DECISION MAKING FOR MANAGEMENT OF appropriate phonemes (hypo- or de-nasality), and VELO- PHARYNGEAL DYSFUNCTION obstructive sleep apnoea. Just as inter-disciplinary team care has become the EVALUATION OF VELO-PHARYNGEAL standard for cleft lip/palate and other congenital cranio- FUNCTION facial anomalies, inter-disciplinary team care is indicated for evaluation and management of VPD. The task a All of the clinical signs and symptoms of VPD which aid specific type of healthcare professional performs may in its diagnosis can be perceived and documented by a vary from team to team, but competence in speech/ trained observer using auditory and visual perceptual language assessment, nasendoscopy, medical imaging, assessments.[5,6] Identification of the anatomic mechanism and velopharyngeal surgery is needed. In the velo- producing VPD, however, requires a thorough assessment pharyngeal assessment team on which I participate, tasks of velo-pharyngeal function through instrumentation.[7-9] are performed as follows: If it be felt that differential management of differential diagnosis is ideal, identification of specific patterns Identification of possible VPD - patient’s local speech/ of VPD would be useful in optimizing intervention language pathologist; patient’s local ENT; cleft/craniofacial outcomes.[10,11] team members from any healthcare discipline Indian J Plast Surg Supplement 1 2009 Vol 42 S130 Velopharyngeal Dysfunction Perceptual speech/language assessment (digital audio/ some 25 years ago [21] is still in use [Figures 1 and 2] video archived) – cleft/craniofacial team speech/language followed by modifications with the introduction of new pathologist technology, unfamiliar operations, and lessons learned from other colleague via symposia and the literature. The Instrumental velo-pharyngeal assessment (digital audio/ basic principle of differential management for differential video archived) – nasendoscopy (cleft/craniofacial team diagnosis has, however, remained constant.[22] speech/language pathologist plus cleft/craniofacial team ENT); fluoroscopy (cleft/craniofacial team speech/language Once it has been determined that the patient has VPD due pathologist plus radiologist) to an inability to achieve sufficient closure of the velo- pharyngeal port for normal nasal resonance and proper Velo-pharyngeal inter-disciplinary team conference to velo-pharyngeal related articulation, several sequential determine treatment recommendation(s) - cleft/craniofacial decisions are made to select the preferred means for VPD team speech/language pathologist, cleft/craniofacial team management. ENT, cleft/craniofacial team plastic surgeon. 1. The primary decision is whether or not the patient The velo-pharyngeal inter-disciplinary team conference is a candidate for velo-pharyngeal surgery. Absolute reviews the patient’s history, views the perceptual and contraindications to VPD surgery include: other congenital instrumental recordings (including prior recordings when defects that unacceptably increase anaesthetic risk (such extant), discusses interpretations and