Velopharyngeal dysfunction

Abstract

Velopharyngeal dysfunction (VPD) is a generic term which describes a set of disorders resulting in the leakage of air into the nasal passages during speech production. As a result, speech samples can demonstrate hypernasality, nasal emissions, and poor intelligibility. The finding of VPD can be secondary to several causes: anatomic, musculoneuronal, or behavioral/mislearning. To identify the etiology of VPD, patients must undergo a thorough velopharyngeal assessment comprised of perceptual speech evaluation and functional imaging, including video nasendoscopy and speech videofluoroscopy. These studies are then evaluated by a multidisciplinary team of specialists, who can decide on an optimal course for patient management. A treatment plan is developed and may include speech therapy, use of a prosthetic device, and/or surgical intervention. Different surgical options are discussed, including posterior pharyngeal flap, sphincter pharyngoplasty, Furlow palatoplasty, palatal re-repair, and posterior pharyngeal wall augmentation.

Keywords: cleft palate; hypernasal speech; insufficiency; velopharyngeal dysfunction.

Figures

Fig. 1

Velopharyngeal anatomy in the sagittal plane.

Fig. 2

Velopharyngeal closure patterns are demonstrated. Note that the velum is anterior and the posterior pharyngeal wall is inferior. (A) Coronal: There is significant movement of the velum with less movement of the lateral pharyngeal walls. (B) Sagittal: The lateral pharyngeal walls have excellent motion and provides the predominant source of closure. The velum demonstrates less movement. (C) Circular: Good movement is seen from the velum and lateral walls, resulting in a circular pattern of closure. A Passavant ridge may also contribute to this phenomenon. (D) Bowtie: Closure is primarily due to the velum and possibly a Passavant ridge from the posterior pharynx. Lateral wall movement is poor.

Fig. 3

Diagram of a palatal lift, which is stabilized on the dentition and is designed to elevate the soft palate tissues with its posterior extension.

Fig. 4

Technique for pharyngeal flap surgery. (A) The soft palate is divided at the midline and retracted laterally. A superiorly-based flap is then designed along the posterior pharynx (dotted lines). (B) The posterior pharyngeal flap is elevated from inferior-to-superior at the level of the prevertebral fascia. (C) The flap is inset into the nasal mucosa of the soft palate. Laterally, nasal mucosa flaps from the soft palate are elevated to serve as lining for the raw edge of the pharyngeal flap. (D) The nasal mucosa flaps are inset onto the undersurface of the pharyngeal flap. The donor site of the pharyngeal flap has also been closed primarily. (E) The oral mucosa is closed. Note that the pharyngeal flap is not visible after closure is completed.

Fig. 5

Technique for sphincter pharyngoplasty. (A) Musculomucosal flaps are elevated from the posterior tonsillar pillars on either side. Not shown: The uvula may be retracted for improved visualization. (B) Flaps are transposed into a horizontal direction to be inset into a transverse incision on the posterior pharyngeal wall. (C) The flaps are inset in an end-to-end fashion and the donor sites are sutured closed. The airway is smaller, but remains patent centrally. Note: For greater tightening of the sphincter, the flaps may be overlapped upon each other.

Fig. 6

Technique for secondary Furlow palatoplasty. (A) The palate is divided at the midline. Oral mucosal incisions (dark lines) and nasal mucosal incisions (dotted lines) are shown. On the right side, an oral musculomucosal flap will be elevated, whereas the left oral flap will contain mucosa only. (B) The nasal Z-plasty has been transposed and this layer has been closed. Note that the left side contains the nasal myomucosal flap, which is now transversely oriented. The oral mucosa flaps remain elevated. (C) The oral mucosa is now closed. The palate has been lengthened by the Z-plasties and the levator musculature has been transposed and overlapped upon itself.