Avaliação de pacientes portadores de disfunção velofaríngea tratados com prótese de palato

O trabalho avaliou a efetividade do tratamento da disfunção velofaríngea com prótese de palato. A amostra consistiu em 48 pacientes, com idades variando entre 8 e 74 anos (X = 31,47±16,03), sendo 42 com insuficiência velofaríngea devido à fissura palatina congênita operada ou não, 2 com insuficiência velofaríngea devido à ressecção total ou parcial do palato (casos que tiveram câncer) e 4 com incompetência velofaríngea devido à paralisia total ou parcial do palato mole. Os resultados do questionário mostraram que: (1) a maioria dos pacientes preferiu se alimentar usando a prótese (81,2%); (2) a maioria relatou melhora da fala com a prótese (85,4%); (3) a prótese ficou estável para a maioria dos pacientes, tanto na alimentação (75%), quanto na fala (91,7%); (4) a maior parte dos pacientes (79,2%) sentiram-se confortável em usar a prótese; (5) a estética com a prótese foi satisfatória para a maioria dos pacientes (97,9%); (6) a qualidade de vida da maioria dos pacientes (85,4%), melhorou com o uso da prótese.Some patients presenting velopharyngeal dysfunction need treatment with a palatal prosthesis, and few researches attempt to evaluate the judgement of its efficacy. For that reason, a questionnaire was submitted to 48 patients with a palatal prosthesis, with ages from 8 to 74 (mean 31.47), from which 42 had a congenital cleft, 2 exhibited an acquired cleft and 4 presented total or partial palsy of the soft palate. Results reveled that 81.2% of these patients were able to eat while using their prostheses; 85.4% stated their speech had improved with the prostheses; 75% considered the prosthesis stable during nourishment, and 91.7% during speech; 79.2% felt comfortable using the prosthesis; and 85.4% related a general improvement in life quality with the prosthetic treatment of velopharyngeal dysfunction. It was concluded that the prosthetic treatment of velopharyngeal dysfunction demonstrated efficacy in improving speech, despite of the heterogeneous sample. Besides, it offered the other basic requirements of a prosthesis whenever it was needed

Nasoendoscopy of velopharynx before and during diagnostic therapy

Nasoendoscopy is an important tool for assessing velopharyngeal function. The purpose of this study was to analyze velar and pharyngeal wall movement and velopharyngeal gap during nasoendoscopic evaluation of the velopharynx before and during diagnostic therapy. Nasoendoscopic recordings of 10 children with operated cleft lip and palate were analyzed according to the International Working Group Guidelines. Ratings of movement of velum and pharyngeal walls, and size, location and shape of gaps were analyzed by 3 speech-language pathologists (SLPs). Imaging was obtained during repetitions of the syllable /pa/ during a single nasoendoscopic evaluation: (a) before diagnostic therapy, and (b) after the children were instructed to impound and increase intraoral air pressure (diagnostic therapy). Once the patients impounded and directed air pressure orally, the displacement of the velum, right, left and posterior pharyngeal walls increased 40, 70, 80, and 10%, respectively. Statistical significance for displacement was found only for right and left lateral pharyngeal walls. Reduction in gap size was observed for 30% of the patients and other 40% of the gaps disappeared. Changes in gap size were found to be statistically significant between the two conditions. In nasoendoscopic assessment, the full potential of velopharyngeal displacement may not be completely elicited when the patient is asked only to repeat a speech stimulus. Optimization of information can be done with the use of diagnostic therapy's strategies to manipulate VP function. Assuring the participation of the SLP to conduct diagnostic therapy is essential for management of velopharyngeal dysfunction

Occurrence of consonant production errors in liquid phonemes in children with operated cleft lip and palate

Information about the prevalence of consonant production errors, including compensatory articulations (CA), in individuals with cleft lip and palate (CLP) who speak Brazilian Portuguese is limited, particularly regarding liquid sounds. The literature primarily reports the occurrence of CA for plosive and fricative sounds, since occurrence of CAs in sounds that require higher amounts of oral air pressure is expected. While the use of CA during liquid sound production is not expected, clinical experience suggests that individuals with CLP present with inadequate backing, elevation, and anteriorization of the tongue as well as tongue clicks during production of /r/ and /l/. Objectives: Describe the occurrence of consonant error productions during liquid sounds for children with CLP; compare the occurrence between children operated with the Furlow and von Langenbeck techniques for palatoplasty; and compare the occurrence between children operated between 9-12 months and 15-18 months of age at primary palatoplasty. Material and Methods: A sample of 397 children (237 males and 160 females) with operated unilateral CLP was studied. In this group, 163 underwent palatoplasty with the Furlow procedure and 234 with the modified von Langenbeck procedure. Age at palatoplasty was between 9 and 12 months for 189 children and between 15 and 18 months for 208 children. Data about production of /l/, /r/, /R/, /λ/ and consonant clusters /l/ and /r/ were obtained from speech pathology records. Speech pathologists registered the speech findings after an auditory-perceptual evaluation of the participants at the sixth year of age. Results: The use of middorsum palatal place (MDP) of production was identified for 2% of the sample. Tongue anteriorization of the /l/ production was observed for 55% of the children. No significant difference was found related to surgical technique, but children operated earlier developed the use of the consonant cluster /r/ sooner than children operated later (p=0.040). Conclusion: We found a low occurrence of use of cleft related CA during attempts of production of liquid phonemes, and the variable age at primary palatoplasty significantly interfered with the acquisition of consonant cluster /r/

Compensatory articulation associated to cleft palate or velopharyngeal dysfunction: literature review

TEMA: articulação compensatória na fissura palatina. OBJETIVO: contribuir para o aprofundamento de informações sobre os tipos de articulação compensatória descritos na literatura e, ainda, discutir as implicações e contribuições da avaliação clínica e instrumental na identificação destas produções. CONCLUSÃO: as articulações compensatórias merecem a atenção de clínicos e pesquisadores que atuam no Brasil, já que estas alterações são encontradas com grande freqüência em crianças e adultos com fissura palatina ou disfunção velofaríngea, o que compromete a qualidade de vida destes sujeitos. Os fonoaudiólogos devem aprofundar seus conhecimentos sobre os tipos de articulação compensatória e os procedimentos de avaliação, bem como devem estabelecer programas preventivos que favoreçam a aquisição fonológica sem o desenvolvimento dessas compensações.BACKGROUND: compensatory articulation in cleft lip and palate. PURPOSE: to contribute with information regarding the types of compensatory articulation described in the literature and discuss the implications and contributions of clinical and instrumental evaluation of these speech productions. CONCLUSION: compensatory articulation deserves attention from Brazilian physicians and researchers, since that these productions occur in children and adults with cleft palate and velopharyngeal dysfunction, compromising their speech intelligibility and consequently quality of their lives. Speech-language pathologists need to improve knowledge regarding different types of compensatory articulation and also on the procedures for evaluating these productions, in order to settle preventive programs that favor phonological acquisition in children with cleft palate without developing compensatory articulation

Cephalometric predictors of hypernasality and nasal air emission

During times of increasingly recognized importance of interprofessional practices, professionals in Medicine, Dentistry, and Speech Pathology areas cooperate to optimize treatment of velopharyngeal dysfunction (VPD), after primary palatoplasty for correction of cleft palate. Objective: Our study aims to compare velar length, velar thickness, and depth of the nasopharynx of patients with unilateral cleft lip and palate (UCLP) with the presence, or absence, of hypernasality and nasal air emission; and to verify if the depth:length ratio, between nasopharynx and velum, would be predictive of consistent hypernasality and nasal air emission (speech signs of VPD). Methodology: Cephalometric radiographs and outcome of speech assessment were obtained from 429 individuals, between 6 and 9 years of age, with repaired unilateral cleft lip and palate. Velar length, velar thickness, depth of the nasopharynx, depth:length ratio, scores of hypernasality, and scores of nasal air emission were studied and compared; grouping the radiographs according to presence or absence of hypernasality and nasal air emission. Results: For the group with speech signs of velopharyngeal dysfunction (those with consistent hypernasality and nasal air emission), the velums were shorter and thinner; the nasopharynx was deeper and the depth:length ratio was larger than the group without hypernasality and nasal air emission. Velar length was significantly shorter in individuals with consistent hypernasality and nasal air emission (p<0.001) and with history of palatal fistula (p=0.032). Depth of nasopharynx was significantly greater in individuals with consistent hypernasality and nasal air emission (p<0.001). Depthlength ratio was significantly larger in individuals with consistent hypernasality and nasal air emission (p<0.001). A depth:length ratio larger than 0.93 was always associated with speech signs of VPD. Conclusion; Estimated with cephalometric radiographs, a depth:length ratio greater than 0.93, between the nasopharyngeal space and the velum, was 100% accurate in predicting hypernasality and nasal air emission after primary repair of unilateral cleft lip and palate

Speech therapy for compensatory articulations and velopharyngeal function: a case report

The objective of this study was to describe the process of intensive speech therapy for a 6-year-old child using compensatory articulations while presenting with velopharyngeal insufficiency (VPI) and a history of cleft lip and palate. The correction of VPI was temporarily done with a pharyngeal obturator since the child presented with very little movement of the pharyngeal walls during speech, compromising the outcome of a possible pharyngeal flap procedure (pharyngoplasty). The program of intensive speech therapy involved 3 phases, each for duration of 2 weeks incorporating 2 daily sessions of 50 minutes of therapy. A total of 60 sessions of intervention were done with the initial goal of eliminating the use of compensatory articulations. Evaluation before the program indicated the use of co-productions (coarticulations) of voiceless plosive and fricative sounds with glottal stops (simultaneous production of 2 places of productions), along with weak intraoral pressure and hypernasality, all compromising speech intelligibility. To address place of articulation, strategies to increase intraoral air pressure were used along with visual, auditory and tactile feedback, emphasizing the therapy target and the air pressure and airflow during plosive and fricative sound productions. After the first two phases of the program, oral place of articulation of the targets were achieved consistently. During the third phase, velopharyngeal closure during speech was systematically addressed using a bulb reduction program with the objective of achieving velopharyngeal closure during speech consistently. After the intensive speech therapy program involving the use of a pharyngeal obturator, we observed absence of hypernasality and compensatory articulation with improved speech intelligibility

Achados espectrais das vogais [a] e [ã] em diferentes aberturas velofaríngeas

BACKGROUND: the size control of velopharyngeal opening is an important variable for the acoustic profile characterization of hypernasal speech. AIM: to investigate frequency spectral aspects of F1, F2, F3, nasal formant (FN) and anti-formant, in Hertz, for vowels [a] and at different velopharyngeal openings produced in the bulb of a palatal prosthesis replica used by a patient with velopharyngeal insufficiency. METHOD: speech recordings were obtained for four words (pato/mato and panto/manto) produced within a carrier phrase in 5 conditions of velopharyngeal functioning: prosthesis with no openings (control condition: CC); prosthesis with bulb opening of 10mm² (experimental condition with 10mm² opening: EC10), prosthesis with a 20mm² opening (EC20), prosthesis with a 30mm² openning (EC30), and without the prosthesis (ECO). Five speech-language pathologists made a live rating of speech nasality during the reading of an oral passage. The recordings were used for spectral analysis. RESULTS: F1 values were significantly higher for [a] when compared to in all conditions. F2 values for [a] in EC20 and EC30 were significantly lower than values in the other conditions, being closer to the values presented for . F3 values were not significantly different between the testing conditions. There was a relationship between FN and anti-formants, and the auditory perception of nasality for conditions EC10 and EC20. CONCLUSION: significant changes were observed in the studied spectral values according to changes in the velopharyngeal opening size.TEMA: o controle do tamanho da abertura velofaríngea é uma variável importante na caracterização do perfil acústico da fala hipernasal. OBJETIVO: investigar os aspectos espectrais das frequências de F1, F2, F3, formante nasal(FN) e anti-formante, em Hertz, para as vogais [a] e [ã] na presença de aberturas feitas no bulbo de réplicas da prótese de palato de uma paciente com insuficiência velofaríngea. MÉTODO: gravações de produções de quatro palavras (pato/mato e panto/manto) inseridas em frase veículo foram obtidas em cinco condições de funcionamento velofaríngeo: prótese sem aberturas (condição controle: CC), prótese com abertura de 10mm² no bulbo (condição experimental - CE10), com abertura de 20mm² (condição experimental - CE20), com abertura de 30mm² (condição experimental - CE30), e sem prótese (condição experimental aberta - CEA). Cinco fonoaudiólogos julgaram a nasalidade de fala ao vivo, durante a leitura de um texto oral. As gravações foram usadas para análise espectral. RESULTADOS: valores de F1 foram significativamente mais altos para [a] que para [ã] em todas as condições. Valores de F2 para [a] em CE20 e CE30 foram significantemente mais baixos que nas outras condições, aproximando-se dos valores para [ã]. Valores de F3 não foram significativamente diferentes nas diferentes condições. Houve relação entre os achados de FN e anti-formantes e a percepção de nasalidade para as condições CE10 e CE20. CONCLUSÃO: foram observadas mudanças significativas nos valores espectrais estudados de acordo com alterações no tamanho da abertura velofaríngea.Universidade Estadual de Campinas Instituto de Estudos da LinguagemUniversity of FloridaUniversidade de São Paulo Hospital de Reabilitação de Anomalias Craniofaciais Laboratório de Fonética ExperimentalUniversidade Estadual de São Paulo Departamento de FonoaudiologiaUniversidade Federal de São Paulo (UNIFESP)USP Faculdade de Odontologia de Bauru Departamento de FonoaudiologiaUniversidade Estadual de Campinas Instituto de Estudos da Linguagem Departamento de LinguísticaUNIFESPSciEL

Nasalance and nasality at experimental velopharyngeal openings in palatal prosthesis: a case study

The use of prosthetic devices for correction of velopharyngeal insufficiency (VPI) is an alternative treatment for patients with conditions that preclude surgery and for those individuals with a hypofunctional velopharynx (HV) with a poor prognosis for the surgical repair of VPI. Understanding the role and measuring the outcome of prosthetic treatment of velopharyngeal dysfunction requires the use of tools that allow for documenting pre- and post-treatment outcomes. Experimental openings in speech bulbs have been used for simulating VPI in studies documenting changes in aerodynamic, acoustic and kinematics aspects of speech associated with the use of palatal prosthetic devices. The use of nasometry to document changes in speech associated with experimental openings in speech bulbs, however, has not been described in the literature. Objective: This single-subject study investigated nasalance and nasality at the presence of experimental openings drilled through the speech bulb of a patient with HV. Material and Methods: Nasometric recordings of the word "pato" were obtained under 4 velopharyngeal conditions: no-opening (control condition), no speech bulb, speech bulb with a 20 mm² opening, and speech bulb with 30 mm² opening. Five speech-language pathologists performed auditory-perceptual ratings while the subject read an oral passage under all conditions. Results: Kruskal-Wallis test showed significant difference among conditions (p=0.0002), with Scheffé post hoc test indicating difference from the no-opening condition. Conclusion: The changes in nasalance observed after drilling holes of known sizes in a speech bulb suggest that nasometry reflect changes in transfer of sound energy related to different sizes of velopharyngeal opening

Speech nasality and nasometry in cleft lip and palate

AbstractIntroductionPerceptual evaluation is considered the gold standard to evaluate speech nasality. Several procedures are used to collect and analyze perceptual data, which makes it susceptible to errors. Therefore, there has been an increasing desire to find methods that can improve the assessment.ObjectiveTo describe and compare the results of speech nasality obtained by assessments of live speech, the Test of Hypernasality (THYPER), assessments of audio recorded speech, and nasometry.MethodsA retrospective study consisting of 331 patients with operated unilateral cleft lip and palate. Speech nasality was assessed by four methods of assessment: live perceptual judgement, THYPER, audio-recorded speech sample judgement by multiple judges, and nasometry. All data were collected from medical records of patients, with the exception of the speech sample recording assessment, which was carried out by multiple judges.ResultsThe results showed that the highest percentages of absence of hypernasality were obtained from judgements performed live and from the THYPER, with equal results between them (79%). Lower percentages were obtained from the recordings by judges (66%) and from nasometry (57%).ConclusionThe best results among the four speech nasality evaluation methods were obtained for the ones performed live (live nasality judgement by a speech pathologist and THYPER)