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2010-05-09 12:36:12

Mod 21 Management of VP Inadequacy
Show Answers:

  1. Physical management of:
    VPI/A that persists after ?
    VPI/A that may re-emerge after?
    2 broad categories of physical management?
    • initial palatoplasty
    • adequate repair

    • Surgical
    • Prosthodontic/prosthetic (intraoral appliances)
  2. Surgical: Velar Augmentation
    Repositioning the velar muscles to:?
    • increase velar length
    • -V-Y pushback
    • Increase velar function
    • -intravelar veloplasty (levator reconstruction)
    • Increase both length and function
    • =furlow z-plasty as a secondary procedure
  3. Surgical: Velar Augmentation when successful these procedures ?
    approximate/creat "normal" VP function
  4. Surgical: Pharyngoplasty
    Includes any procedure that?
    position and/or function of (naso)pharyngeal musculature

    • pharyngeal flap
    • sphincter pharyngoplasty
    • augmentation pharyngoplasty
  5. Pharyngoplasty: Pharyngeal Flap
    ____ based flap
    Incisions made ?
    Flap attached at __ to __?
    Technically more difficult than ___ based?
    Most ?
    • Superiorly
    • left, right, bottom
    • top to PPW
    • inferioly
    • frequently done
    • effective
  6. Pharyngoplasty: pharyngeal flap
    ___ based flap
    ____ procedure
    Incisions made?
    Flap attached at?
    • Inferiorly
    • Earliest design
    • left, right, top
    • bottom to PPW
  7. Pharyngeal flap: endoscopic view
    Flaps work because of ?
    Less the ? wider the ? must be
    Risks being?

    Level of the match between ____ and ___ also a factor in success?
    • LPW movement in against flap
    • LPW movement
    • the flap
    • obstructive

    (height of) flap and most medial
  8. Hynes originated now the "sphincter" pharyngoplasty
    Designed it to?
    • Advance posterior pharyngeal wall
    • Reduce overall diameter of the sphincter (VP port), especially lateral dimensions
    • Produce an active sphincter
  9. Sphincter pharyngoplasty procedure involves?
    • dissection of the posterior pillars-repostitioning them up and back
    • suturing them into the PPW
  10. Good candidates of sphincter pharyngoplasty have?
    some velar movement and smaller VP gaps
  11. Augmentation Pharyngoplasty
    bring the PPW forward to shorten distance between PPW and velum which would enable adequate VP closure.
  12. Augmentation Pharyngoplasty
    Includes variety or approaches:?
    • Rearranging soft tissue on PPW
    • Implanting cartilage in PPW
    • Injecting or implanting a synthetic material into PPW
  13. Augmentation Pharyngoplasty: Soft tissue advancement
    first used in ?
    Has included?
    • Suturing palatopharyngeus muscles in midline to augment Passavants ridge
    • Folding a flap of mucosa on itself to create a passive ridge
    • Raising salpingopharyngeus muscles and mucosa and suturing them into the PPW
    • Rolled mucosal flap to give extra thickness to PPW, for patients with small defects
  14. Augmentation Pharyngoplasty: Cartilage Implants
    Use ?
    Creates ?
    No ?
    • autogenous cartilage (from pts rib)
    • forward projection on PPW
    • speech benefit
    • not stable (in position or size)
  15. Prosthetic management/speech appliances

    Speech bulb appliances (for VPI/S)
    • individuals with clefts
    • those who have had ablative (cancer) surgery involving hard palate, soft palate or both
  16. Prosthetic management/speech appliances

    Palatal lift (for VPI/C)?
    non cleft movement disorders/neurogenic causes; individuals with dysarthria
  17. Prosthetic management/speech appliances

    bulb and lift configurations
  18. Speech bulb appliance
    Oral portion clasps to? can include ?
    ___ = bulb?
    ___ design?
    designed to accommodate?
    • VPI/S
    • teeth
    • missing teeth
    • tailpiece/posterior extension portion =
    • soft palate; residual tissue
    • under and up
    • patient's anatomy
  19. Speech success depends on ?
    contour of the bulb and on correct placement in relation to the level of (medial/inward) movement of the pharyngeal walls
  20. Assessing bulb placement
    can use videoendoscopy to visualize ? and see ?
    • Pharyngeal wall (and velar) movements against appliance
    • gaps in fit
  21. Assessing bulb placement
    Can use videofluoroscopy to visualize ?
    lateral view with respect to level of placement
  22. Assessing bulb placement
    Can use aerodynamic studies to assess ?
    cloasure adequacy in eliminating nasal air emission

    objective measure but cannot determine where gap is with this instrumentation
  23. Speech appliances as training devices:
    to facilitate oral articulation placements in pts with VP inadequacy when:
    Surgery is ?
    There is a ____ pattern that has not responded to traditional therapy (usually a lift type appliance)
    Cannot determine?
    • not possible/advisable
    • learned NAE
    • need for further surgery:
    • repaired clefts with HN and CMA
    • Appliance prevents oronasal coupling/facilitates oral resonance and airflow for learning HPCs
    • Anecdotal reports are positive
  24. VPI/C is typically acquired as a part of?
    Dysarthria is a speech disorder resulting from? of the speech musculature that is of neurological etiology?
    • a more extensive dysarthria
    • weakness, paralysis or incoordination
  25. Preferred tx team?
    • SLP
    • General dentist
    • maxillofacial prosthodontist
  26. Clinical speech evaluation: questions to be answered
    Is there ___ of VP incompetency?
    What is the ___ of the incompetence?
    Does VP incompetency ____ of speech performance?
    • evidence
    • extent
    • influence other aspects
  27. Use instrumental assessment to confirm perceptual speech diagnosis
    allows us to look at velopharyngeal closure and also observe laryngeal behavior/movements
  28. Use instrumental assessment to confirm perceptual speech diagnosis
    • allows us to obtain multiple views
    • -lateral view allows for observing oral tongue movements as well as VP closure
  29. Palatal lift appliance (PLA)
    Used for ?
    designed to?
    Configured to?
    • VP incompetencies
    • for both acquired and congenital dysarthrias
    • raise velum to level that can facilitate
    • to fit individual anatomy
  30. Palatal lift appliance (PLA)
    Basic materials?
    • can be all acrylic less expensive and used with children
    • cast presision metal + acrylic-for adults
  31. Treatment options
    PLA with ?
    PLA with ? for other aspects of dysarthria
    ______ for other aspects of dysarthria, while monitoring for (spontaneous) improvment in VP function
    • periodic speech follow-up
    • speech remediation for other aspects of dysarthria
    • speech remediation
    • physical management
  32. Determining candidacy for PLA factors to consider?
    ___ of dysfunction?
    Patient ___ & ___?
    ____ = problem
    ___ vs ___ disorder
    ___: appliance can increase secretions which can be aspirated
    ___: denture bearing appliance is difficult
    • severity
    • cooperation & motivation
    • Spasticity/"stiff" soft palate
    • progressive vs non-progressive
    • swallowing
    • dentures
  33. Patients with flaccid dysarthria tend to be the best candidates for?
    PLA management
  34. Palatal lifts:
    get best speech results when there is some?
    with no residual movement speech is a compromise between ?
    Best candidates:?
    • residual movement (PWs, velum, both)
    • obstruction that creates densality
    • improved but incomplete closure with less speech change
    • flaccid dysarthria patients
  35. Palatal lift appliance (PLA)
    Important to carefully assess?
    resonance and intraoral pressure ability in this population
  36. Goals of PLA management?
    • Improve VP closure for pressure consonants
    • Allow VP opening for nasal sounds
    • Provide appliance that is functional & painless
    • Provide comfortable nasal rest breathing, not mouth breathing
  37. Goals of PLA management
    • overall speech output
    • Speech intelligibilty (at least 30% improvement)
    • Acceptable resonance balance
    • No audible NAE
    • Improved precision of (pressure) consonant production
    • Improved valving of breath stream for oral airflow & pressures
  38. Tx for VPI/C
    • diagnoses the VPI/C
    • determines the need for and potential benefits of a palatal lift appliance
    • provides any pre-appliance introral desensitization
    • checks the appliance for VP speech adequacy and determines the speech need for any modifications
    • Provides ongoing therapy, as necessary and feasible, or provides guidance to treating SLP
  39. Tx for VPI/C
    General dentist?
    • evaluates dental and oral health
    • and especially
    • evaluates the adequacy of the dentition for retaining the appliance
  40. Tx for VPI/C
    maxillofacial prosthodontist?
    • designs and fits the appliance
    • makes decisions regarding the feasibility of incorporation of a partial or full maxillary denture provides follow-up for the appliance and makes adjustments as necessary