Structure

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mund
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18404
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Structure
Updated:
2010-05-09 12:36:12
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Mod 21 Management of VP Inadequacy
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  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?
    EX?
    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 ?
    More?
    • 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
    Goal:?
    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 ?
    Implants?
    • 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)
    for?
    for?
    • 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

    Combinations?
    bulb and lift configurations
  18. Speech bulb appliance
    For?
    Oral portion clasps to? can include ?
    ___ = bulb?
    fitsup/behind?
    ___ 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 ?
    gives?
    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
    Endoscopy?
    allows us to look at velopharyngeal closure and also observe laryngeal behavior/movements
  28. Use instrumental assessment to confirm perceptual speech diagnosis
    Videofluoroscopy
    • 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
    No?
    • 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
    Improve?
    • 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
    SLP?
    • 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

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