Velopharyngeal Dysfunction Clinical Presentation

  • Author: Luke J Schloegel, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jan 10, 2012
 

History

When a patient is referred for surgical treatment of velopharyngeal dysfunction (VPD), the first steps should be to try to elicit specific information germane to speech problems, cleft palate, or both. A multidisciplinary approach consisting of an initial assessment conducted by an otolaryngologist and a speech pathologist is most effective for the diagnosis and management of VPD.

Historical factors in VPD are primarily related to problems with speech intelligibility. The voice is described as having a nasal resonance; nasal emissions (ie, air escape through the nasal passage with speech) may also be present. Compensatory articulation errors are often present, worsening speech intelligibility. Hoarseness is commonly present in children with VPD.

Nasal regurgitation, especially in infants, may also be a clue to the presence of velopharyngeal dysfunction. Parents may describe food and liquids coming through the nose with feeding and spitting up. Older patients may describe reflux of thin liquids into the nasal cavity, as with drinking water from a fountain.

In older children and adults, recurrent and chronic sinus infections may be a sign of nasopharyngeal reflux resultant from repeated contamination of the nasal cavity. Persistent otorrhea with ear grommets in place may also be due to nasopharyngeal reflux, extending up the eustachian tube and through the middle ear. This problem is particularly common in children with a cleft palate or other structural defect. A history of snoring or middle ear effusions may also be signs of palatal dysfunction.

It is important to look for other factors that may lead to diagnosis of a congenital syndrome. Cleft palate, frequent infections, low muscle tone, heart murmur, and lower lip weakness may suggest velocardiofacial (VCF) syndrome.[14] Poor feeding and hypotonia in infancy may suggest the presence of a neuromuscular disorder. Congenital heart defects in association with VPD are common features of both VCF syndrome and Kabuki syndrome (KS). A family history may reveal other affected individuals, also pointing to a genetic etiology.

Exploring the social impact of the child’s speech intelligibility can affect management strategies. Children with significant social integration issues may warrant more aggressive treatment.

Next

Physical Examination

Aside from abnormal resonance of the voice and articulation problems, the physical examination may be normal. Important physical findings would include the presence of a cleft palate, either overt or submucous. Evidence of previous surgery or traumatic injuries should be noted.

A thorough oropharyngeal examination should be done, looking for palatal fistulae, enlarged tonsils, visibly aberrant carotid pulsations along the posterior pharyngeal wall, a prominent adenoid pad, palatal zona pellucida (trough), a palpable notch at the junction of the hard and soft palate, or a bifid uvula. An assessment of palatal function by asking the patient to phonate /ah/ is also important.

Otoscopy should be performed to look for evidence of Eustachian tube dysfunction, such as middle ear atelectasis or middle ear effusion. Nasal examination should assess for signs of sinus infection or other evidence of nasal reflux. Other physical findings may point to an association with a genetic syndrome. Lower lip asymmetry, orbital hypertelorism, small external ear canals, bulbous nasal tip, or heart murmur may signify velocardiofacial syndrome.

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Contributor Information and Disclosures
Author

Luke J Schloegel, MD  Fellow, Division of Pediatric Otolaryngology, Children's National Medical Center

Luke J Schloegel, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Biavati, MD  Clinical Assistant Professor of Otolaryngology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Private Practice, ENT Care for Kids, Dallas, TX

Michael J Biavati, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association

Disclosure: Nothing to disclose.

Kathleen Sie, MD  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine; Medical Director, Hearing Loss Clinic, Co-Director, Cochlear Implant Program, Director, Childhood Communication Center, Children's Hospital and Regional Medical Center, Seattle

Kathleen Sie, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, and American Society of Pediatric Otolaryngology

Disclosure: Nothing to disclose.

Gregory J Wiet, MD, FACS, FAAP  Associate Professor, Departments of Otolaryngology and Biomedical Informatics, Division of Pediatric Otolaryngology, Ohio State University College of Medicine

Gregory J Wiet, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society of Clinical Oncology, American Society of Pediatric Otolaryngology, Association for Research in Otolaryngology, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Gina Rocha-Worley, CCC/SLP, MS  Speech Pathologist, Department of Speech Pathology, Harlem Hospital Center

Gina Rocha-Worley, CCC/SLP, MS is a member of the following medical societies: American Cleft Palate/Craniofacial Association and American Speech-Language-Hearing Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Additional Contributors

Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Coronal closure.
Sagittal closure.
Circular closure.
Circular closure with Passavant's ridge.
Patient with severe articulation disorder and velocardiofacial syndrome. Little or no velar closure is noted on nasopharyngoscopy ("black hole"). Surgical treatment is with wide pharyngeal flap. Aberrant carotid arteries coursing through nasopharynx complicate surgical management.
Infant born with heart murmur, submucous cleft palate, and lower lip asymmetry. Clinical findings are consistent with velocardiofacial syndrome.
Child with velocardiofacial syndrome. Characteristic clinical findings included unilateral lower lip palsy, small bulbous nose, wide palpebral fissures, and small external ear canals. Patient's speech has hypernasal resonance.
Pharyngeal closure patterns: (A) coronal, (B) sagittal, (C) circular, and (D) circular with Passavant ridge.
Coronal closure noted. Primary movement is palate contacting posterior pharyngeal wall, with minimal or no movement of lateral pharyngeal walls. Notice air escape along lateral margins as palate contacts adenoid pad.
Sagittal closure demonstrated. Soft palate moves little, with most of the closure achieved by movement of lateral pharyngeal walls. Notice notching of soft palate consistent with submucous cleft palate.
Example of circular closure with contributions from palate and lateral pharyngeal walls. Patient underwent recent adenoidectomy as evidenced by nasopharyngeal eschar.
Circular closure with Passavant ridge demonstrated. Note elevation of ridge on posterior pharyngeal wall contributing to closure.
Case study of patient status post cleft palate repair. Child presents with hypernasal speech, especially with /s/. No history of nasopharyngeal reflux. Intraoral examination demonstrates repair to be intact except for posterior most portion (bifid uvula is noted). Nasopharyngoscopy demonstrates notching of soft palate (arrow) and enlarged adenoid pad (asterisk).
Velar closure noted as patient pronounces /s/. Circular closure pattern is noted with central defect and air escape. Palate closure is noted with swallow in middle portion of frame.
Palate closure noted against adenoid pad as the patient speaks /p/. Phoneme-specific velopharyngeal dysfunction is diagnosed, and speech therapy is recommended to improve articulation. Adenoidectomy in this patient would most likely result in structural velopharyngeal insufficiency.
Palatal lift. Hard and soft palatal components are shown.
Palatal lift in situ.
Preoperative nasoendoscopic view of velopharynx, showing nasal septum (1), lateral nasoparyngeal wall (2, 4), and velum (3).
 
 
 
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