Velopharyngeal Dysfunction Clinical Presentation

Updated: Mar 26, 2018
  • Author: Luke J Schloegel, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
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Presentation

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.

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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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