Download PDF
Semin Speech Lang 2011; 32(2): 168-178
DOI: 10.1055/s-0031-1277719
© Thieme Medical Publishers

Instrumental Assessment of Velopharyngeal Closure for Speech

Michael P. Karnell1
  • 1Department of Otolaryngology-Head and Neck Surgery and Department of Communication Sciences and Disorders, University of Iowa, Iowa City, Iowa
Further Information

Publication History

Publication Date:
26 September 2011 (online)

Also available at
    Permissions and Reprints

ABSTRACT

The presence of a palatal cleft at birth should not prevent good speech production in most children provided they have (1) appropriate surgical intervention to close the palate at or around the child's first birthday, (2) careful monitoring of speech development throughout childhood, (3) speech therapy when needed, and (4) secondary surgical or speech-prosthetic intervention when needed. When managed carefully by an experienced, well-prepared multidisciplinary team that applies the criteria listed above, ~70% of children with nonsyndromic palatal clefts will have no significant difficulties with speech intelligibility or speech quality due to velopharyngeal insufficiency by the time they enter elementary school. Speech assessment is the first step toward comprehensive team management of children with cleft palate. The purpose of this chapter is to describe the use of instrumentation in the evaluation of speech of children with palatal clefts, within the context of a multidisciplinary team. The focus of this article is on instruments that are used to supplement the perceptual assessment to document current speech status and plan management strategies.

KEYWORDS

Cleft palate - velopharyngeal insufficiency - nasometry - speech videofluoroscopy - nasendoscopy - nasopharyngoscopy

REFERENCES

  • 1 Karnell M P, Van Demark D R. Longitudinal speech performance in patients with cleft palate: comparisons based on secondary management.  Cleft Palate J. 1986;  23 (4) 278-288
    PubMedGoogle Scholar
  • 2 Hardin-Jones M A, Brown C K, Van Demark D R, Morris H L. Long-term speech results of cleft palate patients with primary palatoplasty.  Cleft Palate Craniofac J. 1993;  30 (1) 55-63
    CrossrefPubMedGoogle Scholar
  • 3 Persson C, Lohmander A, Elander A. Speech in children with an isolated cleft palate: a longitudinal perspective.  Cleft Palate Craniofac J. 2006;  43 (3) 295-309
    PubMedGoogle Scholar
  • 4 Lohmander A, Persson C. A longitudinal study of speech production in Swedish children with unilateral cleft lip and palate and two-stage palatal repair.  Cleft Palate Craniofac J. 2008;  45 (1) 32-41
    CrossrefPubMedGoogle Scholar
  • 5 Fletcher S G, Bishop M E. Measurement of nasality with tonar.  Cleft Palate J. 1970;  7 610-621
    PubMedGoogle Scholar
  • 6 Fletcher S G. “Nasalance” vs. listener judgements of nasality.  Cleft Palate J. 1976;  13 31-44
    PubMedGoogle Scholar
  • 7 Dalston R M, Warren D W, Dalston E T. Use of nasometry as a diagnostic tool for identifying patients with velopharyngeal impairment.  Cleft Palate Craniofac J. 1991;  28 (2) 184-188 discussion 188-189
    CrossrefPubMedGoogle Scholar
  • 8 Hardin M A, Van Demark D R, Morris H L, Payne M M. Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality.  Cleft Palate Craniofac J. 1992;  29 (4) 346-351
    CrossrefPubMedGoogle Scholar
  • 9 Dalston R M, Neiman G S, Gonzalez-Landa G. Nasometric sensitivity and specificity: a cross-dialect and cross-culture study.  Cleft Palate Craniofac J. 1993;  30 (3) 285-291
    CrossrefPubMedGoogle Scholar
  • 10 Watterson T, McFarlane S C, Wright D S. The relationship between nasalance and nasality in children with cleft palate.  J Commun Disord. 1993;  26 (1) 13-28
    CrossrefPubMedGoogle Scholar
  • 11 Haapanen M L. Nasalance scores in normal Finnish speech.  Folia Phoniatr (Basel). 1991;  43 (4) 197-203
    CrossrefPubMedGoogle Scholar
  • 12 Santos Terron M J, Gonzalez-Landa G, Sanchez-Ruiz I. Normal patterns of nasalance in children who speak Castilian.  [in Spanish] Rev Esp Foniatr. 1991;  4 71-75
    PubMedGoogle Scholar
  • 13 Kavanagh M L, Fee E J, Kalinowski J, Doyle P, Leeper H. Nasometric values for three dialectal groups within the Atlantic Provinces of Canada.  J Speech Lang Pathol Audiol. 1994;  18 7-13
    PubMedGoogle Scholar
  • 14 Anderson R T. Nasometric values for normal Spanish-speaking females: a preliminary report.  Cleft Palate Craniofac J. 1996;  33 (4) 333-336
    CrossrefPubMedGoogle Scholar
  • 15 Nichols A C. Nasalance statistics for two Mexican populations.  Cleft Palate Craniofac J. 1999;  36 (1) 57-63
    CrossrefPubMedGoogle Scholar
  • 16 Kummer A W. Simplified Nasometric Assessment Procedures (SNAP): Nasometer Test-Revised. Lincoln Park, NJ: Kay Elemetrics; 2005
    Google Scholar
  • 17 Karnell M P. Nasometric discrimination of hypernasality and turbulent nasal airflow.  Cleft Palate Craniofac J. 1995;  32 (2) 145-148
    CrossrefPubMedGoogle Scholar
  • 18 Sacket D, Straus S, Richardson W, Rosenberg W, Haynes R. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. London, United Kingdom: Churchill Livingstone; 2000
    Google Scholar
  • 19 Hoit J D, Watson P J, Hixon K E, McMahon P, Johnson C L. Age and velopharyngeal function during speech production.  J Speech Hear Res. 1994;  37 (2) 295-302
    CrossrefPubMedGoogle Scholar
  • 20 Devani P, Watts R, Markus A F. Speech outcome in children with cleft palate: aerophonoscope assessment of nasal emission.  J Craniomaxillofac Surg. 1999;  27 (3) 180-186
    CrossrefPubMedGoogle Scholar
  • 21 Dotevall H, Ejnell H, Bake B. Nasal airflow patterns during the velopharyngeal closing phase in speech in children with and without cleft palate.  Cleft Palate Craniofac J. 2001;  38 (4) 358-373
    CrossrefPubMedGoogle Scholar
  • 22 Zajac D J, Hackett A M. Temporal characteristics of aerodynamic segments in the speech of children and adults.  Cleft Palate Craniofac J. 2002;  39 (4) 432-438
    CrossrefPubMedGoogle Scholar
  • 23 Zajac D J, Weissler M C. Air pressure responses to sudden vocal tract pressure bleeds during production of stop consonants: new evidence of aeromechanical regulation.  J Speech Lang Hear Res. 2004;  47 (4) 784-801
    CrossrefPubMedGoogle Scholar
  • 24 Williams W N, Wharton P W, Paulk M F, Brown W S, Turner G E, Stevens G. Intraoral air pressure discrimination under conditions of experimental velopharyngeal insufficiency.  Cleft Palate Craniofac J. 2005;  42 (3) 297-303
    CrossrefPubMedGoogle Scholar
  • 25 de Sousa T V, Marques I L, Carneiro A F, Bettiol H, Freitas J A. Nasopharyngoscopy in Robin sequence: clinical and predictive value.  Cleft Palate Craniofac J. 2003;  40 (6) 618-623
    CrossrefPubMedGoogle Scholar
  • 26 Yoon P J, Starr J R, Perkins J A, Bloom D, Sie K C. Interrater and intrarater reliability in the evaluation of velopharyngeal insufficiency within a single institution.  Arch Otolaryngol Head Neck Surg. 2006;  132 (9) 947-951
    CrossrefPubMedGoogle Scholar
  • 27 Polzer I, Breitsprecher L, Winter K, Biffar R. Videoendoscopic, speech and hearing in cleft palate children after levator-palatopharyngeus surgery according to Kriens.  J Craniomaxillofac Surg. 2006;  34 (Suppl 2) 52-56
    PubMedGoogle Scholar
  • 28 Pereira V, Sell D, Ponniah A, Evans R, Dunaway D. Midface osteotomy versus distraction: the effect on speech, nasality, and velopharyngeal function in craniofacial dysostosis.  Cleft Palate Craniofac J. 2008;  45 (4) 353-363
    CrossrefPubMedGoogle Scholar
  • 29 VanLue M, Cox K M, Wade J M et al.. Development of a microportable imaging system for otoscopy and nasoendoscopy evaluations.  Cleft Palate Craniofac J. 2007;  44 (2) 121-125
    CrossrefPubMedGoogle Scholar
  • 30 American Speech-Language-Hearing Association .Vocal Tract Visualization and Imaging (Policy statement). Available at: http://asha.org/policy Accessed May 4, 2011
    Google Scholar
  • 31 Osberg P E, Witzel M A. The physiologic basis for hypernasality during connected speech in cleft palate patients: a nasendoscopic study.  Plast Reconstr Surg. 1981;  67 (1) 1-5
    CrossrefPubMedGoogle Scholar
  • 32 Stringer D A, Witzel M A. Waters projection for evaluation of lateral pharyngeal wall movement in speech disorders.  AJR Am J Roentgenol. 1985;  145 (2) 409-410
    PubMedGoogle Scholar
  • 33 Karnell M P, Linville R N, Edwards B A. Variations in velar position over time: a nasal videoendoscopic study.  J Speech Hear Res. 1988;  31 (3) 417-424
    PubMedGoogle Scholar
  • 34 Witzel M A, Posnick J C. Patterns and location of velopharyngeal valving problems: atypical findings on video nasopharyngoscopy.  Cleft Palate J. 1989;  26 (1) 63-67
    PubMedGoogle Scholar
  • 35 Golding-Kushner K J, Argamaso R V, Cotton R T et al.. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an International Working Group.  Cleft Palate J. 1990;  27 (4) 337-347 discussion 347-348
    CrossrefPubMedGoogle Scholar
  • 36 Kummer A W, Curtis C, Wiggs M, Lee L, Strife J L. Comparison of velopharyngeal gap size in patients with hypernasality, hypernasality and nasal emission, or nasal turbulence (rustle) as the primary speech characteristic.  Cleft Palate Craniofac J. 1992;  29 (2) 152-156
    CrossrefPubMedGoogle Scholar
  • 37 Witt P D, Marsh J L, Marty-Grames L, Muntz H R, Gay W D. Management of the hypodynamic velopharynx.  Cleft Palate Craniofac J. 1995;  32 (3) 179-187
    CrossrefPubMedGoogle Scholar
  • 38 Sommerlad B, Rowland N, Harland K. Lateral videofluoroscopy: a modification to aid in velopharyngeal assessment and measurement.  Cleft Palate Craniofac J. 1994;  31 (2) 134-135
    CrossrefPubMedGoogle Scholar
  • 39 Lam D J, Starr J R, Perkins J A et al.. A comparison of nasendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency.  Otolaryngol Head Neck Surg. 2006;  134 (3) 394-402
    CrossrefPubMedGoogle Scholar
  • 40 Dudas J R, Deleyiannis F W, Ford M D, Jiang S, Losee J E. Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy.  Ann Plast Surg. 2006;  56 (5) 511-517 discussion 517
    CrossrefPubMedGoogle Scholar
  • 41 Stringer D A, Witzel M A. Comparison of multi-view videofluoroscopy and nasopharyngoscopy in the assessment of velopharyngeal insufficiency.  Cleft Palate J. 1989;  26 (2) 88-92
    PubMedGoogle Scholar
  • 42 Nopoulos P, Choe I, Berg S, Van Demark D, Canady J, Richman L. Ventral frontal cortex morphology in adult males with isolated orofacial clefts: relationship to abnormalities in social function.  Cleft Palate Craniofac J. 2005;  42 (2) 138-144
    CrossrefPubMedGoogle Scholar
  • 43 Shinagawa H, Ono T, Honda E, Kurabayashi T, Iriki A, Ohyama K. Distinctive cortical articulatory representation in cleft lip and palate: a preliminary functional magnetic resonance imaging study.  Cleft Palate Craniofac J. 2006;  43 (5) 620-624
    CrossrefPubMedGoogle Scholar
  • 44 Levine D, Cavazos C, Kazan-Tannus J F et al.. Evaluation of real-time single-shot fast spin-echo MRI for visualization of the fetal midline corpus callosum and secondary palate.  AJR Am J Roentgenol. 2006;  187 (6) 1505-1511
    CrossrefPubMedGoogle Scholar
  • 45 Conrad A L, Dailey S, Richman L et al.. Cerebellum structure differences and relationship to speech in boys and girls with nonsyndromic cleft of the lip and/or palate.  Cleft Palate Craniofac J. 2010;  47 (5) 469-475
    CrossrefPubMedGoogle Scholar
  • 46 Perry J L, Kuehn D P. Three-dimensional computer reconstruction of the levator veli palatini muscle in situ using magnetic resonance imaging.  Cleft Palate Craniofac J. 2007;  44 (4) 421-423
    CrossrefPubMedGoogle Scholar
  • 47 Ha S, Kuehn D P, Cohen M, Alperin N. Magnetic resonance imaging of the levator veli palatini muscle in speakers with repaired cleft palate.  Cleft Palate Craniofac J. 2007;  44 (5) 494-505
    CrossrefPubMedGoogle Scholar
  • 48 Atik B, Bekerecioglu M, Tan O, Etlik O, Davran R, Arslan H. Evaluation of dynamic magnetic resonance imaging in assessing velopharyngeal insufficiency during phonation.  J Craniofac Surg. 2008;  19 (3) 566-572
    CrossrefPubMedGoogle Scholar
  • 49 Karnell M P, Seaver E J. Integrated endoscopic/photodetector evaluation of velopharyngeal function.  Cleft Palate Craniofac J. 1993;  30 (3) 337-342
    CrossrefPubMedGoogle Scholar
  • 50 Dalston R M. Photodetector assessment of velopharyngeal activity.  Cleft Palate J. 1982;  19 (1) 1-8
    PubMedGoogle Scholar

1 After 1133 nasometry tests documented with perceptual ratings of nasal resonance by the author, indices of predictive utility of nasalance measures were as follows: sensitivity = 0.85, specificity = 0.84, negative predictive power = 0.68, relative risk = 5.4.[18]

Michael P KarnellPh.D. 

Department of Otolaryngology-Head and Neck Surgery, Department of Communication Sciences and Disorders, University of Iowa

200 Hawkins Drive, Iowa City, IA 52242-1602

Email: michael-karnell@uiowa.edu