Managing Speech Disorders: How Speech Instrumentation, Surgery and Prosthetics Can Help Your Patients

Application of Instrumental Analysis and the Surgical-Prosthetic Management of Resonance Disorders

Instrumental Evaluation

How can instrumentation and imaging help with speech disorders?

  • They improve our understanding by direct measurement and visualization of the vocal tract during function.
  • The mechanisms of velopharyngeal closure and larynx are not visible from oral exam and are only visible by endoscopy, radiography or fluoroscopy.
  • The ears may detect gross disturbance, but ears are not reliable to discern subtleties of speech.
  • Instrumentation can define the subtleties of speech and measure several speech processes simultaneously.
  • Instrumentation provides quantifiable documentation of change following speech therapy or physical management.

How does computerized instrumentation assist the evaluation?

  • Assessment with computerized instruments is objective and more accurate than perceptual judgments alone.
  • Speech performance can be compared to standardized peer group norms.
  • Pre and postmeasures make outcomes easier to evaluate.
  • Computers can measure several speech qualities simultaneously.
  • Voice and resonance measures can be taken at the same time.
  • Objective measures can be taken during diagnostic/trial therapy to assess the effectiveness of a therapeutic technique.

What instruments are used to image the vocal tract?

  • Flexible endoscopy (Fig. 1a, 1b)
  • Videofluoroscopy
  • Cephalometric radiography (Fig. 2a, 2b)
     
Fig. 1a    Fig. 1b 

Endoscopic view of velopharyngeal port opened and closed

Fig. 1a. Velopharyngeal port of an 8-year-old child open during respiration as observed through nasal endoscope. V labels the velum and A labels the adenoids.

Fig. 1b. Velopharyngeal port closed during speech. Note that the velum contacts the adenoids in this patient.

     
Fig. 2a    Fig. 2b 

Lateral radiograph pre and post sphincter pharyngoplasty

Fig. 2a. Preoperative lateral radiograph of patient with VPI. Attempted velopharyngeal contact is at the adenoid (arrow). The VPI developed as the adenoids became smaller.

Fig. 2b. Postoperative radiograph of same patient. A sphincter pharyngoplasty was constructed at the site of attempted contact (arrow). The lateral view during phonation is critical to placement of the sphincter pharyngoplasty at the appropriate height.

Reprinted with permission from Riski, J.E., Ruff, G., Georgiade, G.S. and Barwick, W., “Evaluation of Failed Sphincter Pharyngoplasties.” Annals of Plastic Surgery, 28:545-553. (1992)

How does imaging assist the evaluation?

  • Allows us to view the structure and the function of the speech mechanism that is not visible during an oral exam (Fig. 1a, 1b, 2a, 2b, 3a, 3b, 4a, 4b).
  • Information from lateral fluoroscopy/radiography and endoscopy has improved the outcome of surgery for hypernasality.

Surgical and Prosthetic Management of Velopharyngeal Incompetence (VPI)

What are methods for physical management of VPI?

Prosthetic and surgical methods are common. Each procedure has been developed to manage a different size and shape of VPI.

When is physical management of velopharyngeal incompetence necessary?

  • Speech is unintelligible due to VPI.
  • Articulation is imprecise due to loss of oral pressure.
  • Misarticulations such as glottal stops cannot be corrected because of nasal air pressure loss.
  • Speech is distorted from hypernasal distortions.

What are the prosthetic management procedures?

The common prosthetic procedures are the palatal lift and the palatal obturator.

  • A palatal lift is appropriate when the VPI is caused by poor movement of the velum. The anterior, retaining portion clasps to the teeth and a posterior tailpiece pushes the soft palate up into position to obturate the nasopharynx.
  • A palatal obturator is appropriate when the VPI is caused by a deficiency in the length of the soft palate to close the velopharyngeal port. That is, the velum may move, but may not be long enough, or the nasopharynx may be too deep to achieve closure.

When is prosthetic management appropriate?

  • Prosthetic procedures are most commonly used in neurogenic VPI.
  • Prosthetic management is best suited to individuals with:
    • Healthy dentition, in good repair.
    • Minimal or controlled gag response.
    • Good motion of the oral articulators.
    • Good oral pressure when the pressure consonants are tested with nasal occlusion.
    • Good manual dexterity or supervision for inserting and removing the prosthesis.

What kinds of surgical management are used to correct VPI?

The two most common types of surgical management (pharyngoplasties) are: (1) the pharyngeal flap (Fig. 3a and 3b) and (2) the sphincter pharyngoplasty (Fig. 4a and 4b). These procedures make the nasopharynx smaller, but in different ways.

  • A pharyngeal flap (Fig. 3a and 3b) raises a vertical flap of tissue from the posterior pharyngeal wall. The flap is pulled across the nasopharynx and sutured into the velum. This leaves two openings on either side of the flap that are closed during speech by the inward movement of the lateral pharyngeal walls.
     
Fig. 3a     Fig. 3b

Pharyngeal flap surgery, and ports opened then closed (for speech)

Fig. 3a. Nasendoscopic view of pharyngeal flap. The flap is in the midline and the portals are on either side. The portals are open during respiration.

Fig. 3b. Nasendoscopic view of pharyngeal flap during speech. The lateral pharyngeal walls have moved in toward the flap, closing the portals.

Reprinted with permission from Riski, J.E., “Secondary Surgical Procedures to Correct Postoperative Velopharyngeal Incompetencies Found After Primary Palatoplasties.” Chapter 6, K Bzoch (Ed.) Communicative Disorders Related to Cleft Lip and Palate, Fifth Edition, Pro-Ed, Austin TX. (2004)

A sphincter pharyngoplasty (Fig. 4a and 4b) raises vertical flaps of tissue from each lateral pharyngeal wall, rotates them inward to a horizontal position and inserts them into the posterior pharyngeal wall. This leaves a single (smaller) opening that is closed by the elevation of the velum.

     
 Fig. 4a   Fig. 4b 

Sphincter pharyngoplasty - orifice opened then closed (for speech)

Fig. 4a. Nasendoscopic view of the sphincter pharyngoplasty and resulting orifice. Note that sphincter pharyngoplasty leaves one single orifice while the pharyngeal flap leaves two (see Fig. 3a). The orifice is open during respiration.

Fig. 4b. The velum is now elevated during speech and is contacting the prominence created by the sphincter pharyngoplasty.

Reprinted with permission from Riski, J.E., “Secondary Surgical Procedures to Correct Postoperative Velopharyngeal Incompetencies Found After Primary Palatoplasties.” Chapter 6, K Bzoch (Ed.) Communicative Disorders Related to Cleft Lip and Palate, Fifth Edition, Pro-Ed, Austin TX. (2004)