Speech Pathology
Service provided at Children's at Scottish Rite
Managing Speech Disorders:
How Speech Instrumentation, Surgery and Prosthetics Can Help Your Patients
by John E. Riski, Ph.D.
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.
- 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 from 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 post measures 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)
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Fig. 1a |
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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.
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| Fig. 2a |
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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 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 type 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 manual dexterity or supervision for inserting and removing the prosthesis.
What kinds of surgical management are used to correct VPI?
The most common types of surgical management (pharyngoplasties) used in the United
States 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.
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| Fig. 3a |
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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 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, Fourth
Edition, Pro-Ed, Austin TX. (1997)
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.
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| Fig. 4a |
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Fig. 4b |
Sphincter pharyngoplasty surgery, and 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 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, Fourth
Edition, Pro-Ed, Austin TX. (1997)