IN THE NAME OF GODTHE MOST MERCIFUL

THE MOST BENEFICENT

HYPONASALITY VS HYPERNASALITY

Under The Supervision of:Dr. Burhan Al Khatib

Done ByMahmoud Amir Alagha

Resonance Disorders andVelopharyngeal Dysfunction

• Modification of the sound that is generated from the vocal cords• Provides the quality of perceived sound during speech

What is resonance?

• Size and shape of the resonating cavities • pharyngeal cavity • oral cavity • nasal cavity• Function of the velopharyngeal valve

What Determines Resonance?

Resonance and Vowels

• Vowels are resonance sounds• They are produced by changing the size and shape of the oral (resonating) cavity

• Smaller resonating cavity results in a ... – higher formant frequency/pitch • Larger resonating cavity results in a ... – lower formant frequency/pitch

Effect of Cavity Size on Resonance

• Velum (Soft Palate) • Lateral Pharyngeal Walls (LPWs) • Posterior Pharyngeal Wall (PPW)

Structures Active in VP Closure

• Moves in a superior and posterior direction• Has a type of “knee” action• Moves toward the posterior pharyngeal wall

Velum (Soft Palate)

Velum: Rest

Velum: During Speech

• Water (and air) flow in a forward direction until something stops it.• An obstructing object will redirect the flow.

Physics and Flow

Velopharyngeal Valve and Flow

• Due to the physics of airflow, even a small opening will be symptomatic for speech.

• Move medially • Usually close against the velum • Sometimes close in midline behind the velum

Lateral Pharyngeal Walls (LPWs)

Lateral Pharyngeal Walls

• Moves anteriorly toward the velum • In some speakers, there’s a bulge called a Passavant’s ridge

Posterior Pharyngeal Wall (PPW)

Passavant’s Ridge

Passavant’s Ridge

• Velopharyngeal valve is closed for oral sounds – Particularly important for “pressure-sensitive” consonants and all vowels• Velopharyngeal valve is open for nasal sounds (m, n, ng)

VP Valve during Speech

Purpose of VP Valve

• Directs transmission of sound energy and air flow in the oral and nasal cavities during speech

• Levator veli palatini (velar “sling”)• Superior constrictor (pharyngeal ring)• Palatopharyngeus (post faucial pillar)• Musculus uvulae (bulge on nasal surface)• Palatoglossus (ant faucial pillar)

Muscles of VP Closure

• Glossopharyngeal (IX) • Vagus (X) • Accessory (XI) • Trigeminal (V) • Facial (VII)

Motor Nerves of VP Function

• Vagus (X)• Glossopharyngeal (IX)

Sensory Nerves of Velum

Normal VP Closure(Nasopharyngoscopy)

• Coronal Pattern - velum and PPW• Sagittal Pattern - LPWs• Circular Pattern - all structures – sometimes includes Passavant’s ridge

Patterns of VP Closure among Normal Speakers

Patterns of Closure

• Non-Pneumatic: – gagging, vomiting, swallowing• Pneumatic: – blowing, whistling, speech (+ pressure) – sucking, kissing (- pressure)

Variations in VP Closure

Normal Velopharyngeal Function

Learning (Articulation)Anatomy (Structure)Physiology (Movement)

Velopharyngeal Dysfunction

Articulation/Speech Learning (Velopharyngeal Mislearning)Anatomy (Velopharyngeal Insufficiency) Physiology (Velopharyngeal Incompetence)

Velopharyngeal Insufficiency (VPI)

• History of cleft• Submucous cleft palate (overt or occult)• Short velum or deep pharynx (cranial base anomalies)• Irregular adenoids• Enlarged tonsilsFollowing Surgery or Treatment

VP Insufficiency

• Adenoidectomy• UPPP or UP3 (Uvulopalatopharyngoplasty)?• Maxillary advancement• Treatment of nasopharyngeal tumors

VP InsufficiencyFollowing Surgery or Treatment

Any disruption to one or more of these subsystems through surgical ablation, invasion or other adjuvant oncologic treatments will result in a functional maladaptive compensation of one or more of the remaining subsystems, creating increased labor of vocalization and speech production.

These subsystems are highly dependent on one another for audible, aesthetic and intelligible oral communication.

The primary subsystems of voice and speech production include: Respiration, Phonation, Resonance, and Articulation.

VPI is described by any of the following:

Velopharyngeal inadequacy (includes incompitence and/or insufficiency but may also suggest a reduction or absense pf pharyngeal wall function.Velopharyngeal insufficiency (when some or all of the soft palate is absent)Velopharyngeal incompetence (soft palate is of adequate dimensions but lacks movement because of disease or trauma affecting mucsular and/or neurological capacity.Velopharyngeal dysfunction.

These terms are used interchangeably to denote any type of velopharyngeal closure problem.

VPI originates from a number of possible etiologies

Structural (i.e. cleft palate and post-surgical insufficiency),Neurologic (i.e. cerebral palsy, dystrophies and myotonias) and Speech sound “mislearning” (i.e. compensatory misarticulations, hearing impairment, and postoperative nasal emission).

The specific etiology needs to be discerned in each case to provide a tailored treatment.

Hypernasality

Swallowing and speaking are complex motor functions requiring the coordination of a diverse group of muscles in the upper airway.

Hypernasality is a speech disorder that occurs when the tissues of the palate and pharynx do not close properly, and air leaks from the nose during speech.

• Too much sound resonating in the nasal cavity• Most perceptible on vowels• Voiced oral consonants become nasalized (m/b, n/d, etc.)

Hypernasality

• Velopharyngeal dysfunction• Open palate, thin velum or fistula• Misarticulation

Causes of Hypernasality

Treatments for Hypernasality

Treatments for hypernasality may include:SurgeryProsthetic appliancesTherapeutic intervention, physical therapy or a combination of these treatments.

Surgery Or Prosthetics

Surgical Management Procedure chosen depends on:• Size of gap• Cause of gap• Location, location, location!

• Pharyngeal augmentation• Furlow Z plasty• Pharyngeal flap• Sphincter pharyngoplastyNote: These do not always work the first time. May need revision or even re-do.

Surgery for VPI

Pharyngeal Augmentation

• Injection of a substance in the posterior pharyngeal wall• Can use fat, collagen (Demalogen, Simetra) or Radiesse (hydroxyl apetit)• Good for small, localized gaps or irregularities of the posterior pharyngeal wall

• Often used as a primary palate repair• Can be used as a secondary repair to lengthen velum• Appropriate for narrow, coronal gaps

Furlow Z Plasty

Pharyngeal Flap

Pharyngeal FlapView from nasopharyngoscopy

before and after flap

Pharyngeal wallVelomNasal surface

Pharyngeal Flap

Pharyngeal Flaps Both are too low

Sphincter Pharyngoplasty

Sphincter Pharyngoplasty Too narrow and too low

Surgical Options

1. Repair of Fistulae (holes in the palate): If any holes remain in the palate after cleft repair, these are surgically repaired. 2. Furlow Palatoplasty:The Furlow palatoplasty is performed in children whose palatal muscles are cleft, whether after palate repair or in the case of submucous cleft palate. This procedure consists of a double z-plasty which realigns the muscles of the soft palate and also lengthens the soft palate at the same time. • This additional length makes it easier for the palate to contact the back of

the throat. Realigning the muscles of the palate may also facilitate improvement in middle ear disease, which is common in children with cleft palate.

Surgical Options

3. Sphincter Pharyngoplasty:• The Sphincter pharyngoplasty is a procedure in which flaps of tissue from

the back of the throat are used to build a "speed bump" in the nasopharynx, behind the soft palate.

• This creates an additional ridge of tissue in the back of the throat which the soft palate can then contact.

• The size of the "speed bump" is tailored to the size and shape of the velopharyngeal gap. It cannot be seen when looking into one’s mouth.

4. Pharyngeal Flap: • This is another procedure performed to correct hypernasality, and has been

the standard speech surgery for many years. • It consists of sewing a flap from the back of the throat into the palate,

which blocks of the back of the throat. • Two openings are left on either side of the flap for breathing and nasal

drainage. • While this procedure can correct the problem, it can sometimes overcorrect

the deficiency, causing obstruction of the nose. • Obstructive sleep apnea is a relatively common complication after

pharyngeal flap surgery. We generally do not recommend this procedure.

Surgical Options

Speech Prostheses

Palatal Lift Appliances

Dental prostheses may be designed to fill the gap in the back of the throat.Such devices prevent excess air leakage from the nose during speech, and are removable.Speech prostheses may be recommended for children who are poor surgical candidates, but if the device is lost or not used, speech will return to its original state until a new appliance can be made.Creating the removable device requires weekly or biweekly visits over the course of several months. Two devices that can be used by patients with VPI are palatal lift appliances and speech bulbs

Palatal Lift Appliances

Speech ProsthesesA palatal lift device acts to lift the soft palate upwards and backwards into full contact with the posterior and sometimes lateral pharyngeal walls.

This device is recommended if the soft palate does not move very much during speech, but appears long enough to reach the back of the throat.

These devices are also useful in non-cleft patients when there is minimal movement of the velum such as neurologically impaired patients.

Speech bulbs

Speech Prostheses

Speech bulbs work best when the device does not have to close a large VP gap and can be designed to close off “most” of the gap and leave a small space for nasal respiration.

The device is most successful in patients that have adequate inward movement of the pharyngeal walls to improve closure.

Speech bulbs are recommended when surgery is not possible because of medical or anesthetic risks, or sometimes when the gap is so large that surgery is unlikely to work.

Speech bulbs

To occlude nasopharynx when the velum is short (velopharyngeal insufficiency)• Can be combined with an obturator

Speech bulbs

Speech bulbs

• Require insertion and removal • Have to redo periodically due to growth • Can be lost or damaged • May be very uncomfortable • Compliance is often poor • Don’t permanently correct the problem Many centers use only if surgery is not possible

Limitations of Prosthetic Devices

Physical Exercise to Improve Hypernasality

Physical therapy principles which stressed improving muscle tone and strength through:• Tactile stimulation• Repeated contraction of muscles• Resistance exercises.

Speech pathologist’s activities included; blowing, whistling, swallowing, sucking, cheek puffing and blowing against resistance.

Continuous Positive Airway Pressure (CPAP)

One approach to alleviate low muscle tone is to increase muscle strength or endurance using a resistance exercise regimen focused on the muscles of the soft palate.Resistance to the muscles of the VP mechanism is delivered via artificially increased nasal resistance through increased air pressure to the nasal cavities.Air pressure is delivered using a commercially available device referred to generically as continuous positive airway pressure (CPAP).

Hyponasality

Hyponasality occurs when the nasal cavity cannot be accessed for the nasal consonants "m", "n" and "ng". This results in the sound "b" being pronounced as an "m" and the "n" sound as a "d".

Reduction in normal nasal resonanceInsufficient nasal airflow during target nasal soundsGenerally caused by blockage in the nasopharynx or obstruction in the nasal cavity particularly affects nasal phonemes (e.g., /m/=> [b]; /n/ => [d])

Causes of Hyponasality

Temporary hyponasality is often caused by excessive mucus secretions and swollen mucus membranes, resulting from a cold, flu, or allergies.

Chronic hyponasality may be caused by allergies, structural deviations of nasopharynx, nasal septum (such as a deviated septum), or sinus cavities. Other causes include growths such as nasal polyps, or enlarged adenoids.

Chronic hyponasality can cause some serious health problems even if the cause of the hyponasality is comparatively benign. Mouth breathing is a common result of hyponasality, which in extreme cases can cause developmental problems affecting dental occlusion, oral health, and perhaps even the proper growth of facial bones.

Blockage of the Eustachian tubes commonly co-occurs with hyponasality, which can lead to chronic ear infections; chronic ear infections may cause permanent hearing loss and in severe cases may lead to meningitis. Blockage of the sinuses is also associated with a decreased sense of smell, which may lead to a decreased appetite. Theoretically lacking a sense of smell is also a health hazard because you can no longer detect gas leaks, smoke, and the like, but personally I'd worry more about the meningitis.

Cul-de-sac resonance

Type of hyponasalityAnterior nasal obstruction“Muffled” quality

Correction of hyponasality will often result in temporary hypernasality, until the speaker learns to adjust their speech to account for the decreased nasal blockage.

Speech should return to normal within six weeks after surgery, otherwise it's time for a another consult.

Mixed resonance disorder

Hypernasality and hyponasality co-existNot uncommon in cleft palate population

Hyponasality can mask hypernasality

Resources

http://www.speechpathology.com/articles/article_detail.asp?article_id=293Bridget A. Russell, Ph.D., CCC-SLP, Department of Speech Pathology & Audiology, State University of New York Fredoniahttp://www.entcolumbia.org/hypernas.htmlDepartment of Otolaryngology, Head & Neck SurgeryHypernasality – Velopharyngeal Insufficiency, Oral Cavity ReconstructionTerry A.Day Douglas A.GirodResonance Disorders and VeloPharyngeal Dysfunction: Evaluation and TreatmentAnn W. Kummer, PhD, CCC-SLP Cincinnati Children’s Hospital Medical Centerhttp://www.choa.org/default.aspx?id=760Speech Pathology, Managing Speech DisordersAn Introduction to Speech Pathology and Resonance Disorders by John E. Riski, Ph.DClinical Management of the Soft Palate DefectSteven E.Eckert, DDS,MSRonald P. Desjardins, DMD,MSDThomas D. Taylor, DDS, MSD

THANKS