Speech pathology Speech therapy will not correct<unk> . The condition results from abnormal structure and requires physical management (surgery, or a prosthetic device if surgery cannot be done). Speech therapy is appropriate to correct the compensatory articulation productions that develop as a result of<unk> . Speech therapy is most successful after correction of<unk> . Speech pathologists who are associated with a cleft palate/craniofacial team are most qualified for this type of therapy. Operation techniques Inferior based pharyngeal flap Superior based pharyngeal flap In patients with cleft palate, the palate must be repaired through a palatoplasty for normal velopharyngeal function. Despite the palatoplasty, 20-30% of these patients will still have some degree of<unk> , which will require surgical (or prosthetic) management for correction. Therefore, a secondary operation is necessary. There is not one single operative approach to surgical correction of<unk> . The surgical approach typically depends on the size of the velopharyngeal opening, its location, and the cause. With diagnostic tools the surgeon is able to decide which technique should be used based on the anatomical situation of the individual. The goal of every operation is to achieve the best possible result with the technique assigned to each individual case, without causing upper airway obstruction and sleep apnea.Nowadays the procedure that is chosen the most from the palatoplasties is the pharyngeal flap or sphincter palatoplasty. Pharyngeal flap When a pharyngeal flap is used, a flap of the posterior wall is attached to the posterior border of the soft palate. The flap consists of mucosa and the superior pharyngeal constrictor muscle. The muscle stays attached to the pharyngeal wall at the upper side (superior flap) or at the lower side (inferior flap). The function of the muscle is to obstruct the pharyngeal port at the moment that the pharyngeal lateral walls move towards each other. It is important that the width and the level of insertion of the flap are properly constructed, because if the flap is too wide, the patient can have problems with breathing through the nose, which can result in sleep apnea. Alternatively, a postoperative situation can be created with the same symptoms as before surgery. Some complications are possible; for example, the flap's width can change because of contraction of the flap. This results in a situation with the same symptoms of hypernasality after a few weeks of surgery. Also a fistula can occur in 2.4% of the cases. Sphincter palatoplasty Sphincterplasty When the sphincter pharyngoplasty is used, both sides of the superior-based palatopharyngeal mucosa and muscle flaps are elevated. Because the distal parts (posterior tonsillar pillars, which the palatopharyngeal muscles are attached to) are sutured to the other side of the posterior wall, the pharyngeal port will become smaller. As a result, the tissue flaps cross each other, leading to a smaller port in the middle and a shorter distance between the palate and posterior pharyngeal wall. There are a few advantages with using this technique. First of all the procedure is relatively easy to execute. This makes the operation cheaper, also because of a reduced anesthesia time. Secondly the dynamic sphincter can be moved as result of a remaining neuromuscular innervation, which gives a better function of the velopharyngeal port. Finally there is a lower complication rate, although obstructive sleep apnoea syndrome (OSAS) is associated. Both techniques are used often, but there is no standard operation. Pharyngeal flap surgery is not better than sphincter palatoplasty. It is more upon the surgeon's experience, knowledge and preference which operation will be done. Also the patient’s age, and the size and nature of the velopharyngeal defect, contribute to which technique is used. Posterior wall augmentation Posterior wall augmentation Another option for diminishing the velopharyngeal port is posterior wall augmentation. This technique is not often used. Additionally this technique can only be used for small gaps. When this operation is performed there are several advantages. It is possible to narrow down the velopharyngeal port without modifying the function of the velum or lateral walls. Furthermore, the chance of obstructing the airway is lower, because the port can be closed more precisely. Many materials have been used for this closure: petroleum jelly, paraffin, cartilage, adjacent soft tissue, silastic, fat, Teflon and proplast. But results in the long term are very unpredictable. There are problems with tissue incompatibility and migration of the implant. Even migration to the brain is noticed. Non-operative techniques Prosthesis Prostheses are used for nonsurgical closure in a situation of velopharyngeal dysfunction. There are two types of prosthesis: the speech bulb and the palatal lift prosthesis. The speech bulb is an acrylic body that can be placed in the velopharyngeal port and can achieve obstruction. The palatal lift prosthesis is comparable with the speech bulb, but with a metal skeleton attached to the acrylic body. This will also obstruct the velopharyngeal port. It is a good option for patients that have enough tissue but a poor control of the coordination and timing of velopharyngeal movement. It is also used in patients with contraindications for surgery. It has also been used as a reversible test to confirm whether a surgical intervention would help.
Velopharyngeal insufficiency
Velopharyngeal inadequacy
Nasal septum deviation
Laryngotracheal stenosis
Patulous Eustachian tube
Eustachian tube dysfunction
Oropharyngeal dysphagia
Salivary gland hypoplasia