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Physical management of:
VPI/A that persists after ?
VPI/A that may re-emerge after?
2 broad categories of physical management?
- initial palatoplasty
- adequate repair
- Surgical
- Prosthodontic/prosthetic (intraoral appliances)
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Surgical: Velar Augmentation
Repositioning the velar muscles to:?
- increase velar length
- -V-Y pushback
- Increase velar function
- -intravelar veloplasty (levator reconstruction)
- Increase both length and function
- =furlow z-plasty as a secondary procedure
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Surgical: Velar Augmentation when successful these procedures ?
approximate/creat "normal" VP function
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Surgical: Pharyngoplasty
Includes any procedure that?
EX?
position and/or function of (naso)pharyngeal musculature
- pharyngeal flap
- sphincter pharyngoplasty
- augmentation pharyngoplasty
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Pharyngoplasty: Pharyngeal Flap
____ based flap
Incisions made ?
Flap attached at __ to __?
Technically more difficult than ___ based?
Most ?
More?
- Superiorly
- left, right, bottom
- top to PPW
- inferioly
- frequently done
- effective
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Pharyngoplasty: pharyngeal flap
___ based flap
____ procedure
Incisions made?
Flap attached at?
- Inferiorly
- Earliest design
- left, right, top
- bottom to PPW
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Pharyngeal flap: endoscopic view
Flaps work because of ?
Less the ? wider the ? must be
Risks being?
Level of the match between ____ and ___ also a factor in success?
- LPW movement in against flap
- LPW movement
- the flap
- obstructive
(height of) flap and most medial
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Hynes originated now the "sphincter" pharyngoplasty
Designed it to?
- Advance posterior pharyngeal wall
- Reduce overall diameter of the sphincter (VP port), especially lateral dimensions
- Produce an active sphincter
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Sphincter pharyngoplasty procedure involves?
- dissection of the posterior pillars-repostitioning them up and back
- suturing them into the PPW
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Good candidates of sphincter pharyngoplasty have?
some velar movement and smaller VP gaps
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Augmentation Pharyngoplasty
Goal:?
bring the PPW forward to shorten distance between PPW and velum which would enable adequate VP closure.
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Augmentation Pharyngoplasty
Includes variety or approaches:?
- Rearranging soft tissue on PPW
- Implanting cartilage in PPW
- Injecting or implanting a synthetic material into PPW
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Augmentation Pharyngoplasty: Soft tissue advancement
first used in ?
Has included?
- Suturing palatopharyngeus muscles in midline to augment Passavants ridge
- Folding a flap of mucosa on itself to create a passive ridge
- Raising salpingopharyngeus muscles and mucosa and suturing them into the PPW
- Rolled mucosal flap to give extra thickness to PPW, for patients with small defects
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Augmentation Pharyngoplasty: Cartilage Implants
Use ?
Creates ?
No ?
Implants?
- autogenous cartilage (from pts rib)
- forward projection on PPW
- speech benefit
- not stable (in position or size)
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Prosthetic management/speech appliances
Speech bulb appliances (for VPI/S)
for?
for?
- individuals with clefts
- those who have had ablative (cancer) surgery involving hard palate, soft palate or both
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Prosthetic management/speech appliances
Palatal lift (for VPI/C)?
non cleft movement disorders/neurogenic causes; individuals with dysarthria
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Prosthetic management/speech appliances
Combinations?
bulb and lift configurations
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Speech bulb appliance
For?
Oral portion clasps to? can include ?
___ = bulb?
fitsup/behind?
___ design?
designed to accommodate?
- VPI/S
- teeth
- missing teeth
- tailpiece/posterior extension portion =
- soft palate; residual tissue
- under and up
- patient's anatomy
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Speech success depends on ?
contour of the bulb and on correct placement in relation to the level of (medial/inward) movement of the pharyngeal walls
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Assessing bulb placement
can use videoendoscopy to visualize ? and see ?
- Pharyngeal wall (and velar) movements against appliance
- gaps in fit
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Assessing bulb placement
Can use videofluoroscopy to visualize ?
lateral view with respect to level of placement
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Assessing bulb placement
Can use aerodynamic studies to assess ?
gives?
cloasure adequacy in eliminating nasal air emission
objective measure but cannot determine where gap is with this instrumentation
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Speech appliances as training devices:
to facilitate oral articulation placements in pts with VP inadequacy when:
Surgery is ?
There is a ____ pattern that has not responded to traditional therapy (usually a lift type appliance)
Cannot determine?
- not possible/advisable
- learned NAE
- need for further surgery:
- repaired clefts with HN and CMA
- Appliance prevents oronasal coupling/facilitates oral resonance and airflow for learning HPCs
- Anecdotal reports are positive
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VPI/C is typically acquired as a part of?
Dysarthria is a speech disorder resulting from? of the speech musculature that is of neurological etiology?
- a more extensive dysarthria
- weakness, paralysis or incoordination
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Preferred tx team?
- SLP
- General dentist
- maxillofacial prosthodontist
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Clinical speech evaluation: questions to be answered
Is there ___ of VP incompetency?
What is the ___ of the incompetence?
Does VP incompetency ____ of speech performance?
- evidence
- extent
- influence other aspects
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Use instrumental assessment to confirm perceptual speech diagnosis
Endoscopy?
allows us to look at velopharyngeal closure and also observe laryngeal behavior/movements
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Use instrumental assessment to confirm perceptual speech diagnosis
Videofluoroscopy
- allows us to obtain multiple views
- -lateral view allows for observing oral tongue movements as well as VP closure
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Palatal lift appliance (PLA)
Used for ?
designed to?
Configured to?
- VP incompetencies
- for both acquired and congenital dysarthrias
- raise velum to level that can facilitate
- to fit individual anatomy
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Palatal lift appliance (PLA)
Basic materials?
- can be all acrylic less expensive and used with children
- cast presision metal + acrylic-for adults
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Treatment options
PLA with ?
PLA with ? for other aspects of dysarthria
______ for other aspects of dysarthria, while monitoring for (spontaneous) improvment in VP function
No?
- periodic speech follow-up
- speech remediation for other aspects of dysarthria
- speech remediation
- physical management
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Determining candidacy for PLA factors to consider?
___ of dysfunction?
Patient ___ & ___?
____ = problem
___ vs ___ disorder
___: appliance can increase secretions which can be aspirated
___: denture bearing appliance is difficult
- severity
- cooperation & motivation
- Spasticity/"stiff" soft palate
- progressive vs non-progressive
- swallowing
- dentures
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Patients with flaccid dysarthria tend to be the best candidates for?
PLA management
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Palatal lifts:
get best speech results when there is some?
with no residual movement speech is a compromise between ?
Best candidates:?
- residual movement (PWs, velum, both)
- obstruction that creates densality
- improved but incomplete closure with less speech change
- flaccid dysarthria patients
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Palatal lift appliance (PLA)
Important to carefully assess?
resonance and intraoral pressure ability in this population
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Goals of PLA management?
- Improve VP closure for pressure consonants
- Allow VP opening for nasal sounds
- Provide appliance that is functional & painless
- Provide comfortable nasal rest breathing, not mouth breathing
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Goals of PLA management
Improve?
- overall speech output
- Speech intelligibilty (at least 30% improvement)
- Acceptable resonance balance
- No audible NAE
- Improved precision of (pressure) consonant production
- Improved valving of breath stream for oral airflow & pressures
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Tx for VPI/C
SLP?
- diagnoses the VPI/C
- determines the need for and potential benefits of a palatal lift appliance
- provides any pre-appliance introral desensitization
- checks the appliance for VP speech adequacy and determines the speech need for any modifications
- Provides ongoing therapy, as necessary and feasible, or provides guidance to treating SLP
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Tx for VPI/C
General dentist?
- evaluates dental and oral health
- and especially
- evaluates the adequacy of the dentition for retaining the appliance
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Tx for VPI/C
maxillofacial prosthodontist?
- designs and fits the appliance
- makes decisions regarding the feasibility of incorporation of a partial or full maxillary denture provides follow-up for the appliance and makes adjustments as necessary
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