1. Levator veli palatini

2. Muculus Uvulae

3. Superior Constrictor Muscle

short, paired muscles that overlies the junction of the right and left levators in an anteroposterior direction

arises from the posterior nasal spine (bony edge of the hard palate) and terminates at the tip of the uvula

-essential for velopharyngeal closure

-If this is absent air escapes laterally around the sides of the palate, even when the palate is in full contact with the posterior pharyngeal wall

-forms a circular layer of muscle around the pharynx

-fibers arise from the soft palate, sides of tongue, medial pterygoid plate, hamulus, and insert into the median pharyngeal raphe

-forms the PPW (responsible for PASSAVANT'S RIDGE the localized anterior motion of the PPW)

-form the posterior faucial pillars, extending from the later pharyngeal wall to the side of the soft palate

-Velopharyngeal narrowing, ELEVATION of the larynx, DEPRESSION of the pharynx, and formation of Passavant's ridge.

-extend from the oral surface of the velum to the sides of the tongue

-form the anterior faucial pillars

-arises from the base of skull and inserts into the palatine aponeurosis

-DOES NOT TENSE THE PALATE OR HAVE ANY ROLE IN VELOPHARYNGEAL CLOSURE

-Opens eustachain tube to equalize middle ear pressure

1. Voice

2. Resonance

3. Articulation

-vocal signal goes through the pharynx/vocal tract is modified by the shape, size, and tissue characteristics

-vocal tract has a branch in the nasal cavity that can be included/excluded during speech production by velopharyngeal closure

1. coronal pattern

2. sagittal pattern

3. circular pattern

4. circular with passavant's ridge pattern

Most common (40%)

-velum moves up and back to contact the posterior pharyngeal wall with just enough lateral wall motion to prevent the escape of air around side of the palate

(occurs 20%)

-lateral pharyngeal walls move together between the palate and PPW

(Occurs 20%)

-Velum and LPW move equally

(occurs 20%)

-movement of the velum, LPW and localized forward motion of the PPW

(less common anomaly)

-discontinunity of the underlying orbicularis oris muscle but the outer layers of the skin are intact

-may appear as an indentation or faint indentical line and often resembles a repaired cleft lip

-mildest type of cleft lip may require no treatment; unless accompanied by a nasal deformity

1. Unilateral Complete (one side floor to nose)

2. Bilateral Complete (both sides floor to nose)

3. Unilateral Incomplete (one side just on vermillion/red part of the lip)

an opening in the palate (roof of mouth) present at birth and results in a total or partial lack of seperation between the mouth and nose

unilateral or bilateral

incomplete or complete

type of cleft palate that is not readily visible because the overlying mucosa membrane is intact

(not usually found at birth; found during examination because of difficulty with feeding, speech, hearing, or sudden onset of hypernasal speech following an adenoidectomy)

1. Bifid Uvula

2. Zona Pellucida/ bluish discoloration along the central part of the palate; caused by muscular diastasis (seperation of underlying muscles)

3. Notch at posterior edge of hard palate

features of the SMCP are absent and oral examination yields normal appearance even though a SMCP is present

-impossible to diagnose with and oral examination

-only be identified looking at the palatal morphology from nasal side

-Radiographic techniques used to detect

1. Flattening or grooving of the dorsal (nasal) surface of the velum

2. Deficiency of absence of the musculus uvulae (m.u.)

-lip and/or palate

-unilateral/bilateral

-complete/incomplete

-overt/submucous

1. Cleft of soft palate only

2. cleft of hard & soft palate extending to the incisive foramen

3. Complete unilateral cleft of lip, alveolus, hard& soft palate

4. Complete bilateral cleft of lip, alveolus, hard & soft palate

cleft lip with or without cleft palate

racial differences

-native americans (3.7 in 1,000 births)

-Asians (3 in 1,000 births)

-Caucasians (1 to 2 in 1,000 births)

-African Americans (.2 to 1.7 in 1,000 birhts)

reoccuring patterns of anomalies with a SINGLE etiology

ex: over 342 known syndromes involving orofacial clefting; many of which are genetic

percent with other malformations:

only cleft palate

percent with malformations:

cleft lip and palate

percent with malformations:

cleft lip alone

-primary anomaly (mandibular deficiency)

-mandible must descend in order for the palatal shelves to grow horizontally and fuse

-failure of the mandible to grow in utero prevents tongue from lowering

-elevated tongue prevents the lateral segments of the palate from growing together resulting in incomplete cleft palate

-after birth have difficulty breathing (glossoptosis)

1. Chromosomal abnormalities

2. Genetic abnormalities

3. Teratogenic Agents

4. Mechanical Influences

-miscarriage

-severe malformations

-delays

-mental retardation

-down syndrome

Velo-Cardio-Facial Syndrome

(Most Common Syndrome associated with Cleft Palate)

-incomplete cleft palate (velo)

-Cardiac defect (cardio)

-Characteristic facial apperance (facial)

-breathing problems (related to robin sequence)

-facial asymmetry (when crying)

-Laryngeal web

-severe compensatory artic. disorders

-Severe hypernasality

-Hoarse voice and high vocal pitch

-delayed language

-learning disabilities (2 and 3rd grade: inferential reasoning abstract thinking math and reading)

-possible psychiatric disorders in teen years

genetic disorder affecting the connective tissue

*1/3 of robin sequence have this*

-incomplete cleft palate or submucous cleft palate

-severe/progressive myopia (nearsightedness)

-Early arthritis; painful joints even in y. children

-high frequency sensorineural hearing loss

-scoliosis

-infants obstructed airway (robin sequence) & narrow

-not all have cleft palate if they do many have normal speech

-normal language and hearing skills

-those who have cleft palate are mildly hypernasal and have compensatory artic. disorders

Van der Woude Syndrome

(VDW)

-inherited cleft lip and/or palate with low lip pits; congentially absent premolars

-clefting VARIABLE (even among siblings)

-normal lang./learning skills

-speech often normal after palatal repair (but 40% have hypernasal resonance and compen. artic. errors)

involves:

face bilaterally

orbits bilaterally

ears bilaterally

-cleft palate, submucous palate, maybe lip

-max. conductive HL (outer/middle ear malformations)

-bone conduction HL (microtia and/or atresia)

-defects lower eye lids

-clefting of zygomatic arch (gives eyes downward slant)

-maxiallary hypoplasia; mandibular deficiency (RS)

-narrow Vocal tract; obstructed airway (infancy)

-hypernasality mild/intermittent

-tongue backing artic. errors

muffled oral resonance (small oral cavity)

(3) Teratogenic Effects

What is a teratogen?

-teratogen

-stage of pregnancy

-frequency, duration, and intensity of exposure

-exposure to combo's of potential teratogens

-mothers metabolism

Well known teratogens:

-alcohol

-crack/cocaine

-OTC Medications

-Prescription Medications

-Viruses (rubella)

-prenatal/postnatal growth deficiency

-mental retardation

-irritability

-hyperactivity

-cardiac defects

-micrognathia

-lang./learning problems

-if have cleft palate (risk for artic errors and hypernasality)

-cleft palate

-neonatal cocaine withdraw

-challenging early feeding time

-clefts (occur from uterine abnormalities)

-multiple prenancies (intrauterine crowding)

--craniofacial anomalies

-amniotic tears resulting in severe deformities affecting the face, limbs, and digits

-necessary surgeries

-parents acceptance of not having a perfect baby

-communication skills

-acceptance by peers

-neglect

-concealment

-infanticide

-pediatrician

-plastic surgeon

-otolaryngologist

-orthodontist

-SLP

3 months of age

-weight at least 10 lbs

-hemoglobin of at least 10 grams

-white count no higher than 10,000

-at least 10 weeks old

Palate Repair

1 surgery (hard palate) 2 surgeries (soft palate)

Purpose: to seperate nasal and oral cavities

most important reason is to facilitate speech

others to facilitate eating and reduce nasal regurgitation

hypernasality due to VPI occurs following palata surgery 16-20% of the time

Purpose:

-provide potential velopharyngeal closure

-creates normal resonance in hypernasal individual

-acts as a cork to prevent leaking of air into nasal cavity

-elminates the need for contact between the velum and posterior pharyngeal wall

-flap of tissue from the PPW

-top of flap connected

insertion of the bottom end of flap into a slit in the soft palate

-plan width of PF the surgeon views the LPW during speech with a nasopharyngoscopy (4th b-day)

-too wide can cause airway obstructions (snoring, hypernasality)

-when LPW motion is asymmetric the flap can be skewed to one side

1. Direct Visualization

2.Indirect Visualization

1. Endoscopy

2. Radiography

-inserted through nostril; moved around nasal and larynx and connected to a light source

-best view of velar structure

Multiview Videofluroscopy

-technique of choice for examination of velopharyngeal closure together with nasopharyngoscopy

-less radiation

-three views (lateral, frontal, base)

1. pressure-flow

2.nasometer

-measure airflow through orifice and resulting in change in air pressure

-nasal air measure through a catheter on one nostril

-calculate using info obtained from catheters in other nostril and mouth

-computes ratio btwn nasal and oral acoustic energy

-based on TONAR

-microphone positioned at the nose and mouth the shield acts as a sound seperator and data fed into a computer and displayed on a monitor

99% surgical or prosthetic management

elimination of compensatory artic.disorder requires intensive ind. therapy (3-5 times per week)

-nonspeech activities (sucking, blowing) do not result in improvement in artic. or VP closure