Division of Pediatrics

Hypernasality – Velopharyngeal Insufficiency

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.

Hypernasality occurs in children after cleft palate surgery, in certain craniofacial syndromes, in children with neurologic problems, rarely after adenoidectomy surgery, and sometimes in otherwise healthy children. It can render a child’s speech unintelligible and can significantly impair communication. The consequences of hypernasality are potentially devastating to a child’s quality of life, as studies have shown that people with hypernasal speech are often considered less intelligent, less pleasant, and less attractive than people with normal speech. Such perceptions can seriously affect the social life and self-esteem (and in the future, vocational opportunities) of children with hypernasality.

In children with cleft palate, the muscles of the palate may remain separated under the palate’s lining and do not form a sling across the back of the soft palate as in a normal child. The muscles work less effectively in such cases. After many types of palate repairs, the palate still remains too short to reach the back of the throat and achieve closure between the mouth and nose. In other disorders, the walls of the throat may not move well enough to adequately close the back of the throat.

Evaluation of Hypernasality

The Craniofacial Speech Disorders Center in the Division of Pediatric Otolaryngology at the Children’s Hospital of New York focuses entirely on children with hypernasality, using a team approach in a child-friendly environment. Your child’s speech will first be analyzed by a pediatric speech physiologist Etoile LeBlanc, CCC-SLP, with expertise in velopharyngeal insufficiency. Evaluation will also include a complete head and neck exam by Dr. Lianne deSerres, and then possibly a nasopharyngoscopic examination. Hearing testing may be ordered as well.

The nasopharyngoscopic examination involves looking at the back of your child’s throat while she is speaking in order to see how the muscles of the throat work during speech, and determine what anatomic problem should be treated. To prevent discomfort during the nasopharyngoscopic exam, the physician places anesthetic drops in one side of the nose. A very small, flexible telescope is gently placed in the nose in order to see the back of the throat. Your child will be asked to say a few words of sentences with the telescope in place. This takes just a minute or two to complete.

If additional information is needed to help determine correct treatment, the team may request a videofluoroscopic exam at a later date. This is an x-ray study performed by a radiologist and a speech pathologist. A few drops of dye are placed in the nose, and with your child speaking, a 1 – 2 minute x-ray film is taken.

Treatments for Hypernasality

Treatments for hypernasality may include prosthetic appliances, surgery, therapeutic intervention, or a combination of these treatments. Ongoing speech therapy may be very important to your child’s overall success with treatment. If hypernasality is a learned behavior or is isolated to one or two sounds, speech therapy may be sufficient in itself. Usually, however, it is used to correct articulation problems in conjunction with surgery or prosthetic devices.

Surgical Options

Surgical procedures are performed in order to reduce the air leakage from the nose in order to help speech sound normal. Procedures are tailored to your child’s anatomy. The following operations take about 1½ hours to perform and require one or two nights in the hospital. In a small number of children, speech may not be corrected with a single procedure, and a second operation may be necessary.

  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.

  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.

Speech Prostheses

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. Appliances are designed by a speech prosthodontist at the Craniofacial Speech Disorders Center; creating the device requires weekly or biweekly visits over the course of several months. 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.

Additional Information:

Craniofacial Speech Brochure - General

Craniofacial Speech Brochure - What To Expect From Your Visit

For more on Velopharyngeal Insufficiency, please see the emedicine.com article -- http://www.emedicine.com/ent/topic596.htm

Cleft Lip and Palate

Profile of Dr. Lianne de Serres

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