Successful and rapid response of speech bulb reduction program combined with speech therapy in velopharyngeal dysfunction: a case report
© Shin and Ko. 2015
Received: 3 July 2015
Accepted: 24 July 2015
Published: 6 August 2015
Velopharyngeal dysfunction in cleft palate patients following the primary palate repair may result in nasal air emission, hypernasality, articulation disorder and poor intelligibility of speech. Among conservative treatment methods, speech aid prosthesis combined with speech therapy is widely used method. However because of its long time of treatment more than a year and low predictability, some clinicians prefer a surgical intervention. Thus, the purpose of this report was to increase an attention on the effectiveness of speech aid prosthesis by introducing a case that was successfully treated. In this clinical report, speech bulb reduction program with intensive speech therapy was applied for a patient with velopharyngeal dysfunction and it was rapidly treated by 5months which was unusually short period for speech aid therapy. Furthermore, advantages of pre-operative speech aid therapy were discussed.
KeywordsVelopharyngeal dysfunction VPD Velopharyngeal insufficiency Velopharyngeal incompetence VPI Speech aid prosthesis Speech therapy Speech bulb
Velopharyngeal dysfunction (VPD) is a term describing an inappropriate function of velopharyngeal (VP) port which consists of lateral and posterior pharyngeal walls and soft palate. This muscular valve can control the air passage between oro- and nasopharynx. When the proper closure cannot be performed, liquid regurgitation during swallowing, nasal air emission, hyper-nasality and poorly intelligible speech may occur . Furthermore, this physical disability usually causes psychological stress on the patients with VPD, especially during childhood .
The impairment of velopharyngeal function can be attributed to structural causes, neurologic causes and speech mislearning . Even though there is sufficient soft tissue to close the VP port with normal anatomical structure, velopharyngeal function can be incompetence (velopharyngeal incompetence; VPI) due to neuromuscular disorders: cerebral palsy, myotonic dystrophy, cerebral vascular accidents, etc. On the other hand, soft tissue deficiency for closing VP port, surgical removal or congenital loss of normal structure separating the nasal and oral cavity can lead to a state called velopharyngeal insufficiency (VPI) and most common cause of this condition is cleft palate. Even after repair surgery, VPD has been found among cleft patients in range of 30~50 % .
Diagnosis of VPD, identifying a critical cause of the dysfunction, can be carried out through physical and oral examination, perceptual speech assessment, radiographic mulitplanar videofluoroscopy and nasendoscopy. Treatment options of VPD with history of cleft palate repair include surgical and prosthetic interventions in combination with speech therapy. Various surgical techniques, such as pharyngeal flap surgery, sphincter pharyngoplasty and Furlow palatoplasty, have been used, but success rate of the surgical treatment is approximately 50 % [5, 6]. Prosthetic devices for VPD can be alternative treatment method when surgical approach is not considered. Widely used types of these devices, called speech aids, are palatal lift appliance and speech bulb.
The purpose of this report was to introduce an unusual case of VPD that was successfully treated using a prosthetic device and speech therapy and to increase an attention on the effectiveness of speech aid prosthesis.
Results of nasometric assessment before and after intervention
Nasalance score (%)
Degree of nasalance and suggested treatment options for VPD (Shin’s criteria)
Recommended options of treatment
Below 20 %
20 ~ 35 %
35 ~ 45 %
Moderate nasality (marginal VPD)
Speech aid appliance with speech therapy
45 ~ 60 %
Surgery or speech aid
Over 60 %
Severe nasality (VPD)
A rational explanation of this successful outcome of the presented case was not fully understood. In this case, specific consonant /s/ was only one with distortion which was affected by nasal emission. And vowel /i/ was also showed prominent and severe nasalance comparing the other vowels. Because of this specificity, fabrication of speech aid and speech therapy could be focused on the distinct target that should be corrected. And because of a psychological stress on her nasal sound, the patient was very cooperative with long time wearing of the appliance and intensive speech therapy.
Speech therapy combined with the prosthesis is widely accepted treatment method for VPD. However due to the low predictability, some clinicians may be negative to this treatment method. According the several literature, successful outcome of the therapy were reported as approximately around 10~30 % [10–12]. However, there is still a possibility of improvement in this poor success rate. According to Yamashita et al., success rate, a percentage of patients who finally removed the prosthesis, was approximately 40 % when the therapy was applied on children less than 7 years old . With consideration of commonly poor treatment compliance of children, this rate was quite high and it suggests that early intensive treatment could improve the prognosis.
Furthermore, using speech aid can avoid permanent complications of surgical intervention such as snoring, sleep apnea, airway obstruction and hyponasality [5, 13]. For the case of delayed surgery, temporary use of the prosthesis can train the velopharyngeal function and minimize the speech mislearning – the effectiveness of pre-operative prosthesis therapy already have reported . Therefore, ahead of surgical intervention, speech therapy with the prosthesis should be considered as early as possible. And, all of the cleft team members who take care of VPD should make a greater effect to improve the compliance of the young patients and their parents.
This clinical report introduces a case of VPD which was successfully and promptly treated with speech therapy using the speech aid. This effective intervention may be due to the fact that nasal emission affected only single consonant /s/ and this phonemic target can be focused well during the therapy. This report also suggests that pre-operative use of the prosthesis even in the patient group of severe nasal score, since young children showed better outcome and early use of the speech aid can improve the prognosis of the velopharyngeal surgery.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
Velopharyngeal incompetence; velopharyngeal insufficiency
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