1. An Overview: Nature of the Velopharyngeal (VP) Mechanism Delivery of Service Linda D. Vallino-Napoli, PhD, MS, CCC-SLP/A

2. Normal Speech Ability to coupling* and decoupling* the nasal cavity from the oral cavity (velopharyngeal valving) –Normal resonance –Normal articulation –Normal phonation *oral-nasal coupling – nasal sounds *oral-nasal decoupling – oral sounds

3. Hard Palate (inferior view) http://www.yorku.ca Posterior nasal spine Incisive foramen Palatine process of maxillary bone Premaxilla

4. Nature of VP Mechanism: 3 components  Velum  Posterior pharyngeal wall (ppw)  Lateral pharyngeal wall (lpw)

5. Velopharyngeal Closure In a nutshell… During normal speech production, the velum moves upward and backward to contact the posterior pharyngeal wall. Simultaneously, the lateral pharyngeal walls move medially to abut against the edges of the velum.* These movements (vp closure)separate the oral and nasal cavities for oral consonants. *The contribution of these components vary among individuals.

6. Velopharyngeal Mechanism = Velum + PPW + LPW + Velum PPW LPW

7. Function of Soft Palate Tensor Palati (#1) Levator Palati (#2) (pulls palate upward and backward) Palatoglossus (#3) Palatopharyngeus (#4) Superior Constrictor (#5) (medial movement of lpw) Fritzell (1969)

8. Velopharyngeal Port at rest (open) during speech Source: www.choa.org/default.aspx?id=762 (choa=Children’s Healthcare of Atlanta)

9. Velopharyngeal Inadequacy (VPI) (“dysfunction” - VPD) ??? VPI VP??

10. VPI (VPD): A definition Faulty velopharyngeal closure or… The inability for the velum and related musculature to separate the oral and nasal cavities on oral consonants

11. Causes of VPI  Cleft VPI –Opening in the palate (cleft palate, large fistula)  Velopharyngeal insufficiency –Short palate –Post adenoidectomy –Post maxillary advancement  Velopharyngeal incompetency –Poor muscle function  Velopharyngeal mislearning –Phonemic-specific nasal emission

12. Velopharyngeal Inadequacy (VPI) velum VP gap Adenoid pad

13. What happens to speech??????

14. Effect of VPI on Speech (and…the terminology to describe it)  Hypernasality  Nasal air emission*  Weak or omitted consonant sounds  Articulation errors (compensatory)  Facial grimace  Phonatory disorders *not = hypernasality

15. What Next??????

16. Delivery of Care “…children with special health care needs (Koop, 1987)…require comprehensive, coordinated care provided by health care systems that are readily accessible and responsive to the individual needs of the parents and their families.” (ACPA, Parameters of Care, 2007)

17. ACPA, Parameters of Care (1993, 2000, 2007) Optimal care of children with clefts and craniofacial conditions: Best provided by an interdisciplinary team of specialists From neonatal period through adulthood - until all management needs are met

18. Team Composition  Audiology  Dentistry  Genetics  Oral maxillofacial surgery  Plastic surgery  Psychology  Speech-language pathology  Patient and caregivers

19. Team Responsibilities  Recognize the needs of each patient and assist in providing all services needed to complete care  Evaluate patients at regular intervals  Hold regularly scheduled meetings to discuss findings  Develop treatment plan based on patient needs  Maintain comprehensive records for each discipline  Communicate findings & recommendations  Collaborate with providers in the community

20. Birth of the CLP Team Lancaster Cleft Palate Clinic - 1938 Photo: Courtesy of Dr. Ross Long, Jr.

21. Referring to a Team  When a child has a cleft or craniofacial disorder  When a resonance disorder or VPI is suspected

22. Where do you find a team?  www.acpa-cpf.org  www.cleftline.org  http://www.cleftline.org/team_listings/state_dfg

23. Summary  Cleft and other conditions affecting VP function can present complex problems  Careful evaluations are essential to making an appropriate diagnosis and planning effective treatment  Interdisciplinary team management is the standard of care for these patients

24. Acknowledgements  Ross Long Jr, DMD, PhD (Lancaster Cleft Palate Program) for the photos of the Lancaster Cleft Palate Team.  ASHA and ACPA for sponsoring this symposium

25. Thank you very much.

26. References Nature of VP Function  Peterson-Falzone SJ, Hardin-Jones, MA, Karnell MP. Cleft Palate Speech. 3rd ed. St. Louis (MO): Mosby, Inc. 2001.  Zemlin WR. Speech and hearing science: anatomy and physiology. 4 th ed. Englewood Cliffs (NJ): Prentice-Hall, 1997.

27. Delivery of Care Resources  http://www.acpa- cpf.org/teamcare/Parameters07rev.pdf  Contact ACPA, Cleft Palate Foundation, or your local team