Hypernasal Speech and Velopharyngeal Ins

Hypernasal Speech and Velopharyngeal Insufficiency (VPI)

How is normal speech produced?

Speech results from a sequence of events that includes producing airflow out of the lungs (exhaling), a vibration of the muscles of the voice box (vocal cords), and regulating the amount of resonating air allowed to escape the body through the mouth and/or nose. The air escaping the mouth can then be manipulated by the lips, teeth and tongue to produce a specific speech sound.

What is the difference between hypernasal and hyponasal speech?

There is often a lot of confusion between the terms hypernasal as opposed to hyponasal speech. Both of these speech disorders are known as disorders of resonance (problems regulating the amount of air leaving the mouth and/or nose).

Hyponasal speech is the sound of speech that results from too little air escaping through the nose (sounds like talking with a stuffy nose). It would be hard to normally pronounce the letter "m" for example. The most common reason for this type of speech are enlarged ADENOIDS that block the air passage to the nose and can be corrected with ADENOIDECTOMY.

Hypernasal speech is the sound of speech that results from too much air escaping through the nose while talking. There are certain letters and sounds that should not have air escaping through the nose during speech. Examples of these are vowels, or letters like "s", "b", and "k". To keep air from passing through the nose, the roof of the mouth (velum) must touch the back of the throat (pharynx). If these do not touch correctly, resulting in a complete seal of this area, too much air is allowed to pass through the nose and hypernasal speech results. This is known as velopharyngeal incompetence or VPI .

What are the causes of hypernasal speech?

Hypernasal speech can be caused by anything resulting in velopharyngeal incompetence. Clefting (splitting) of the roof of the mouth (CLEFT PALATE), a palate that is too short, or the inability to move muscles involved with closure of the velopharyngeal complex (as in cerebral palsy) can cause hypernasal speech. Less commonly, hypernasal speech can occur in someone with an undiagnosed problem of the palate muscles, especially if an ADENOIDECTOMY is performed.

How is hypernasal speech evaluated?

Hypernasal speech may be first noted by the parent, primary care doctor, or teacher. The child should then be evaluated by a speech-language pathologist (a specialist in speech problems). A speech pathologist is able to evaluate and identify abnormal speech patterns. The speech pathologist will also look for obvious abnormalities in the mouth and listen with special instruments to the amount of airflow passing through the nose.

Instruments using computer analysis of airflow (nasometry) may also be used during an evaluation to detect abnormalities, as well as follow progress of therapy. If hypernasal speech is identified, an x-ray study is done to help localize the problem area and referral to an ear, nose and throat specialist occurs.

What will an ear, nose and throat specialist do?

The ear nose and throat specialist is an expert in evaluating and treating hypernasal speech. We have the ability to look at your child's anatomy to determine the cause of hypernasal speech.

This is done through nasal endoscopy, a procedure that uses a tube to look closely at the anatomy inside the nose and deeper in the throat. Nasal endoscopy is used with the speech pathologist in attendance. This will allow a plan of treatment to be developed for your child's hypernasal speech. This treatment plan, either medical or surgical therapy, will then be discussed with you.

What is the treatment for hypernasal speech?

Speech therapy may be all that is necessary for some forms of hypernasal speech. This type of therapy may take several months or years to achieve the desired result. However, if therapy does not result in resolution of the hypernasal speech, or if the defect is very large, surgical correction may be necessary.

This generally involves three basic methods:

PHARYNGOPLASTY - Augmenting (adding to) the back of the throat, to make closure easier
PHARYNGOPLASTY - Making the velar port (back of nose) smaller
PALATOPLASTY - Lenthening or repairing the palate (roof of mouth).

Laryngopharyngeal Reflux (LPR) and Gastro-oesophageal Reflux Disease (GORD)

How does GORD compare to LPR?

Although children may have GORD, we now believe many children suffer with laryngopharyngeal reflux (LPR). LPR causes symptoms you may not ordinarily associate with reflux. The vast majority of patients will LPR do not have esophagitis or heartburn. They usually do not complain of stomach ache or have pain associated with meals which is typical for GERD. Patients that have LPR are predominantly daytime refluxers although they can have symptoms at night. The length of exposure of acid in LPR is also shorter than GORD. In addition, the primary defect in GORD is thought to be failure of the lower esophageal sphincter keeping stomach acid from entering the swallowing tube whereas in LPR the primary defect is thought to be the upper esophageal sphincter allowing acidic fluid to backflow into the back of the throat and back of the nose.

What are the symptoms of LPR?

Symptoms of LPR, especially in children, can be very nonspecific and in many times puzzling.

Symptoms include:

Hoarseness
Chronic throat-clearing, excessive mucous
Chronic cough
Stridor (noisy breathing)
Difficulty swallowing
“Lump in the throat “(globus)
Reactive airway disease (wheezing)
Chronic bronchitis
Chronic airway obstruction
Wheezing
Apnea
Aspiration pneumonia
Nasal obstruction
Ear pain
Chronic nasal congestion
Sore throat
Gagging

These symptoms are also related to many conditions thought to be aggravated or caused by LPR.

These conditons include:

Otitis media (ear infections)
Sinusitis
Chronic nasal congestion
Vocal cord nodules
Chronic laryngitis
Laryngomalacia
Apnea
Subglottic stenosis
Arytenoid fixation
Laryngospasm
Recurrent pharyngitis
Chronic cough
Exacerbation of asthma or reactive airway disease

What is the treatment for LPR?

A child with LPR may be treated with antibiotics for other conditions including ear infections (otitis media), sinus infections (sinusitis), and sore throats (pharyngitis). The first hint that your child may have LPR may be the failure of standard antimicrobial therapy or allergic therapy. However, because otitis media, sinusitis and allergic rhinitis are very common in children, it is important to rule out these conditions prior to moving to rule out a diagnosis of LPR.

How is LPR diagnosed?

The diagnosis of LPR is made by demonstrating that there is acid reflux into the back of the throat. The “gold standard” for testing of LPR is by double lumen PH probe monitoring for 24 hours measuring acid reflux both into the swallowing tube and into the back of the throat. Sometimes barium studies (X-ray test) and oesophagoscopy (scope looking at oesophagus) can be used to evaluate the swallowing tube for related conditions. In addition, some physicians will use biopsy as a means for identifying changes in the lining of the throat that correspond to chronic irritation due to reflux. There is also a non-acidic reflux that may be present in some children who would not be picked up by PH probe or biopsy and new studies are underway to determine whether a different type of probe can be used to identify these particular children.

What are the treatments for LPR?

Once LPR is diagnosed, principal therapy remains the administration of proton pump inhibitors (PPIs). These drugs stop the production of acid in the stomach, therefore reducing the amount of acid that is refluxed into the throat. Within two to three months of treatment, most patients will report reduction in their symptoms due to LPR. However, many patients will show symptomatic improvement within three to four weeks. The length of treatment currently is somewhat controversial although it is clear that at least six months of therapy is necessary to see resolution of laryngeal damage caused by LPR. Therefore, a minimum treatment of six months is recommended in patients with LPR. After six months, PPI therapy can be weaned off.

If the patient has return of symptoms off medication, therapy should be continued indefinitely.

What is a congenital neck mass?

A congenital neck mass is a growth that is present at birth and slowly becomes noticeable to the patient or family. Although the neck abnormality is present since birth, the resulting lump may not appear until much later in life.

What are the types of congenital neck masses?

Congenital neck masses can take many forms. The most common congenital masses that are treated by an ear, nose, and throat specialist are:

Branchial Cleft Anomalies
Thyroglossal duct remnants
Lymphatic vascular malformations (lymphangiomas or cystic hygromas)
Hemangiomas (blood vessel abnormalities)
Dermoid cysts

What are Branchial Cleft Anomalies?

Branchial cleft fistulas and cysts are found in the neck and are composed of tissue trapped in the developing neck. These anomalies appear as a soft lump or draining opening on one side of the neck. They can appear in any age group yet are very common in the first decade of life. Because these anomalies develop in the growing embryo, any tract that forms in combination with a cyst follows a fairly predictable pattern. The tracts connect the cyst to the inside of the throat at a specific area. It is important to understand this relationship so that the entire tract can be excised and will not recur.

There are three kinds of branchial cleft anomalies. A first branchial cleft anomaly is more unusual and may be involved with the nerve that moves the facial muscles (Facial nerve). Second and third branchial anomalies are common.

If your child has been diagnosed with a branchial cleft anomaly, many times the physician will order a CT scan. This test will allow us to identify the exact location of the mass and/or tract as well as its relation to blood vessels and nerves in the neck.

Once an anomaly has been identified, treatment consists of surgically removing the cyst before it has a chance to get infected and become an abscess. Surgery is performed under general anesthesia by making an incision over the cyst or draining area. Every effort is made to place the incision in an existing skin crease so that cosmetically the child's scar will be minimal. Plastic surgery techniques are always used to close the incision. These operations usually last between one and two hours. If the cyst has become infected (or formed an abscess) prior to removal, incision and drainage of the abscess may be necessary first, followed by treatment with antibiotics. The cyst and tract can then be safely removed at a later date.

What are Thyroglossal Duct Cyst?

Thyroglossal duct cysts are cysts that are left over when the thyroid migrates from the base of the tongue into the neck before birth. The cyst is connected to the back of the tongue by a small tract. The cyst usually lies in the middle of the neck in front of the "Adam's Apple".

Thyroglossal duct cysts usually show up in the first ten years of life, but may be found in older children or even adults. It is a benign cyst that usually contains mucous or even pus-like fluid. Many times, these cysts will not be evident until your child has an upper respiratory infection (cold). After which, the cyst will suddenly appear in the front of the neck. The sudden appearance or rapid enlargement of these cysts can be alarming. If a cyst is infected, many times antibiotics and/or drainage may be necessary to control the infection prior to definitive removal.

However, if the cyst appears without infection, and you wish to avoid further problems with infection, surgical removal is best performed before the cyst is ever infected.

Thyroglossal duct cysts are usually in the middle of the neck and seem to move up and down during swallowing. Because thyroid tissue may be inside the cyst, it is important to make sure that the thyroid gland has developed normally (and that not all the thyroid tissue is within the cyst). Your doctor may order an ultrasound and/or a thyroid scan to make sure the "cyst" is not the only functioning thyroid gland.

Once these tests have been completed, excision of the cyst may be performed as an outpatient procedure. This operation usually takes 45 minutes to an hour. Your child may leave the same day but will require decreased activity in the first week after surgery.

What is a lymphatic vascular malformation (also known as lymphangioma)?

A lymphangioma is the result of an abnormal collection of lymph channels in the body. These channels usually link the disease-fighting lymph nodes together. During fetal development connections may occur causing cysts made up of these channels to grow. Large extensive collections of these are known as lymphangiomas or cystic hygromas. They grow steadily with the child and usually surround normal muscles, blood vessels, and nerves. These cysts can involve the neck, oral cavity, face and airway. They can also extend into the chest.

How are lymphatic vascular malformations recognized?

Because of their size, lymphangiomas are usually visible as a large compressible (can flatten when pushed on) mass. Those not noticed at birth are recognized before most children reach their second birthday.

Why are lymphatic vascular malformations of concern?

Lymphangiomas grow around normal muscles, blood vessels, and nerves. They may become quite extensive and cause significant cosmetic (appearance) deformities and functional disabilities. They may prevent the child from swallowing normally, speaking, or even breathing. The cysts are not cancerous. However, they continue to grow and many times cannot be completely removed without sacrificing an important normal structure.

How is a lymphatic vascular malformation diagnosed and treated?

DIAGNOSIS: These lesions are first evaluated by examination. Magnetic Resonance imaging (MRI) is the imaging study that gives the best information regarding the extent and location of the lymphangioma. X-rays and CT scans may also be used to help fully realize the extent. Once the location and extent into surrounding structures has been studied, therapy best suited for the patient can be initiated.

TREATMENT: There are generally two methods used to treat lymphatic malformations:

Medical - This method utilizes medications (sclerosing agents) injected into the cyst to reduce the size of the cyst. This means that the cyst is not removed, but "scars" down on itself so that growth stops.

Surgical - This approach to treatment of a lymphangioma is excision of the cyst with a surgical procedure. Please see EXCISION OF CONGENITAL NECK MASSES for more information on this procedure.

*If airway involvement is present, the lymphangioma is removed as soon as it is diagnosed. Sometimes, a TRACHEOSTOMY may be needed to secure the airway.

Our practice's philosophy is to surgically remove those lesions that appear to be removable with a single operation. Many times this is done in the first few months of life. If, however, the lesion is quite extensive and places the child at risk for nerve, blood vessel, or muscle damage, or, would result in significant deformity in the appearance of the child, sclerosing agents are recommended. Scleroisng agents work best for lesions which have a large cysts (macrocystic disease) and are less effective in cases where there are many small cysts (microcystic disease)

What is a haemangioma?

A haemangioma is an abnormal growth of blood vessels that are formed before or shortly after birth. They can be very small (pinpoint) or grow to be quite large. They need to be distinguished from vascular malformations (abnormal connections between blood vessels) because treatment is different.

What do haemangiomas look like?

Haemangiomas may look like small red pimples on the skin, large bulging bluish-red masses protruding from the forehead or eyelid, or soft compressible bluish masses in the neck. Haemangiomas may also involve the breathing tube just below the voice box (subglottic area) causing noticeable breathing problems. Haemangiomas usually start to grow larger shortly after birth (proliferative stage) reaching a peak at 18 months to 2 years of age. At that point, most haemangiomas will start to shrink (involute). This process may take several years.

How are haemangiomas diagnosed and treated?

DIAGNOSIS: Magnetic resonance imaging (MRI) is used to diagnose haemangiomas. Sometimes, a biopsy (a small amount of tissue from the lesion) is required to confirm the diagnosis.

TREATMENT: If haemangiomas are located in areas that cause the patient breathing problems (in the airway) or problems seeing (covers part of the eye), steroids may be given to shrink the mass. However, steroids only give temporary relief and therefore need to be given over long periods of time. In addition, this form of treatment has its own risks due to side effects of steroids. Should this treatment option be recommended, your physician will discuss these issues in detail with you.

If steroids are not advised, then surgical therapy is an alternative to remove or reduce the size of the haemangiomas more permanently. Surgical therapy using laser has been very helpful in shrinking or excising (removing) haemangiomas.

Both the CO2 (carbon dioxide) and YAG laser are used in our practice.

What is a dermoid cyst?

A dermoid cyst is a mass containing skin, hair, and skin glands that are trapped under the skin, usually located in a line drawn from the middle of the forehead to the bottom of the neck. An ear, nose, and throat specialist is commonly consulted to evaluate a congenital dermoid cyst located on the scalp, face, in the nose or on the neck.

How is a congenital dermoid cyst recognized?

A dermoid cyst is recognized as a small, painless swelling on the face, scalp, nose, or neck. They can range in size from 1 to 4 centimeters (about 1/2 to 3 inches) across. These cysts may need to be differentiated from other congenital neck masses, which can be done with careful physical exam. Sometimes, imaging (picture type) studies such as CT scans or MRI's are needed. CT scans are also useful to look for any part of the dermoid cyst that may extend into the skull bone. This is especially true of nasal dermoid cysts, which look like a small hole on top of the nose, usually with a hair sticking out.

How are dermoid cysts treated?

Dermoid cysts need to be surgically removed and this is usually a simple surgical procedure. Nasal dermoid cysts, however, require more extensive evaluation looking for invasion into the skull, and may require surgical removal by an ear, nose, and throat surgeon, working with a neurosurgeon. Please see DERMOID CYST EXCISION in surgeries we perform for more information.

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