What is palatopharyngeal insufficiency?
Palatopharyngeal insufficiency is a disorder of articulation and swallowing caused by a lesion in the soft palate or pharyngeal wall that prevents the palatopharynx from closing properly. It is most common in patients with congenital cleft palate. Palatopharyngeal closure is the most common cause of speech disorders or abnormal speech in patients after cleft palate surgery. Inadequate palatopharyngeal closure occurs in 5% to 44% of patients after cleft palate surgery.
What are the signs of palatopharyngeal insufficiency?
The inability to close the palatopharynx during articulation leads to open nasal sounds, slurred speech, and speech disorders. Food may flow back into the nasal cavity during swallowing, which is obvious when eating liquid food. Because the eustachian tube cannot open normally, there may be ear stuffiness, obstruction and hearing loss. On examination, there are scars and defects in the soft palate, and the soft palate cannot close with the posterior pharyngeal wall when the “ah” sound is made.
What is the cause of palatopharyngeal closure failure?
Inadequate closure after cleft palate repair occurs in 5%-44% of patients (inadequate soft palate length, ectopic soft palate muscles and scar formation, short webbed pharyngopalatine arches that can affect soft palate uplift, and overly wide pharyngeal cavity causing relative lack of soft palate length are all causes of incomplete palatopharyngeal closure after cleft palate surgery); soft palate lesions such as soft palate palsy that prevents the soft palate from moving upward and backward to contact the posterior pharyngeal wall; soft palate defects and scar contracture, tumor destruction or surgical removal of part of the soft palate, trauma, tuberculosis, ulcers, non-specific inflammatory diseases, etc. that cause scar contracture of the soft palate. Posterior pharyngeal wall lesions such as paralysis of the pharyngeal constrictor muscle, post-operative proliferation, pharyngeal wall tumors, inflammatory lesions that destroy the pharyngeal wall and prevent forward contraction to narrow the pharyngeal cavity; all of these can lead to palatopharyngeal closure insufficiency.
What tests should be done for palatopharyngeal insufficiency?
On examination, there are signs such as scars and defects in the soft palate, and the soft palate cannot close with the posterior pharyngeal wall when the “ah” sound is pronounced.
At present, the evaluation of palatopharyngeal function is mainly divided into subjective and objective evaluation. In medicine, the following evaluation methods are mainly chosen.
Subjective evaluation: Speech evaluation and articulation test are mainly used to grade the severity of palatopharyngeal insufficiency by the speech therapist. Advantages: This method is simple, easy to perform, and can be used in children, and is easy to promote clinically. Disadvantages: It requires a normal hearing person and a certain level of expertise to listen, and its results are still affected by subjective factors.
Objective evaluation.
①Lateral cephalometric radiograph: a simple and long-used method. It can be used to observe the height of soft palate lift, extension length, depth of pharyngeal cavity and the ratio of soft palate to pharyngeal cavity during sagittal palatopharyngeal closure. The disadvantage is that the image clarity is poor, the two-dimensional image does not truly reflect the three-dimensional movement, and there is a radiation hazard.
② Nasopharyngeal fiberscope: It is a more direct examination means than X-ray examination. It can not only examine and evaluate the morphology and function of the palatopharynx, but also serve as a means of feedback treatment. Foreign scholars use the relative percentage calculation method to evaluate the soft palate, lateral pharyngeal wall, posterior pharyngeal wall movement and posterior pharyngeal flap width, and use the ratio to compare between individuals. In China, we proposed to use the palatopharyngeal closure rate to reflect the function of palatopharyngeal closure, and also proposed the physiological permissible range of palatopharyngeal closure rate. Advantages: non-invasive, direct static and dynamic observation and easy data retention provide the advantages of visual, qualitative and even quantitative analysis of palatopharyngeal closure. Disadvantages: Only cross-sectional two-dimensional images are available, the magnification of the images cannot be directly measured quantitatively, and the examination is not easily accessible to preschool children.
MRI: The static and articulatory position of the palatopharynx at the time of closure can be observed from multiple angles, and exact numerical calculations can be performed, while three-dimensional reconstruction can be performed to obtain the three-dimensional structure of the palatopharynx. Advantages: Non-invasive quantitative measurements. It does not expose to radiation and provides clear images of soft tissues, while allowing the observation of pharyngeal aberrations of blood vessels. Disadvantages: MRI is difficult to reflect the natural state of palatopharyngeal closure during continuous speech, and the examination is expensive, and dental metal restorations interfere with the image.
Nasal phonometer: The nasal phonometer can collect the sound energy radiated from the oral and nasal cavities during the test person’s pronunciation. The average nasal phonation rate of 35% is proposed as the reference value of palatopharyngeal closure function in China. The nasal phonometer can reflect the physiological condition of the test subject’s articulation in numerical and graphical terms, and can also reflect the normal tongue movement and position through the graph. Advantages: rapid analysis, non-invasive and painless, can be used in children. It is useful for predicting clinical outcomes and analyzing abnormal mechanisms of cleft palate speech. Disadvantages:Poor compensatory movements of the tongue can reduce the rate of nasal phonation to some extent.
How should palatopharyngeal closure insufficiency be treated?
Find the etiology for appropriate treatment.
In mild cases, the movement of the soft palate can be increased by functional training of palatopharyngeal closure and speech training to achieve better results effectively.
In severe cases, surgery is required. After surgery with palatopharyngeal closure function training, language therapy, you can get a more desirable effect. Speech therapy is not a substitute for surgical treatment, and surgical treatment is not a substitute for speech therapy. Usually, the palatopharyngeal closure can be formed after surgery, and most patients do not need long time speech training, as long as patients are active and practice pronunciation, singing and reading aloud, they can get good speech function in 3-6 months at most.
How to do the function training of palatopharyngeal closure?
You can train palatopharyngeal closure at home by blowing balloons, blowing harmonica, blowing bubbles, etc.
What are the surgical options for palatopharyngeal insufficiency?
The principle of surgical treatment for palatopharyngeal insufficiency is to reduce the anterior-posterior, left-right diameter of the pharyngeal cavity, lengthen the soft palate and move the posterior pharyngeal wall forward.
① soft palate posterior push surgery: most of them are associated with postoperative scar contracture which makes the effect unstable;
②Posterior pharyngeal flap surgery: At present, pharyngeal flap surgery is recognized by most scholars as one of the most valuable surgical methods for the treatment of palatopharyngeal insufficiency;
(iii) Palatopharyngeal muscle flap surgery: it forms a sphincter-like effect, but disrupts the morphology of the palatopharyngeal arch;
④Posterior pharyngeal wall filling: historically filled with artificial tissues such as Vaseline, liquid paraffin, TEFLON, etc., and autologous tissues such as cartilage, fat, dermal fat, fascia, etc. Artificial tissues lead to foreign body reaction, displacement, and limited use, and autologous tissues alone are only suitable for palatopharyngeal closure insufficiency with small palatopharyngeal gap;
⑤ Palatopharyngeal ring ligation: In 1982, Professor Sun Yongquan proposed and implemented palatopharyngeal ring ligation based on the principle that palatopharyngeal closure is similar to that of the sphincter. It can be used for the short soft palate, wide pharyngeal cavity, incomplete palatopharyngeal closure after cleft palate surgery and cleft palate surgery, and failure of other surgical methods.
The mechanisms of palatopharyngeal closure insufficiency can be divided into three categories based on findings such as nasopharyngeal fiberscopy and dynamic radiography.
1, good movement of the lateral wall of the pharynx and insufficient movement of the soft palate.
2, Insufficient movement of the lateral pharyngeal wall and good movement of the soft palate.
3, Insufficient movement of both the lateral pharyngeal wall and the soft palate.
According to the patient’s age and the different mechanisms of palatopharyngeal closure insufficiency, we combined our innovative technique of mucosal flap of the insular buccal muscle, palatopharyngeal ring ligation, soft palate lengthening, and posterior pharyngeal wall filling, and chose the appropriate procedure for each patient according to their individual needs.