A Study of Border Line Cases of Velopharyngeal Incompetence Using Cephalometry and Nasofibroscopy
A Study of Border Line Cases of Velopharyngeal Incompetence Using Cephalometry and Nasofibroscopy
The aim of this work is to evaluate the role of cephalometry &nasofibroscopy as objective
 tools in order to confirm the diagnosis based upon the clinical judgment of border line cases
 suspected to have velopharyngeal incompetence or insufficiency.
The velopharyngeal mechanism is constituted by the muscles of the soft palate, posterior and
 lateral pharyngeal walls (1), separating the oropharynx from the nasopharynx. Such
 structures, particularly the soft palate, play a key role in the velopharyngeal closure
 physiology (2). Velopharyngeal closure patterns may be classified as follows: coronal, where
 there is predominant soft palate movement toward the posterior pharyngeal wall; sagittal,
 where there is predominant movement of the lateral pharyngeal walls toward the pharynx
 midline; circular, where balanced movements of lateral pharyngeal walls and soft palate are
 observed; circular with Passavant's ridge, where the circular closure is associated with the
 development of a mucosal fold named Passavant's ridge on the posterior pharyngeal wall(3).
 The velopharyngeal closure allows the separation between the nasal and oral cavities during
 activities such as oral sounds emission, blowing, whistling, swallowing, sucking and vomiting
 reflex, respecting the level of closure demanded by each activity (4,5).

 In cases where the structures of the velopharyngeal mechanism do not work properly, the
 presence of a space called velopharyngeal aperture is observed between them, characterizing a
 velopharyngeal dysfunction. One of the reasons for the occurrence of such an aperture is the
 shortage of soft palate tissue. This dysfunction is called velopharyngeal insufficiency and
 may be corrected either surgically or by prosthetic management followed by speech therapy. In
 cases where such dysfunction occurs because of a failure in the velopharyngeal structures
 movement, physiological or neuromotor deficiency, it is called velopharyngeal incompetence
 that may be eliminated by means of speech therapy (2,6). On the other hand, if such condition
 is a result of the presence of compensatory articulations or other speech learning errors, it
 does not reflect physical or neuromuscular alterations, constituting indication for speech
 therapy(7). Individuals with velopharyngeal dysfunction present hypernasality, nasal air
 emission, poor intraoral pressure, and may present associated nasal/facial movements and
 compensatory articulations during the emission of oral consonants (8,9).

 Assessment of the velopharyngeal function can be done by the following procedures:

 1. Flexible fiberoptic nasopharyngoscopy (FFN) allows direct transnasal observation of the
 anatomy and dynamic activity of the velopharyngeal sphincter. Such observations can be
 recorded for permanent documentation by coupling FFN to a video camera with simultaneous
 audio recording. Numerous published reports discuss the advantages of FFN as a clinical
 method for evaluating velopharyngeal function during speech (10).

 Flexible fiberoptic nasopharyngoscopy (FFN) is a valuable tool for direct visualization
 because it allows observation of the velopharyngeal valve during dynamic activity for a
 prolonged period with (1) Minimal interference of the structures involved and (2) No
 radiation exposure. Whereas most clinicians acknowledge the theoretic advantages of FFN
 and accept it as a valid technique for assessing velopharyngeal function, there are few
 published studies that have addressed the validity and reliability of endoscopic
 procedures (10). Endoscopic evaluation has high face validity, and several reports have
 indicated that FFN has good construct validity when compared with radiologic assessments
 (11).

 2. Cephalometric analysis, is the clinical application of cephalometry. It is analysis of
 the dental and skeletal relationships of a human skull and is frequently used by
 dentists, orthodontists, and oral and maxillofacial surgeons as a treatment planning
 tool.

 Cephalometric analysis can also be applied for assessing the velopharyngeal structure and
 function. More specifically, velopharyngeal function in terms of its shape and mobility was
 analyzed quantitatively on the basis of cephalometric principle (12,13).

 Border line cases of velopharyngeal incompetence of insufficiency are known to be problematic
 and usually causes confusion for phoniatricians especially in patients who will undergo
 adenotonsillectomy. For this purpose, objective assessment is necessary to support or reject
 the clinical findings of VPI cases.
Inclusion Criteria:

 Patients must have border line velopharyngeal abnormality which was diagnosed clinically.

 Ability to understand and the willingness to sign a written informed consent(if he was a
 child so his parents or his guardian should has tis ability)

 Exclusion Criteria:

 1. Mental Retardation.

 2. Presence of Neurological deficit affecting speech.

 3. Palatal paralysis or paresis.

 4. Overt cleft palate.