Velopharyngeal closure

1 - oral cavity (cavum oris)
2 - nasal cavity (nasal cavity)
3 - hard palate (hard palate)
4 - soft palate (soft palate)
5 - uvula (uvula)
6 - tongue root (Radix lingnae)
7 - pharyngeal wall
8 - throat throat ( laryngopharynx or pars laryngea pharyngis)
9 - oropharynx (oropharynx or pars oralis pharyngis)
10 - nasopharynx (nasal pharyngeal nasopharynx or Pars)

The velopharyngeal closure (VP closure; also velopharyngeal closure - VPA - or nasopharyngeal closure ) is the short-term physiological closure of the nasopharynx (Latin nasopharynx ) by the soft palate (Latin velum palatinum ; soft palate - Latin palatum molle ). The velopharyngeal closure seals the nasopharynx from the oropharynx, while speaking the velopharyngeal muscles close the oro and nasopharynx - velopharyngeal sphincter. It is important for swallowing or pronouncing certain plosives . The velopharyngeal closure separates the oropharynx from the nasopharynx when non-nasal sounds are formed.

During the act of swallowing , in the pharyngeal transport phase , the velopharyngeal closure of the soft palate against the posterior wall of the pharynx prevents the food pulp from passing into the upper airways. During the velopharyngeal occlusion, the contraction of the back wall of the pharynx forms a transverse bulge, the Passavant bulge , which extends towards the soft palate and improves the occlusion.

The soft palate is pressed against the posterior wall and side walls of the pharynx by the levator veli palatini muscle (lifting muscle of the soft palate) and the tensor veli palatini muscle (soft palate tensioner ). The musculature of the pharyngeal walls consists of the musculus constrictor pharyngis superior (upper pharyngeal constrictor ) and the musculus palatopharyngeus (palatine pharynx muscle).

Insufficient velopharyngeal closure

In oral surgery, insufficient velopharyngeal closure after surgical treatment of the cleft palate is a problem - functional or structural velopharyngeal insufficiency (VPI), also known as occlusive insufficiency . Purely functional disorders are also summarized as velopharyngeal dysfunction (VPD).

Patients with complete cleft palates, which also affect the soft palate, do not have a velopharyngeal closure. Feeding infants with an open palate, even when the soft palate is intact, is a problem. Because of the open palate, they cannot create negative pressure in the mouth and cannot suck. When they are spoon-fed, some of the food comes out through the cleft palate to their nose - a portion of the bolus penetrates the nasopharynx (nasal regurgitation ). One attempt to remedy this is to use a plastic palate plate as an obturator. Among other things, because of the lack of closure to the nasopharynx, cleft patients are very often prone to otitis media. The eustachi tube connects the nasopharynx with the middle ear.

A cleft palate is closed as early as possible in order to enable normal language acquisition for the toddler. The operation scar is a problem. It partially inhibits the further growth of the upper jaw. In addition, scars are prone to scar contraction. Even if the soft palate is of sufficient length immediately after the operation to enable adequate velopharyngeal closure, this situation can worsen in the further course of healing and growth.

Small shortenings of the soft palate (structural VPI) are not so problematic, as the muscles of the back of the pharynx meet the soft palate during velopharyngeal closure. Much more important is the adequate postoperative function (motility) of the muscles of the soft palate. If the velopharyngeal closure is insufficient, the posterior edge of the soft palate or the uvula (Latin: uvula ) may have to be sutured to the posterior wall of the nasopharynx - velopharyngeal plastic surgery (VPP). The air passage is not significantly impaired, as there is still enough space on both sides. For the velopharyngeal closure then only the contraction of the lateral and rear throat muscles is required. The side walls of the throat then often develop a pronounced wall excursion.

In order not to increase the CPI in split patients, no adenotomy is performed if possible .

A speech sample is sufficient for a preliminary examination of the velopharyngeal occlusion. If the closure is inadequate, the patient cannot pronounce the closure sound [k]. Instead of “potatoes in the cellar” he then says “Gartoffeln im Geller” and his language is generally difficult to understand. In addition, patients have problems with the opening and closing movements in the velopharyngeal area when changing from vowels to consonants and vice versa. For more precise clinical and experimental investigations, a wide variety of measuring devices for oronasal pressure measurement and recording have been devised, which are necessary, among other things, to assess the success of the operation according to the various surgical techniques. Overall, however, the quantitative recording methods (e.g. intraoral pressure measurement; velopharyngeal functional diagnostics with electromagnetic articulography ; aerodynamic measurements using pressure flow methods; pressure difference measurement; sonogram) are not yet fully developed and are reserved for therapy studies due to the large amount of equipment required. The endoscopic assessment of the VPI, especially the endoscopic video recordings of speech samples, is a standard method. There is also an assessment with a flexible nasopharyngoscope and flexible video nasopharyngoscopy.

Inadequate velopharyngeal closure after cleft palate surgery is often resistant to therapy. Speech-improving operations and long-term speech therapies without satisfactory symptom improvement are not uncommon and the patient retains his nasal voice sound (open nasal voice, hypernasal voice sound). Even if there is insufficient velopharyngeal occlusion when speaking, it is usually achieved when swallowing. This applies to both the functional and the structural CPI, since the act of swallowing occurs much more slowly and with greater muscle strength. Sound formation is primarily influenced by the soft palate, while it is only slightly influenced by the extent of movement of the side walls of the throat. The back of the pharynx hardly modifies the sound formation at all. During the act of swallowing, however, the side and rear walls are of great importance.

Augmentative pharyngoplasty

The enlargement (augmentation), actually the structure of the back wall of the pharynx, aims to alleviate the occlusion problem. In 1862, Passavant tried to shift the soft tissue of the back wall of the pharynx forward by suturing two palatopharyngeal muscles in the midline in order to replicate Passavant's bulge. He later tried folding a flap from the lining of the throat. Since then, various techniques have been tried: soft tissue plasty, cartilage implantation, implantation or injection of various synthetic materials (lining the back of the throat with silicone, Teflon or collagen). Most of the techniques have been abandoned because of their unpredictable results.

Individual evidence

1. ↑ Peterson-Falzone, Sally J., Hardin-Jones, Mary J., Karnell, Michael P .: "Cleft Palate Speech" (German: "Language for cleft palates"), 3rd edition, 2001, Mosby, USA
2. ^ Witt, Peter D., O'Daniel, Thomas G., Marsh, Jeffrey L., Grames, Lynn M., Muntz, Harlan R., Pilgram, Thomas K .: "Surgical management of velolpharyngeal Dysfunction: outcome analysis of autogenous posterior pharyngeal wall augmentation. ”in: Plastic and Reconstructive Surgery , 99 (5), 1287–1296; 1997

Web links

• Dissertation, "Relationship between facial skull structure, velopharyngeal morphology and nasal attachment in people without congenital malformations in the orafacilaen area", dissertation, 2004
• "A prospective clinical study on the objective diagnosis of hypernasality with the ... system in patients with cleft lip and palate", dissertation, 2004

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !