Passavant’s ridge during speech production with and without pharyngeal bulb
Introduction
Surgical repair is the primary approach for correction of cleft palate (CP) and should establish structural conditions that support normal speech development with minimum impact on facial growth. Literature reveals that between 5% and 43% of patients with cleft palate may present with velopharyngeal dysfunction (VPD) after primary palatoplasty (Kummer, Clark, Redle, Thomsen, & Billmire, 2012; Mahoney, Swan, & Fisher, 2013; Pearson & Kirschner, 2011; Rullo, Di Maggio, Festa, & Mazzarella, 2009; Williams et al., 2011). VPD following a primary palatal repair in cases of isolated CP can occur due to a velopharyngeal insufficiency (VPI), when the velum is too short or does not stretch sufficiently to reach the posterior pharyngeal wall during speech, and/or due to velopharyngeal mislearning, resulting in none or poor movement of the velum and pharyngeal walls. Hypernasality and nasal air emission are the symptoms most commonly associated with VPD. Diagnosing the etiology of VPD is crucial for the identification of the best treatment approach to correct the insufficiency and/or mislearning, and requires perceptual speech assessment, intraoral examination, and videofluoroscopic/nasoendoscopic assessment during speech production. Current methods for management of VPD for patients with history of cleft palate may include surgical, prosthetic and/or behavioral interventions.
The clinical decision regarding the best approach for management of VPD is a complex process, with important implications for the patient as well as the healthcare system (Gart & Gosain, 2014; Henningsson et al., 2008; Pinto, Dalben, & Pegoraro-Krook, 2007). Pharyngeal flap is one of the most commonly used surgical procedure to treat VPI (Cable, Canady, Karnell, Karnell, & Malick, 2004). A successful pharyngeal flap should be tailored to be placed in the middle of the velopharyngeal port, in the level of the maximal potential movement of lateral pharyngeal walls to facilitate velopharyngeal closure for speech. Two permeable lateral ports should be established to minimize the potential risk for upper airway obstruction (Yoshida et al., 1992). For a successful pharyngeal flap, the lateral pharyngeal walls should move medially during oral speech reaching the flap, thus completely closing the lateral ports (Forrest, Klaiman, & Mason, 2009).
Pharyngeal bulb prosthesis can be an alternative approach to correct velopharyngeal insufficiency for those patients with conditions that preclude surgery, and for those with velopharyngeal mislearning due to hypodynamic velopharynx. According to the literature (Witt, Marsh, Marty-Grames, Muntz, & Gay, 1995, p. 180), the hypodynamic velopharynx for speech involves “the concurrence of a residual VP [velopharyngeal] endoscopic or fluoroscopic gap size, or both forms, during attempts at maximal closure… greater than 50% of the resting VP space, and the endoscopic observation of feeble velopharyngeal motion.’’
Patients with hypodynamic velopharynx usually combine insufficiency (structural cause for the VPD) and mislearning (functional cause for the VPD) leading to the need of a combination of physical treatment (surgical or prosthetic) and behavioral treatment. The differential diagnosis between VPI and hypodynamic velopharynx generally is made by nasoendoscopy (Dutka, Uemeoka, Aferri, Pegoraro-Krook, & Marino, 2012). Nasoendoscopic evaluation is needed for differential diagnosis between cases of isolated insufficiency and cases in which insufficiency is combined with hypodynamic velopharynx. Endoscopically, hypodynamic velopharynx is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Isolated insufficiency is recognized also when there is a consistent gap, independently of its size, with poor or good pharyngeal wall movements. Velopharyngeal mislearning, velopharyngeal neglect or velopharyngeal surrender are terms that can be used to explain the lack of movement or feeble movement of pharyngeal walls and velum in response to speech demands during nasoendoscopy. In this group of patients, the prognosis for surgical treatment of velopharyngeal insufficiency prior correcting the hypodynamism is very poor and choosing a surgical procedure before correcting mislearning is complex and difficult. For this population, correcting only the structural problem (with a large pharyngeal flap, for example) without behaviorally addressing the velopharyngeal function for speech does not resolve hypernasality and nasal air emission (Dutka et al., 2012). Prosthetic treatment, in these cases, is an alternative for management of the VPD particularly when combined with speech therapy (Goiato, Santos, & Villa, 2010; Patel, Mehta, Kohli, Makwana, & Choudhry, 2014; Pegoraro-Krook, Aferri, & Uemeoka, 2009).
The pharyngeal bulb prosthesis is a prosthetic device that can be used for short or long-term management of VPD (insufficiency and/or mislearning). It involves an anterior portion that is similar to a dental retainer, but attached to an extension (bulb) projected into the velopharynx, customized to fill the gap between the velum and pharyngeal walls. During speech, the pharyngeal walls can medialize closing against the bulb eliminating or minimizing hypernasality and nasal air emissions associated with VPD. The long-term use of a pharyngeal bulb is indicated when surgery is contraindicated to repair VPI, as in the case of potential surgical comorbidities such as severe obstructive sleep apnea or cardiac anomalies, or when the patient chooses not to undergo surgery. The pharyngeal bulb can also be used as a temporary tool when combined with SLPs speech therapy to increase movement of the velopharyngeal structures to improve the prognosis of the surgical correction of VPI (Dutka et al., 2012; Pinto et al., 2007). Pinto and Pegoraro-Krook (2003) evaluated the prosthetic treatment of VPI with regard to mastication, stability, esthetics, comfort and life quality through a caseload of 48 patients (mean age of 31 years). Eighty one percent reported to be able to eat while using their prostheses; 85% stated speech improvement; 75% considered the prosthesis stable during nourishment, and 92% during speech; 79% felt comfortable using the prosthesis; and 85% related a general improvement in life quality with the prosthetic treatment of VPI. The current investigators’ clinical experience, at the research site, is similar to that reported by Pinto and Pegoraro-Krook (2003) suggesting that, while the process of constructing the pharyngeal bulb may be uncomfortable and associated with gagging at its beginning, the specialized SLPs’ in the craniofacial team can prepare patient and family to handle the sensorimotor adaptations associated with the pharyngeal bulb. Patients and family members are usually frustrated when a pharyngeal bulb is indicated instead of a secondary surgical procedure. They have to accept the replacement of a single surgery by a series of visits to construct, fit and adapt a three-piece appliance (retainer, intermediary portion and bulb), followed by behavioral treatment to manage a hypodynamic velopharynx. Learning that the pharyngeal bulb is the only alternative to correct velopharyngeal mislearning at the presence of insufficiency helps the family and patient overcome the fear of gagging and discomfort. That is, the patient and family, the surgeon, the dentist and the SLP need to concur that the best treatment alternative for insufficiency combined with mislearning is the prosthetic/behavioral, otherwise the pharyngeal bulb should not be recommended.
The approach to behavioral modification of velopharyngeal mislearning is made upon the assumption that patterns of velopharyngeal function can be modified and feeble movement can be improved. Velopharyngeal closure must be an attainable goal for the velopharyngeal mechanism to respond to speech therapy targeting VP mislearning. The pharyngeal bulb in these cases, is used as a therapeutic tool to stimulate, guide and modify movement of velopharyngeal structures. Once the mislearning is corrected (with the velopharynx responding adequately during sound production) and the pattern of velopharyngeal function during speech involves maximum displacement of walls and velum (with bulb reduction therapy), a surgical correction of the insufficiency can be recommended with excellent prognosis.
Four patterns of velopharyngeal function during speech were described by Skolnick, McCall, and Barnes (1973) and confirmed by Croft, Shprintzen, and Rakoff (1981): 1) Coronal, in which the velum is the prime mover coming into broad apposition with the posterior pharyngeal wall in the absence of lateral pharyngeal wall motion, 2) Sagittal, in which de lateral pharyngeal walls are the prime movers to achieve velopharyngeal closure, 3) Circular, in which movement contribution from the velum and lateral pharyngeal walls is almost the same, and 4) Circular with Passavant’s ridge, in which the velum, lateral pharyngeal walls and posterior pharyngeal wall make equal contributions to velopharyngeal closure. Knowledge regarding the pattern of velopharyngeal function is critical in selecting the surgical procedures for correction of VPI. Knowledge regarding the pattern of velopharyngeal function is critical in selecting the surgical procedures for correction of VPI. When the pharyngeal bulb is recommended instead of a pharyngeal flap, identifying the pattern of velopharyngeal function is essential to establishing position, size and configuration of a pharyngeal bulb to effectively elicit movement and seal a gap during speech production. The circular pattern of velopharyngeal function with Passavant’s ridge has been associated with the best prognosis for prosthetic combined with behavioral treatment of velopharyngeal insufficiency combined with mislearning in our practice.
Fitting a pharyngeal bulb is particularly challenging for patients with hypodynamic velopharynx present with large gaps and little (or lack of) pharyngeal wall movement. In these cases, designing a bulb large enough to occupy most of the gap space could “overblock” the velopharynx causing hyponasality and reducing upper airway permeability to an uncomfortable condition. Designing a pharyngeal bulb too small for the gap size would maintain unacceptable hypernasality and nasal air emission, but may be used as a therapeutic strategy when pharyngeal bulb is combined with speech therapy to correct VPD. The key element for correction of hypernasality and nasal air emission related to VPD involves associating a tailor made pharyngeal bulb (that provides possibility of velopharyngeal closure) with speech therapy guided to elicit and improve displacement of the pharyngeal walls and velum (Lam, Hundert, & Wilkes, 2007; Pegoraro-Krook et al., 2009; Sikka, Jain, Kaushik, & Rani, 2014). In these cases, establishing a tailored made bulb and identifying the speech strategies to modify the pattern of velopharyngeal function requires visualization of the velopharynx (Karnell, 2011) during stimulability testing for identification of the phonetic context most favorable to the best attempt of VP closure (Pegoraro-Krook, Dutka-Souza, & Marino, 2008). Auditory-perceptual assessment of speech outcome, with and without the pharyngeal bulb, is used to guide the therapeutic process (Bispo et al., 2011; Dutka et al., 2012; Lima-Gregio et al., 2011).
Literature suggests a relationship between the use of pharyngeal bulbs and an increase in muscle activity during speech, with reports of a considerably decrease in the velopharyngeal gap size (Anandakrishna & Gali, 2010; Bispo et al., 2011; Dutka et al., 2012; Lam et al., 2007; Tachimura, Nohara, & Wada, 2000). Changes in velopharyngeal activity during prosthetic combined with behavioral treatment of VPD, however are not completely understood. Voluntary modification of velopharyngeal movement is difficult to implement therapeutically since the velopharynx offers no proprioception (Hixon, Weismer, & Hoit, 2008). It has been suggested that when a speaker has some voluntary or proprioceptive control of velopharyngeal function for speech (Kuehn & Moon, 1998), it seems that the presence of the bulb fulfilling the velopharyngeal gap (therefore reducing the ‘space’) may trigger some type of “feedback” (auditory, tactile) increasing information regarding velopharyngeal activity during speech. The physical contact of the bulb against the velum and pharyngeal walls may also stimulate activity against the resistance offered by the bulb (Pegoraro-Krook et al., 2009; Pinto et al., 2007). If the pharyngeal bulb can stimulate velopharyngeal activity, it could also contribute to the occurrence of Passavant's ridge.
Gustave Passavant first described the ridge as an anterior displacement of the posterior pharyngeal wall during velopharyngeal function in 1863 (Zemlin, 1997). The ridge involves a muscle bulge of 5 mm or more in thickness across the pharyngeal walls (Kummer, 2007; Williams, Henningsson, & Pegoraro-Krook, 2004), which might be involved in the velopharyngeal function (Bzoch, 2004). However, since velopharyngeal closure normally occurs at or above the level of the palatal plane, and the ridge occurs below this level, the question remains as to the role of this ridge during velopharyngeal function for speech.
Several studies reported occurrence of Passavant´s ridge for individuals with cleft palate. Nylen (1961) observed the ridge in 11 of 27 (41%) patients; Massengill, Walker, and Pickrell (1969) found it in 18 of 190 (9%) patients; Skolnick et al. (1973) observed in 17 of 62 (27%); Croft et al. (1981) identified the ridge in 120 of 500 (24%) patients; and Henningsson and Isberg (1986) in 3 of 8 (37%) patients. Some authors also observed Passavant´s ridge in normal speakers (Benson, 1972; Carpenter & Morris, 1968; Croft et al., 1981; Graber, Bzoch, & Aoba, 1959; Skolnick et al., 1973). Benson (1972), however, observed that the ridge was too low to be effective in aiding velopharyngeal closure. Observed that out of the 57 patients with repaired cleft palate who presented Passavant’s ridge (from a caseload of 150 patients) the ridge occurred at the level of the palatal plane in only one patient, whereas for the remaining 56 patients (98%) the ridge was seen at a point considerably lower than the palatal plane. Additionally, as reported by Bento-Gonçalves and Pegoraro-Krook (1996) the ridge had an active role in velopharyngeal closure in 11 out of the 57 patients.
Some studies indicated that increased displacement of pharyngeal walls can be observed during a bulb reduction’s program. According to Blakeley and Porter (1971), and Weiss (1971), for example, some patients develop and increase movement in both posterior and lateral pharyngeal walls to the point of closing the gap between the bulb and the pharyngeal walls. Despite the fact that more recent literature suggests a relationship between pharyngeal bulb and changes in the displacement of the pharyngeal walls (Bispo et al., 2011; Dutka et al., 2012; Dhakshaini, Pushpavathi, Garhnayak, & Dhal, 2015; Lima-Gregio et al., 2011; Reham, Lobna, Ahmed, & Mohamed, 2016), there is limited information regarding the relationship between pharyngeal bulb and Passavant´s ridge. In our clinical practice using pharyngeal bulbs, we use nasoendoscopic assessment to document movement of velopharyngeal structures, to verify proper soft tissue-bulb contact during speech and swallowing, and to revise the bulb impression in case of under or over obturation. During prosthetic treatment of VPD, when the Passavant´s ridge is observed, its location is used to guide the placement of the pharyngeal bulb, favoring contact between the pharyngeal walls, the velum and the bulb. During surgical treatment of VPD, the presence of the Passavant´s ridge can be associated with a better prognosis for a surgical procedure that is recommended for patients who present with good movement of pharyngeal walls. The presence of Passavant's ridge, therefore, is of extreme importance to the cleft palate team during the decision making process for management of VPD and to the prosthodontist and speech therapist treating with pharyngeal bulb and speech therapy.
The objective of the present study was to investigate the occurrence of Passavant's ridge in patients with history of cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatal surgery, undergoing prosthetic treatment of VPI with pharyngeal bulb. We hypothesized that cleft palate patients with VPI (with or without hypodynamic velopharynx) can develop Passavant´s ridge with the use of pharyngeal bulb.
Section snippets
Setting
This research was approved by the institutional review and ethical board of the Hospital for Rehabilitation of Craniofacial Anomalies at University of Sao Paulo - HRAC/USP (209/2007-SVAPEPE-CEP).
HRAC/USP is a comprehensive-care hospital and rehabilitation center specializing in the treatment of patients with cleft lip/palate (CLP) and other craniofacial anomalies. For many years HRAC/USP was one of few craniofacial centers serving all Brazilian population with craniofacial anomalies. Over
Results
According to the raters Passavant’s ridge was present for 11 patients in C1 (44%) and remained present for 7 (28%) in C2, C3, and C4. For 2 patients, the ridge did not appear during the confection of the bulb (C2) but reappeared in conditions C3 and C4. For the remaining two patients in this group, the ridge was present in C1 but was not observed in C2, C3 and C4. Table 2 also indicates that for three patients with absence of Passavant`s ridge prior to the bulb (C1), the ridge was later
Discussion
The population in this study presented with a higher occurrence of Passavant´s ridge (presence ranging between 40% and 68%) than the average of 23% reported in previous studies (Bento-Gonçalves & Pegoraro-Krook, 1996; Croft et al., 1981; Henningsson & Isberg, 1986). The presence of the ridge associated with the continuous use of the bulb also corroborates other studies which reported changes in velopharyngeal movement with the placement of the bulb after a period of adaptation to its use (
Conclusion
The pharyngeal bulb may elicit the Passavant`s ridge in patients with history of cleft palate presenting with VPI. However, future studies are needed to corroborate the present findings.
Declaration of Competing Interest
None.
Acknowledgements
Funding: This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) – Finance Code 001”. Master's Scholarship for the main author.
References (50)
- et al.
Surgical management of velopharyngeal insufficiency
Clinics in Plastic Surgery
(2014) - et al.
Speech assessment in cleft palate patients: A descriptive study
International Journal of Pediatric Otorhinolaryngology
(2009) - et al.
Prosthetic rehabilitation of a child with velopharyngeal dysfunction–A case report
Journal of Oral Biology and Craniofacial Research
(2014) - et al.
Management of velopharyngeal disorders. A case series
Journal of Prosthodontics
(2010) Secondary surgery for velopharyngeal insufficiency
Roentgenographic cephalometric study of palatopharyngeal closure of normal adults during vowel phonation
The Cleft Palate-Craniofacial Journal
(1972)- et al.
Estudo videofluoroscópico do anel de Passavant em pacientes portadores de fissura lábio-palatina
Pro-Fono
(1996) - et al.
Pharyngeal wall motion in prosthetically managed cleft palate adults
The Cleft Palate-Craniofacial Journal
(1983) - et al.
Speech therapy for compensatory articulations and velopharyngeal function: A case report
Journal of Applied Oral Science
(2011) - et al.
Unexpected reduction and removal of an obturator in a patient with palate paralysis
The British Journal of Disorders of Communication
(1971)
Introduction to the study of communication disorders in cleft palate and related craniofacial anomalies
Prosthodontic management of hypernasality: Two very different cases
Canadian Journal of Speech-Language Pathology and Audiology
Pharyngeal flap surgery: long-term outcomes at the University of Iowa
Plastic and Reconstructive Surgery
A preliminary study of Passavant’s ridge
The Cleft Palate-Craniofacial Journal
Passavant’s ridge in patients with soft palatectomy
The Cleft Palate-Craniofacial Journal
Patterns of velopharyngeal valving in normal and cleft palate subjects: A multiview videofluooroscopic and nasoendoscopic study
Laryngoscope
Prosthodontic management in conjunction with speech therapy in cleft lip and palate: A review and case report
Journal of International Oral Health
Total obturation of velopharynx for treatment of velopharyngeal hypodynamism: Case report
The Cleft Palate-Craniofacial Journal
Bulb for rehabilitation of cleft palate with implant-supported retention system
The Journal of Craniofacial Surgery
A functional study of the palatal and pharyngeal structures
The Angle Orthodontist
Posterior pharyngeal flaps
Preclinical speech science: Anatomy physiology acoustics perception
Speech parameters group. Universal parameters for reporting speech outcomes in individuals with cleft palate
The Cleft Palate-Craniofacial Journal
Velopharyngeal movement patterns in patients alterning between oral and glottal articulation: A clinical and cineradiographical study
The Cleft Palate-Craniofacial Journal
Intraindividual change in the occurrence of Passavant’s ridge due to change in velopharyngeal sphincter function: A videofluoroscopic study
The Cleft Palate-Craniofacial Journal
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