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Objective: The purpose of this study was to examine whether a speech-aid prosthesis normalizes the activity of the levator veli palatini muscle for patients with cleft palate who exhibit velopharyngeal incompetence. Design: Each subject was instructed to produce repetitions of /mu/, /u/, /pu/, /su/, and /tsu/ and to blow with maximum possible effort. Electromyographic (EMG) activity of the levator veli palatini muscle was recorded with and without a hybrid speech-aid prosthesis in place. Participants: The participants were five patients with repaired cleft palate who were routinely wearing a hybrid speech-aid prosthesis. Results: With the prosthesis in place, the mean value of levator activity changed positively in relation to oral air-pressure change during blowing. Differences in levator activity in relation to speech samples were similar to those in normal speakers. With the prosthesis in place, levator activity for speech tasks was less than 50% of the maximum levator activity for all subjects. The findings were similar to those reported previously for normal speakers. Conclusion: Placement of the prosthesis changed EMG activity levels of the levator veli palatini muscle to levels that are similar to normal speakers. It is possible that, with the increase in the differential levator activity between speech and a maximum force task, the velopharyngeal mechanism has a greater reserve capacity to maintain velopharyngeal closure compared with the noprosthesis condition.

Objective: To obtain detailed anatomic information on the levator veli palatini (LVP) muscle from magnetic resonance imaging (MRI). Quantitative measures of the configuration of the LVP muscle at rest and during speech activities were obtained. Design: Prospective study using MRI of adult subjects with normal velopharyngeal mechanisms to determine anatomic and physiologic parameters of the levator muscle. The levator veli palatini muscle was imaged at rest and during speech activities consisting of nasal and nonnasal sounds mixed with vowels, consonants, or both (e.g., /ansa, asna, amfa, afma/). Participants: Ten normal healthy adults (five men, five women) between 21 and 53 years of age and free of oropharyngeal abnormalities. Main Outcome Measures: Two-dimensional spin echo static images and dynamic fast gradient echo images of the levator muscle in both the sagittal and oblique/coronal planes. Results: On average across female (F) and male (M) subjects: distance between LVP muscle origin point...

Most dynamic magnetic resonance imaging of the levator veli palatini (levator) muscle has been limited to studies using sustained phonation (Yamawaki et al. 1996; Ettema et al. 2002; Tian et al., 2010a, 2010b; Kollara and Perry, 2013). Dynamic MRI sequences at faster imaging speeds using word-level productions have been described along the midsagittal image plane (Sutton et al., 2009; Bae et al., 2011; Scott et al., 2013) and oblique coronal image plane (Perry et al., 2013b, 2013c; Scott et al., 2013). The purpose of this presentation is to describe methods for analyzing the velopharyngeal mechanism and velar muscles during rest and speech production using MRI. This presentation will demonstrate a potentially useful technique in dynamic MRI that does not rely on cyclic repetitions or sustained phonation and can provide dynamic information related to muscle function. Innovative techniques in imaging and interpreting dynamic MRI of velopharyngeal function during speech will be described. It is expected thes...

Objectives:Review the long-term outcomes of cross-hatching Eustachian tuboplasty (ChEt) in patients with chronic obstructive Eustachian tube dysfunction (COETD), as well assess the clinical factors associated with surgical success.Methods:Case series with chart review in a tertiary health care institution. This is a retrospective review by the senior author of all cases of patients who had nonrevision ChEt for COETD. Follow-up period was 5 years. The curvature of the posterior cushion was modified using an argon laser to alter the spring of the cartilage, alleviating the obstructed valve’s aperture. Several clinical factors were reviewed in relation to the successful opening of Eustachian tube valve.Results:One hundred twenty patients, 72 males/48 females, average age 42.4 ± 2 years old, met inclusion criteria to the study. COETD patients/obstructive causes were: Posterior cushion hypertrophy, 68 (56.6%); tensor veli and levator veli palatini muscles hypertrophy, 15 (12.5%); and remarkable mucosal hypertr...

Objective: The aim of this study was to analyze, morphologically and biochemically, one of the soft palate muscles, the levator veli palatini (LVP), in children born with cleft palate. Subjects and Methods: Biopsies were obtained from nine male and three female infants in connection with the early surgical repair of the hard and soft palate. Samples from five adult normal LVP muscles were used for comparison. The muscle morphology, fiber type and myosin heavy chain (MyHC) compositions, capillary supply, and content of muscle spindles were analyzed with different enzyme-histochemical, immunohistochemical, and biochemical techniques. Results: Compared with the normal adult subjects, the LVP muscle from the infantile subjects with cleft had a smaller mean fiber diameter, a larger variability in fiber size and form, a higher proportion of type II fibers, a higher amount of fast MyHCs, and a lower density of capillaries. No muscle spindles were observed. Moreover, one-third of the biopsies from the infantile subjects with cleft LVP either lacked muscle tissue or contained only a small amount. Conclusions: The LVP muscle from children with cleft palate has a different morphology, compared with the normal adult muscle. The differences might be related to different stages in maturation of the muscles, changes in functional demands with growth and age, or a consequence of the cleft. The lack of contractile tissue in some of the cleft biopsies offers one possible explanation to a persistent postsurgical velopharyngeal insufficiency in some patients, despite a successful surgical repair.

The recent report of a transforming growth factor-beta 3 (TGF-beta 3) knock-out mouse in which 100 percent of the homozygous pups have cleft palate raised the question as to the potential usefulness of these animals as a model for cleft palate research. The specific aim in this study was to carefully document the anatomy of the cleft palate in the TGF-beta 3 knock-out mice as compared with wild type controls. Special attention was paid to the levator veli palatini muscle, the tensor veli palatini muscle, and their respective innervation. Because the TGF-beta 3 knock-out is lethal in the early perinatal period and because the heterozygotes are phenotypically normal, polymerase chain reaction was required to genotype the animals before mating. Time-mated pregnancies between proven heterozygotes were then delivered by cesarean section at gestational day 18.5 to prevent maternal cannibalism of homozygote pups. All delivered pups were killed and their tails processed by polymerase chain reaction to verify genotype. The heads were then fixed and sectioned in axial, coronal, or sagittal planes. Sections were stained with hematoxylin and eosin or processed for immunohistochemistry with nerve specific protein gene product 9.5 and calcitonin gene-related peptide antibodies. Sections were analyzed in a serial fashion. Nine wild type control animals were analyzed along with nine TGF-beta 3 knock-out homozygotes. Time matings between proven heterozygotes yielded wild type pups, heterozygote pups, and homozygote knock-out pups in the expected mendelian ratios (28 percent to 46 percent to 26 percent; n = 43). The results demonstrated 100 percent clefting in the homozygous TGF-beta 3 knock-out pups. Complete clefting of the secondary palate was seen in four of nine and incomplete clefting was seen in five of nine. The levator veli palatini and tensor veli palatini muscles were demonstrated coursing parallel to the cleft margin in all cleft mice. The orientation of these muscles differs from the normal transverse sling of the levator veli palatini muscle and the normal palatine aponeurosis of the tensor veli palatini muscle at the soft palate in control animals. Innervation of the levator veli palatini muscle by cranial nerve IX and the tensor veli palatini muscle by cranial nerve V were demonstrated in both cleft and control animals by use of immunohistochemistry with nerve-specific antibodies. Demonstration of a teratogen-free, reproducible animal model of clefting of the palate with a known, single-gene etiology is an important step in the systematic understanding of a congenital defect whose multifactorial etiology has hampered previous research efforts. This study presents a detailed anatomic description of such a model, including a description of the muscular anatomy and the innervation of the muscles of the palate. Because of early perinatal mortality, this model has limited applications for postnatal studies.

Objective: The purpose of this study was to examine whether mechanical elevation of the velum can directly affect the levator veli palatini muscle (LVP) activity using normal speakers as subjects. Design: Each subject was instructed to produce /mu/, /u/, /pu/, /su/, and /tsu/ in a speech task and to blow with maximum possible effort. Smoothed electromyographic activity of the LVP was recorded with an experimental palatal lift prosthesis (PLP) both in place and removed. Participants: Four normal speakers were used as subjects. Results: LVP activity for all tasks was significantly smaller (p < .001; Student's t test) with the PLP in place than without the PLP for all subjects. An analysis of variance (p < .001) clarified that activity ranges of the LVP were significantly different between the removal and placement conditions for all the subjects. Conclusion: The result was similar to that previously obtained for patients with velopharyngeal incompetence wearing a PLP. It is possible that the decrease in the LVP activity in association with placement of a PLP is caused by the direct effect of mechanical elevation, which decreases the distance the velopharyngeal mechanisms must travel for complete closure of the velopharynx.

A retrospective study was undertaken to assess speech outcomes in patients undergoing Furlow palatoplasty. Since 1994, the authors have used the position of the levator veli palatini musculature to determine type of surgical intervention recommended for the management of velopharyngeal insufficiency. Furlow palatoplasty has been used in patients with clinical evidence of sagittally oriented levator veli palatini musculature. Forty-eight patients who underwent a Furlow palatoplasty between June of 1994 and August of 1998 were included. All patients underwent preoperative and postoperative perceptual speech analyses to describe velopharyngeal insufficiency severity, nasal air emissions, and resonance, and preoperative nasendoscopy to assess velopharyngeal gap size and palatal and lateral pharyngeal wall movement. Other patient characteristics considered included gender, age at time of surgery, previously repaired cleft palate, submucous cleft palate, and syndrome diagnosis. Speech outcomes were determined on the basis of postoperative perceptual speech analyses and were categorized in one of three ways: (1) complete resolution of velopharyngeal insufficiency, (2) substantial improvement of velopharyngeal insufficiency, and (3) audible residual velopharyngeal insufficiency. Complete resolution of velopharyngeal insufficiency was defined as normal resonance and an absence of nasal air emissions. Substantial improvement of velopharyngeal insufficiency was defined as an improvement of at least two categories in velopharyngeal insufficiency severity in those patients without complete resolution. Audible residual velopharyngeal insufficiency refers to patients with postoperative velopharyngeal insufficiency severity ratings of mild, moderate, or severe. The male:female ratio in the study was 27:21. Twelve patients were syndromic; three had velocardiofacial syndrome. The median age at surgery was 6.5 years (range, 2 to 22 years). The average duration of follow-up was 14.7 months (range, 1.3 to 58.6 months). Postoperatively, the severity of velopharyngeal insufficiency was rated as none in 19 of the 48 patients (39.6 percent), minimal in eight (16.7 percent), mild in six (12.5 percent), moderate in nine (18.75 percent), and severe in six (12.5 percent). Substantial improvement was seen in seven of the 29 patients without complete resolution. There was a significant association between male gender and complete resolution of velopharyngeal insufficiency (p < 0.05). Presence of syndrome and female gender was associated with audible residual velopharyngeal insufficiency (p < 0.05). The main complication was palatal fistula (two cases). In conclusion, most patients who underwent a Furlow palatoplasty had a complete resolution or substantial improvement of velopharyngeal insufficiency postoperatively, and there were few surgical complications.

We report a rare case of a congenital anomaly with unilateral soft palate aplasia. A 10-monthold girl presented with nasal discharge. We recognized a right velar defect. No other abnormalities were noted. In her family, there was no history of cleft lip, cleft palate, or other congenital abnormalities. We examined velopharyngeal closure function by means of cineradiography. The soft palate on the normal side moved upward on swallowing, although nasal escape was recognized.She was operated on with modified push-back procedures at 2 years of age. On operation, the right side of the levator veli palatini and the palatoglossus muscle were absent, while the tensor veli palatini and palatopharyngeus muscle were present. The right side of the palatine tonsils was also absent.After operation, nasal discharge and nasal speech resolved.

Objective This study was performed to investigate aspects of velopharyngeal closure demonstrated by movements of the parapharyngeal wall under various physiological conditions and especially the stimulation of several intrapneumonal receptors. Materials and Methods Fifteen mongrel dogs were anesthetized and a nasopharyngeal fiberscope was inserted from the oronasal fistula at the center of the hard palate, with the tip fixed around the choana. Mechanical and chemical stimulation was applied, and ongoing velopharyngeal movements were observed. In each case examined, the muscle nerve located under the bilateral levator veli palatini (LVP) was severed. Results Two different closure patterns were recognized between rebreathing and deglutition. Chemical stimulation of the pulmonary irritant receptor and type-J receptor induced a sphincteric tight closure of the velopharynx but only a weak inward movement of the lateral pharyngeal wall at lung inflation. Conclusion The movements of the parapharyngeal wall, mainly represented by the pharyngeal constrictor muscle's contraction, are facilitated as a sphincteric velopharyngeal closure under reflexive movements such as deglutition or gagging.

The abnormal anatomy in the cleft palate has been of interest to surgeons for a long time. Different authors have independently evolved the techniques of radical reconstruction of the palatal musculature and have suggested the medial approach to dissect the levator. We hereby report the technique in which the levator is identified through the lateral incision of the soft palate. This lateral approach helps in the complete release of the levator from all abnormal attachments and ensures reconstruction of an effective sling. This technique is of particular benefit in a palate re-repair.

Objective As a step toward better understanding of normal and abnormal velar control, a finite element model of the soft palate was developed. Design A static two-dimensional midsagittal model of the velum was given physical dimensions to match that of a 10-year-old boy. Biomechanical properties of the tissues were inferred based on previous histologic studies. Velar movements were induced by the influence of three extrinisic velar muscles: the levator veli palatini, the palatoglossus, and the palatopharyngeus, which were simulated as external forces acting on the velar model. Results and Conclusions Velopharyngeal opened and closed positions were simulated as well as a variety of intermediate steps between the two configurations. Velopharyngeal closure was also simulated in a manner appropriate for both high and low vowels. Future extensions of the model will incorporate the muscles as an intrinsic component of the model and will include a full time-dependent implementation, including inertial effects. Future studies will compare model predictions with experimental data from the laboratory, including both kinematic data and velopharyngeal closure forces.

Objective We have observed clinically that some speakers wearing a speech appliance for correction of velopharyngeal incompetence can blow with variable intensity without nasal air escape. This clinical finding suggests that tightness of velopharyngeal closure may be regulated in accordance with oral air pressure during blowing. The purposes of this electromyographic study were (1) to examine whether levator veli palatini muscle activity can be changed in relation to oral air pressure during blowing when the speech appliance is removed, (2) to clarify whether or not the change is related to the severity of velopharyngeal incompetence, and (3) to examine whether placement of a speech appliance can alter levator muscle activity into the equivalent of that of normal speakers during blowing. Design Eight patients with repaired cleft palate, who routinely wear a palatal lift prosthesis (PLP) or a hybrid speech appliance of a pharyngeal bulb and palatal lift (bulb-PLP), served as subjects. Subjects were classified into one of two groups according to their speech appliance (PLP group and bulb-PLP group). Electromyography of the levator veli palatini muscle was recorded with a speech appliance in place and then with the speech appliance removed as the subject blew through a tube at three different effort levels. Results In the removed condition, the change in levator activity in relation to oral air pressure was variable across subjects in the bulb-PLP group, whereas levator activity changed in relation to oral air pressure change for all subjects in the PLP group. However, levator activity changed in relation to oral air pressure with either speech appliance in place for all subjects irrespective of their speech appliance types. Conclusion The severity of velopharyngeal incompetence might be related in part to change in levator activity in association with oral air pressure. The effect of a speech appliance to correct velopharyngeal incompetence might consist not only of mechanical obturation of the velopharynx but also of alteration of velopharyngeal function to become similar to normal speakers. Moreover, it is likely that the velopharyngeal system could be well regulated so as to exhibit a consistent outcome of velopharyngeal function.

1. The palatal myoclonus in symptomatic cases is usually silent as the involved muscle is the levator veli palatini. This is in contrast to the audible clicking sound (generated by the synchronous collapse of the eustachian tube) in patients with essential palatal myoclonus in which the involved muscle is the tensor veli palatini. 2. The hyperintense signal on T2-weighted MRI in transneuronal hypertrophic degeneration of the inferior olivary nucleus reflects increased water content and gliosis. Enlargement of the inferior olivary nucleus results from astrocytic hypertrophy and vacuolar cytoplasmic degeneration. Eventually, permanent atrophy of olivary neurons ensues within 3 to 4 years. A 63-year-old man with a history of treated hypertension presented with sudden onset of right hemiparesis and horizontal diplopia that was worse on rightward gaze. His blood pressure was 220/120 mm Hg. On neurologic examination, the patient had a right hemiplegia. Examination of the extraocular movements demonstrated conjugate left lateral gaze palsy, impaired adduction of the left eye, and abduction nystagmus of the right eye. These signs were consistent with a left “one and a half syndrome.” Further assessment revealed a bilateral facial nerve palsy of the lower motor neuron type. The cranial CT revealed intraparenchymal brainstem hemorrhage involving the left side of the pontine tegmentum with extension into the fourth ventricle (figure 1). His motor weakness and the facial diplegia improved, but the extraocular eye movements remained limited with persistent horizontal diplopia, particularly on rightward gaze. Figure 1 Initial CT of the head showing the intraparenchymal brainstem hemorrhage that mainly involved the left side of the pontine tegmentum with extension into the fourth ventricle Six months later, he presented again with a precipitous onset of oscillopsia …

Objective The palatal aponeurosis is a controversial structure, both in terms of its anatomy and its function. This article points out a pathologic finding in the cleft palate condition that has not been previously described. Design and Method By means of surgical dissections, this study demonstrates in detail that the palatal aponeurosis exists even in cleft palates, but it is disrupted, malpositioned, and folded in two layers. Patients This dissection method has been performed on more than 150 patients with cleft of the hard and soft palate, with or without cleft of the lip and alveolus. At the time of operation, the children were between 6 and 8 months of age. Results It is possible to dissect the two layers of the palatal aponeurosis, to unfold the aponeurosis, and to form a tough tendinous plane. Conclusion For a functional physiologic reconstruction of the cleft palate, it is necessary not only to reconstruct the levator veli palatini and palatopharyngeus muscle slings, but also to approximate and suture the fibers of the palatal aponeurosis to the corresponding fibers of the opposite side after unfolding them in a medio-dorso-cranial direction. In this manner, a continuous palatal aponeurosis can be created, which subsequently can serve as a transmitter of the muscle forces.

The purpose of this study was to measure velopharyngeal closure force in varying phonetic contexts for normal men and women subjects. Levator veli palatini muscle activity was measured as well. Place and manner of articulation, voicing, and the effects of consonant sequencing were studied in different vowel contexts. When the data were grouped by sex of subject, no differences were found in absolute values of velopharyngeal closure force for the men versus women subjects. As expected, nonnasal consonants were produced with greater velopharyngeal closure force than nasal consonants. High vowels were produced with greater closure force than low vowels. Closure force was greater for voiceless than for voiced consonants but only for the men and only within /i/ and /u/ contexts. The lingua-dorsal consonant was associated with greater closure force than the lingua-apical consonant but only for the men and only in the high-back vowel environment. Significant differences in closure force were not found between fricatives or stops. A tendency for greater closure force for the fricative consonant was observed when the fricative followed rather than preceded the nasal consonant. Vowel identity had an effect on closure force during consonant production in the men in that closure force was greater for /s/ and /n/ in high versus low vowel contexts. Men exhibited a larger number of significant differences in closure force than did the women. The results suggest that velopharyngeal closure force is not controlled by a single muscle (the levator veli palatini) but that other muscles and mechanical factors are likely contributors.

Launois, Sandrine H., Judy Tsui, and J. Woodrow Weiss.Respiratory function of velopharyngeal constrictor muscles during wakefulness in normal adults. J. Appl. Physiol. 82(2): 584–591, 1997.—The levator veli palatini (LVP) and the superior pharyngeal constrictor (SPC) influence velopharyngeal patency and soft palate position, but their behavior during respiration is incompletely characterized. To further clarify their respiratory function, we recorded electromyographic activity (EMG) in the LVP and the SPC in awake normal subjects breathing orally. EMG data were obtained in six subjects for the LVP and in nine subjects for the SPC. EMG activity and timing and ventilation were measured during isocapnic hypoxia and hyperoxic hypercapnia. Phasic EMG activity was inconsistently present during unstimulated oral breathing. Timing of EMG phasic activity was variable for both muscles. Peak LVP activity was mainly or exclusively expiratory in three of six subjects. Peak SPC activity was mainly or exclusively expiratory in five of nine subjects. With chemostimulation, recruitment of phasic activity was observed in the LVP in four of six subjects and in the SPC in five of nine subjects. Tonic activity increased in four of six subjects for the LVP and in three of nine subjects for the SPC. However, the response was alinear, and intersubject as well as breath-to-breath variability was substantial. In conclusion, LVP and SPC are characterized by the high inter- and intrasubject variability of EMG activity, timing of activation, and response to chemostimulation.

Objective The ideal palatal surgery for obstructive sleep apnea (OSA) and snoring must maintain the airway patency and correct anatomic abnormalities without complications. The purpose of this study was to investigate the efficacy of limited palatal muscle resection (LPMR) to improve OSA severity. Subjects and methods Twenty-three patients with OSA underwent LPMR. The LPMR was initiated with a bilateral tonsillectomy in patients with tonsil size 2 and 3. The LPMR consisted of partial resection of palatal muscles (levator veli palatini, palatoglossus, and musculus uvulae) with preservation of the uvula and a simple double layer suturing. The retropalatal space and the length of soft palate were evaluated by magnetic resonance imaging. Subjective outcomes using visual analog scales, Epworth Sleepiness Scale, and overnight polysomnography (PSG) data were assessed. Results Six months after the operation, there was significant symptomatic improvement in snoring, morning headaches, tiredness, and daytime sleepiness. Postoperative magnetic resonance images showed upward and forward movement of uvula and soft palate after LPMR. The length of the soft palate was significantly shortened and the retropalatal space was significantly increased. Postoperative PSG revealed significant improvement in apnea–hypopnea index (AHI) and the total sleep time spent with oxygen saturation below 90%, and reduction in AHI following PMR was found in all patients. Furthermore, no patient experienced velopharyngeal insufficiency, voice changes, and pharyngeal dryness at 6 months follow-up. Conclusions The LPMR obtained significant improvement in subjective and objective outcomes in OSA, with preserved pharyngeal function. PMR is an effective and safe technique to treat oropharyngeal obstruction in OSA surgery.

The main purpose of palatoplasty is to establish normal speech and deglutition. To enhance the chance of successful palatal repair, as well as optimal velopharyngeal competence, the anatomy of the palate has to be thoroughly understood. While carrying out the repair, some surgeons prefer to cut the tensor veli palatini (TVP) tendon, others perform a tenopexy or fracture the hamulus around which the tendon passes, to facilitate mobilisation of palatal tissue. However, the exact anatomy and function of the TVP is still controversial and severing the tendon or its path could be of potential harm. A review of the literature was conducted to summarise the current knowledge of the TVP and its relevance to palatoplasty. It was found that there is sufficient evidence that the TVP plays an important part in velar tautening and Eustachian tube opening, under normal circumstances. TVP's role in the cleft patient population is, however, less certain. Whether or not TVP tenotomy or dislocation reduces ET function further in these patients is also unclear. There is, however, little or no evidence of reduced middle ear effusions if such actions are avoided, at least not in children younger than 3 years of age.

Summary This study examined the aspect of the regulation of velum movement in the transition from the oral to pharyngeal phases of swallowing in relation to changes in the swallowing volume and viscosity by means of measurment of levator veli palatini muscle activity. The subjects were nine normal adults, ranging in age from 24 to 30 years. The swallowing volume was set at 1/4, 1/2 and 1 volume of the optimum volume of green tea for swallowing determined in each subject, and the viscosity was adjusted to 0, 2·0 and 4·6 Pa·s by mixing with thickener. Nine test foods were prepared in total. The electromyographic activity of the levator veli palatini muscle was monitored using bipolar hooked wire electrodes. The levator veli palatini muscle activity was defined as the integrated electromyographic wave. The mean in swallowing each test food was determined in each subject. The levator veli palatini muscle activity increased with the swallowing volume for all subjects (P

Congenital cleft palate is one of the most common birth defects in the craniofacial region. Patients with cleft palate may experience maxillary growth retardation as well as dysfunctions in speech and feeding. Over the past centuries, management of cleft palate has evolved from simple closure of the cleft, although now surgical reconstruction of the palatal structures is one of the most important treatment steps. The optimal palatoplasty should achieve velopharyngeal competence (VPC) in order to develop normal speech, while causing the least growth disturbance to the maxilla and occlusion. This requires not only the closure of the cleft, but also restoration of palatal functions.

Contains fulltext : 118436.pdf (Publisher’s version ) (Open Access) BACKGROUND: Children with a cleft in the soft palate have difficulties with speech, swallowing, and sucking. Despite successful surgical repositioning of the muscles, optimal function is often not achieved. Scar formation and defective regeneration may hamper the functional recovery of the muscles after cleft palate repair. Therefore, the aim of this study is to investigate the anatomy and histology of the soft palate in rats, and to establish an in vivo model for muscle regeneration after surgical injury. METHODS: Fourteen adult male Sprague Dawley rats were divided into four groups. Groups 1 (n = 4) and 2 (n = 2) were used to investigate the anatomy and histology of the soft palate, respectively. Group 3 (n = 6) was used for surgical wounding of the soft palate, and group 4 (n = 2) was used as unwounded control group. The wounds (1 mm) were evaluated by (immuno)histochemistry (AZAN staining, Pax7, MyoD, MyoG, MyHC, and ASMA) after 7 days. RESULTS: The present study shows that the anatomy and histology of the soft palate muscles of the rat is largely comparable with that in humans. All wounds showed clinical evidence of healing after 7 days. AZAN staining demonstrated extensive collagen deposition in the wound area, and initial regeneration of muscle fibers and salivary glands. Proliferating and differentiating satellite cells were identified in the wound area by antibody staining. CONCLUSIONS: This model is the first, suitable for studying muscle regeneration in the rat soft palate, and allows the development of novel adjuvant strategies to promote muscle regeneration after cleft palate surgery.

Sphincter pharyngoplasty has demonstrated time-tested results as a surgical treatment for velopharyngeal incompetence (VPI). However, controversy surrounding the contractility of the transposed muscles persists. Completely unaddressed in the literature is whether the dynamism of the sphincter affects speech outcomes.To determine whether active sphincter contraction following sphincter pharyngoplasty influences velopharyngeal closure, nasal emission and hypernasality.A prospective analysis of patients with VPI after cleft palate repair undergoing sphincter pharyngoplasty by a single surgeon was performed. Video nasendoscopy and videofluoroscopy were performed preoperatively and postoperatively at three and 12 months. Eighteen consecutive patients with cleft palate with or without cleft lip and VPI were reviewed. The average age of the patients at initial evaluation was 7.3 years, with a range of three to 19 years. Dynamicity of sphincter pharyngoplasty, velar closing ratio (VCR), and lateral wall movement (LWM) were assessed by nasendoscopy and videofluoroscopy. Nasal emission and hypernasality were assessed by perceptual speech examination.FOR LONGITUDINAL COMPARISON, THREE GROUPS WERE CREATED: dynamic at three and 12 months (n=12); adynamic at three months and dynamic at 12 months (n=4); and adynamic at three and 12 months (n=2). Perceived hypernasality scores significantly improved at three months (P=0.0001) and showed continued improvement at 12 months (P=0.03), despite no change in VCR and LWM from three to 12 months. There were no significant differences among the three groups at any time point.Sphincter pharyngoplasty effectively treats VPI in appropriately selected patients. Although the VCR and LWM remained stable between three months and one year, four of six adynamic sphincters became dynamic. Considering all patients, hypernasality showed continued improvement from three months to one year.There were no differences between dynamic and adynamic sphincters in terms of speech outcomes or the mechanical properties of velopharyngeal closure.La pharyngoplastie du sphincter est un traitement chirurgical de l’incompétence vélopharyngienne (IVP) qui a fait ses preuves. Cependant, une controverse persiste à l’égard de la contractilité des muscles transposés. Les publications n’abordent pas du tout l’influence du dynamisme du sphincter sur les issues du discours.Déterminer si la contraction active du sphincter après une pharyngoplastie du sphincter influe sur la fermeture vélopharyngienne, l’émission nasale et l’hypernasalité.Les chercheurs ont procédé à une analyse prospective des patients présentant une IVP après la réparation d’une fente palatine qui ont subi une pharyngoplastie du sphincter exécutée par un seul chirurgien. Ils ont procédé à une nasendoscopie vidéo et à une vidéofluoroscopie avant l’opération, puis trois et 12 mois après l’opération. Ils ont examiné 18 patients consécutifs ayant une fente palatine, accompagnée ou non d’une fente labiale, et une IVP. Les patients de trois à 19 ans avaient un âge moyen de 7,3 ans au moment de la première évaluation. Les chercheurs ont évalué le dynamisme de la pharyngoplastie du sphincter, le ratio de fermeture vélaire (RFV) et le mouvement des parois latérales (MPL) par nasendoscopie et vidéofluoroscopie. Ils ont également évalué l’émission nasale et l’hypernasalité au moyen de l’examen du discours perceptuel.Pour des besoins de comparaison longitudinale, les chercheurs ont créé trois groupes, soit un groupe dynamique à trois et 12 mois (n=12), un groupe adynamique à trois mois et dynamique à 12 mois (n=4) et un groupe adynamique à trois et 12 mois (n=2). Leurs indices d’hypernasalité perçus s’étaient considérablement améliorés à trois mois (P=0,0001) et avaient continué de s’améliorer à 12 mois (P=0,03), malgré l’absence de changement de l’IPV et du MPL entre trois et 12 mois. On ne constatait pas de différence significative à un moment ou à un autre entre les trois groupes.La pharyngoplastie du sphincter traite l’IPV de manière efficace chez des patients bien sélectionnés. Même si le RFV et le MPL étaient demeurés stables entre trois mois et un an, quatre des six sphincters adynamiques sont devenus dynamiques. Chez l’ensemble des patients, l’hypernasalité s’est atténuée de manière continue entre trois mois et un an.On n’a constaté aucune différence entre les sphincters dynamiques et adynamiques sur les issues du discours ou les propriétés mécaniques de la fermeture vélopharyngienne.

This study, using mongrel dogs, showed the individual movements caused by the levator veli palatini muscle (LVP) and pharyngeal constrictor (PC) contraction, induced by electrical stimulation to each peripheral motor nerve. Each bilateral peripheral motor nerve of the LVP and PC muscles was isolated and stimulated electrically to induce the individual contraction of bilateral LVP and PC muscles. The movements were visualized by use of a fiberscope. Vertical movement of the middle soft palate was observed mainly at LVP contraction. Circular closure in the posterior region of the velopharynx was induced by contraction of the PC muscle. The posterior and lateral wall movements clearly occurred following PC contraction.

The dynamic mechanism of velopharyngeal function not only in normal individuals but also in patients with velopharyngeal insufficiency, which is mainly related to cleft palate, has been the subject of considerable interest and controversy. Recently, in order to clarify velopharyngeal movement in the valvular action on phonation we examined dynamic MR images of this area taken in the transverse plane in parallel with the muscle sling of levator veli palatini. In cases in whom the closure pattern in that plane is circular, detailed observation revealed a very interesting result; that is, the longus capitis muscle, one of the group of anterior vertebral muscles, is directly involved in velopharyngeal valving function. It has not previously been reported that the longus capitis muscle acts as one of the velopharyngeal closure muscles, in addition to levator veli palatini. The present study demonstrated that contraction of the muscle contributed to velopharyngeal closure by forward movement of the pharyngeal wall.

This study was designed to determine if levator veli palatini muscle activity can be elicited by simultaneous changes in oral air pressure and nasal air flow when a speech appliance is in place. The speech appliances routinely worn by 15 subjects were each modified experimentally by drilling a hole in the vertical center of the pharyngeal bulb. The air flow rate into the nasal cavity through the opening in the bulb was altered by changing the circular area of the opening in the bulb from the occluded condition (Condition I), to circular area of 12.6 mm2 (4 mm in diameter; Condition II), and then to 38.5 mm2 (7 mm in diameter; Condition III). Electromyographic activity was measured from the levator veli palatini muscle with changes in nasal air flow rate and oral air pressure. Levator veli palatini muscle activity was correlated with changes in nasal air flow and oral air pressure. Increases in levator veli palatini muscle activity were associated with increases in nasal air flow rate compared to oral air pressure changes. The results indicated that aerodynamic variables of nasal air flow and oral air pressure might be involved in the neural control of speech production in individuals wearing a speech appliance, even if the subjects exhibit velopharyngeal incompetence without using a speech appliance. Also, the stimulating effect of bulb reduction therapy on velopharyngeal function might be achieved through the change in aerodynamic variables in association with the bulb reduction.

Assessment of the role of gravitational forces in the motor control of the velopharyngeal mechanism was the focus of this study. Specifically, the effect of gravity on activation levels of the levator veli palatini and palatoglossus muscles was assessed. Nineteen volunteers repeated a CV syllable in upright and supine body positions. Overall, lower peak activation levels of levator veli palatini were observed in the supine body position. The results suggest that less muscle activity was seen in the levator veli palatini in the supine body posture, where gravitational effects worked in the same direction (i.e., toward closure). No statistically significant group effects were seen in muscle activation levels of palatoglossus across the two body postures, although clear gravity effects were observed in some subjects. The implications of these findings from a speech motor control perspective are discussed in relation to normal and disordered velopharyngeal function.

A comparison of the ranges of levator veli palatini EMG activity for speech versus a nonspeech task for subjects with cleft palate was the focus of this study. EMG values are also compared with subjects without cleft palate obtained in a previous study. Hooked-wire electrodes were inserted into the levator muscle of five adult subjects with cleft palate exhibiting mild hypernasality. Intraoral air pressure was measured concurrently. A blowing task was used to determine the subject's operating range for the levator muscle. Both the nonspeech and speech tasks were designed to sample the widest possible ranges of levator EMG activity. It was found that the subjects with cleft palate used a relatively high activation level for the levator muscle during speech, in relation to their total activation range, compared with the subjects without cleft palate. Implications are discussed In relation to possible anatomic and physiologic differences for cleft palate subjects compared to normal.

Summary: When the lesser palatine nerve (LPN) is supposed to be a branch of the trigeminal nerve and innervate sensation of the soft palate, whether the LPN contains motor fibers is unclear. In this study, we monitored the electromyogram of the levator veli palatini (LVP) muscle on stimulating the LPN during palatoplasty in 3 patients. The electromyogram of the muscles showed the myogenic potential induced by electrostimulation of the LPN. Taken together with the finding from our previous anatomical study that the motor fibers come from the facial nerve, this result supports the double innervation theory of the LVP, which posits that both the pharyngeal plexus and the facial nerve innervate it. Identifying and preserving the LPN during palatoplasty might improve postoperative speech results.

Objective To determine the role played by the tensor veli palatini and levator veli palatini muscles (mTVP and mLVP, respectively) in eustachian tube (ET) opening. Design Prospective study. Setting Research laboratories at a tertiary care hospital. Patients Fifteen healthy adults with normal middle ears and documented ET openings. Interventions Submental and ground surface electrodes were placed. After anesthetizing and decongesting the nasal passages, paired electromyographic needle electrodes were inserted into both the mTVP and mLVP on the test side. A microphone was placed into the ipsilateral ear canal and the probe from a sound generator was introduced into the opposite nostril. A 45° telescope was used on the test side to video-record the soft palate and ET movements while the individual swallowed. Main Outcome Measures Concurrent recordings of the ET openings by sonotubometry, the electromyographic activity for the LVP, TVP, and submental muscles, and video of the nasopharyngeal orifice of the ET during swallowing. Results During swallowing, the median peak amplitude and duration of ET openings by sonotubometry were 30.6 mV and 196 milliseconds, respectively. For the mLVP and mTVP, the median peak amplitudes were 0.33 and 0.82 mV, and peak durations were 131 and 85 milliseconds, respectively. The mean onsets of muscle activity referenced to the sonotubometry peak amplitude were −0.28, −0.24, and −0.14 milliseconds for the mLVP, mTVP, and submental muscles, respectively. Video recording of ET movements were consistent with the timing of these events. Conclusions The mTVP activity had a shorter duration but greater amplitude than the mLVP activity and was associated with peak ET opening by sonotubometry. The mLVP activity occurred before that of the mTVP, the submental muscle group, and peak ET opening. The mLVP contractions were associated with movements of the soft palate, anterior ET orifice, and rotation of the ET cartilage.

The relative contributions of the levator veli palatini, palatoglossus, and palatopharyngeus muscles were assessed relative to a range of positions of the velopharynx during production of the vowels [a] and [I] by four normal adult speakers. The results indicate that velopharyngeal positioning is determined by the relative contributions of the levator veli palatini, palatoglossus, and palatopharyngeus muscles. There was an increase In coefficients of determination (i.e., amount of closure level variability explained) when activity levels of all three muscles are included in the statistical model compared to activity in any one muscle analyzed independently. Both consistent and inconsistent relations among activity levels in the three velopharyngeal muscles studied were observed across speaker and vowel produced.

Objective Submucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI. Methods This prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy. Results Significant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory. Conclusions Furlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

Purpose To report the feasibility of using a 3-dimensional (3D) magnetic resonance imaging (MRI) protocol for examining velopharyngeal structures. Using collected 3D MRI data, the authors investigated the effect of sex on the midsagittal velopharyngeal structures and the levator veli palatini (levator) muscle configurations. Method Ten Caucasian healthy adults (5 women and 5 men) participated. A whole-head 3D MRI scan was obtained while participants were at rest in the supine position. Basic anatomic parameters of the velopharynx including midsagittal velopharyngeal structures and levator muscle configurations were compared between sexes. Results Detailed information on the 3D MRI protocol and data analysis method was introduced in the study. On the basis of the data, only the length of the levator muscle showed a statistically significant sex difference: Male participants had significantly longer levator muscles than those of female participants. Conclusions The present study successfully demonstrated the use of 3D MRI in quantifying major velopharyngeal structures and provided additional data on the anatomic variations that exist in healthy adult individuals.

Objective: Evaluate normal human Eustachian tube (ET) function during swallowing and other maneuvers that open the ET using a variety of modalities including EMG of the Tensor veli palatini (mTVP), Levator veli palatini (mLVP), and submental muscles, videoendoscopy, and sonotubometry; and compare these results with ET function tests in a pressure chamber.Method: In adult volunteers surface electrodes and needle EMG electrodes were placed into the mTVP and mLVP muscles. A 45° telescope was used to video-record the ET orifice, and sonotubometry recorded the ET openings. A subset was also tested in a pressure chamber.Results: Seventeen subjects were enrolled. EMG data was recorded from both the mTVP and mLVP in 15 subjects but from only one muscle in 2 subjects. In 9 subjects ET functions tests were performed in the pressure chamber. Video recording of ET opening was consistent with the EMG activity and ET openings by sonotubometry. mTVP activity had a shorter duration but a greater amplitude than mLVP activ...

Objective To use finite element analysis animated simulations to investigate factors affecting velopharyngeal closure. Design A coronal section multicomponent finite element analysis model of a human soft palate was created in Simulia Abaqus 6.5–1 from high resolution WIR I images of a single adult female subject, interpreted by reference to published anatomic dissections. Tissues were assigned hyperelastic property coefficients for neo-Hookean behavior, with gravity at 9.8 ms–2 in the y-axis. Vector forces based on estimations in previous publications were applied throughout levator veli palatini and palatopharyngeus muscles, using a nonlinear analysis algorithm, to produce animated simulations of velopharyngeal space closure. Variation of levator veli palatini angle from 60° to 49°, the contribution of palatopharyngeus muscle, and the effect of submucous cleft were investigated for their effects on velopharyngeal closure. Results The animated simulations showed anthropomorphic behavior and supported the previously suggested effects of the levator veli palatini angle, with reduced effectiveness of velopharyngeal closure as levator veli palatini angle decreases. Palatopharyngeus action reduced the efficiency of closure for a levator veli palatini angle of 60°, and a submucous cleft reduced this for both our normal subject and for a levator veli palatini angle of 60°, but both palatopharyngeus action and a submucous cleft enhanced closure for a levator veli palatini angle of 49°. Conclusions This study advances soft palate finite element analysis to a real-subject-based multicomponent hyperelastic model that demonstrates anthropomorphic behavior. Animated simulations using the model demonstrate the possible effects of levator veli palatini angle, a submucous cleft, and the contribution of the palatopharyngeus.

There is debate concerning the mechanism of Eustachian tube (ET) ventilation. While a mechanism of complete opening has been advocated previously, sequential contraction of the levator veli palatini and medial pterygoid muscles followed by the tensor veli palatini and lateral pterygoid muscles may produce a transient sequential opening mechanism, allowing an air bolus to traverse the ET. This may explain confusion surrounding sonotubometry reports that not every swallow leads to sound passage in normal subjects. We hypothesize that the ET may not need to open completely when ventilating the middle ear; rather, a discrete air bolus can pass through it. Five normal and five disordered subjects underwent low-radiation dose cine computed tomography (CT) scans of the ET. Sixteen contiguous 2.5 mm slice locations were chosen through a 4 cm area in the nasopharynx that were parallel to and encompassed the entire ET. Twelve images were acquired at each slice over 4.8 s during swallowing and other tasks. Serial images were analyzed. An air bolus was observed passing through the ET in the normal subjects, but not the subject with ET dysfunction. Medial and lateral pterygoid contractions were also observed. A new hypothetical mechanism of transient sequential ET ventilation is presented. This is not a definitive conclusion, as the number of scans taken and maneuvers used was limited. Improved understanding of ET ventilation may facilitate management of middle ear disease as treatment evolves from ventilatory tube placement to ET manipulation.

Background and Methods. To research the pathophysiology of the Eustachian tube (ET), electromyographies (EMG) of the tensor and levator veli palatini muscles (TVP and LVP) in 46 fresh specimens of nasopharyngeal carcinoma (NPC) were studied. Results. Sixty-eight percent of the of TVP on the symptomatic side had abnormal EMG. Normal EMG recordings were noted in all TVP on the asymptomatic side. The abnormal TVP EMG observed most often was poor interference pattern or decreased interference with swallowing, and not uncommonly, there were some abnormal motor unit action potentials of serrated or large polyphasic waveforms found on motor unit potential analysis. This is strong evidence of neurogenic abnormality of the TVP caused by the NPC invasion. Despite the large polyphasic or serrated action potentials often being recorded on the symptomatic sides of LVP, the abnormal EMG finding also was found in 12 LVP on the asymptomatic sides. Conclusions. There was no evidence that an ET dysfunction could be caused solely by an abnormal LVP function. This investigation and the study of ET function of these patients demonstrate that functional obstruction induced by the invasion of NPC to the nerve of TVP, rather than mechanical obstruction caused by the tumor mass effect on the ET, gives rise to the ear symptoms and signs of these patients. The authors suggest that the LVP action has little or no role in the function of the ET.

Objective: This study was designed for two purposes: (a) to obtain qualitative and quantitative information of the velopharyngeal mechanism in infants born with cleft palate before and after primary palatoplasty using MRI and 3D computer technology and (b) to demonstrate the potential of using computer technology and MRI for presurgical planning. Methods: Clinical MRI data were obtained from the medical charts of four infants (two with cleft lip and palate and two without) between 8 - 15 months of age. Computer technology was used to obtain quantitative measures of the levator veli palatini (levator) muscle and to create 3D computer models. Results: There was little difference in angles of origin between individuals with normal velopharyngeal anatomy (ranging from 41 masculine-45 masculine). Subjects with cleft palate displayed smaller angles of origins (average of 40 masculine) prior to surgery compared to that of the subjects without cleft palate (average of 43 masculine). Following surgery, the levator muscle increased in length (ranging from 32mm-40.4mm) and formed larger angles of origin (average of 39 masculine) becoming more similar to the angles of origin observed in the subjects without cleft palate. Conclusions: Although the subjects with normal anatomy displayed levator muscle lengths, thickness, and distance between origins that were dissimilar, nevertheless the angles of origin measures were similar. Subjects with cleft palate had greater variations in the angle of origin. It is possible that the angle of the muscle as it descends from the base of the skull might be a critical feature to produce velopharyngeal closure.

It has been reported that the levator veli palatini muscles of speakers with velopharyngeal incompetence tend to demonstrate muscle fatigue during speech. This study examined whether a speech aid prosthesis might reduce levator muscle fatigue in such speakers. Eight individuals with post-surgical cleft palates, and who wore a speech aid prosthesis, were studied. Each person was asked to pronounce the syllable [pu] more than 50 times. Mean power frequency (MPF) of one syllable was obtained from electromyographic data from the levator muscle. The MPF regression line was calculated during the course of syllable repetition. The absolute values of the slopes of the regression lines with the prosthesis were significantly smaller than those without the prosthesis. It was shown that the prosthesis reduced the decrease in MPF during speech. These results suggested that speech aid prostheses reduce levator muscle fatigue during speech in persons with velopharyngeal incompetence.

This study Investigated the activities of the tensor and levator veli palatini muscles related to respiration. During quiet breathing, no activity was observed in either muscle. With either hypercapnic or hypoxemic condition, the tensor veli palatini muscle exhibited phasic activity during inspiration. The levator veli palatini muscle showed phasic activity during expiration with hypoxemia (PaO2 < 40 mm Hg). NaCN perfused bilaterally through the carotid sinus induced these respiratory activities. The tensor veli palatini muscle was more sensitive than the levator veli palatini muscle to NaCN.

To test the hypothesis that soft palate muscles are abnormal in cleft palate, we compared soft palate morphogenesis in fetuses with cleft palate (n=4) to age-matched (n=3) and nonmatched (n=1) control specimens. The morphologic status of all soft palate and masticatory structures were classified into one of six stages based on the level of histogenesis. At 54 mm crown-rump length (CRL), the levator veli palatini (L), palatopharyngeus (PP), and palatoglossus (PG) in cleft subjects demonstrated mesenchymal condensation into myoblastic fields, lagging behind the control specimens (97 mm CRL), which displayed definitive fields of myoblasts and myotube formation. In the 175 mm and 225 mm cleft and the 170 mm and 192 mm control specimens, muscular morphology was similar and had reached its postnatal appearance for the tensor veli palatini (175 m only) and L, PP, PG (225 mm only). Muscle fiber directions were, however, disoriented and disorganized, especially close to the medial epithelial edge of the cleft. The levator veli palatini, could not be distinguished as a discrete muscle in the cleft specimens, and what we believed to be the PP and PG seemed “normal” at the level of light microscopy, but malpositioned in a superior direction. This preliminary study demonstrates for the first time that early myogenesis in cleft palates differs from normal.

In spite of its clinical importance in cleft palate, there are few detailed accounts of the blood supply of the soft palate and palatal muscles. A series of dissections was carried out to investigate the supply of the levator and tensor veli palatini muscles. Ten adult cadavers and 12 fetuses were used, all of which had been previously injected with a variety of media to outline the vascular tree. Conventional dissection was performed on the cadavers, and microsurgical instruments and a dissection microscope were utilized for fetal dissections. In 70% of dissections the m. levator veli palatini had a dual arterial supply, from the ascending palatine and ascending pharyngeal arteries. In the remainining cases the muscle was supplied by a single artery, either the ascending palatine or ascending pharyngeal. In 79% of dissections the tensor muscle had a dual supply from the accessory meningeal artery along with either the ascending palatine, ascending pharyngeal, or, in one case, the lesser palatine arteries. The results suggest that in careful surgical closure of the cleft soft palate the normal dual arterial supply would protect the tensor and levator muscles from vascular damage. In the minority of patients where only a single vessel supplies the levator, a radical intrapalatal dissection may jeopardize its vascularity.

The aim of this study was to elucidate microscopic relation between the levator veli palatini, palatopharyngeus (PP), and superior constrictor (SC) muscle in transverse, parasagittal, and coronal sections.In 10 Korean adult cadavers, the entire soft palate was removed, trimmed, and preserved in 10% neutral buffered formalin. Specimens were embedded in paraffin and sectioned at a thickness of 10 mum. Blocks were cut the course of levator veli palatini. Also, transverse, parasagittal, and coronal section were made, stained using Masson trichrome, and observed under light microscope.Levator veli palatini was inserted between mucous gland anteriorly and musculus uvulae posteriorly in the midline of the soft palate, where they interdigitated with those in the contralateral side. Palatopharyngeus originated from the palatine aponeurosis and posterior mucosa of the soft palate. Most of the fibers of the PP did not cross the midline in their origin; however, some fibers interdigitated across the midline. As PP went downward and crossed the levator, it divided into anterior fasciculus and posterior fasciculus. Anterior fasciculus was thick and went downward along the anterolateral side of the levator. Posterior fasciculus was thin and widely spread along the posteromedial side of levator. Below the levator, 2 fasciculi united and were inserted to the medial side of SC. There were close attachment between the PP and SC.A detailed understanding of the microscopic relationship between the levator veli palatini, PP, and SC muscle is desirable for performing pharyngeal flap surgeries.

The purpose of this study was to find out the incidence of palatal fistula and study the factors that influence its development after palatoplasty with repositioning of the levator veli palatini. We retrospectively reviewed 176 consecutive repairs of cleft palates during a 2-year period (2004-2006). The age of the patients at the time of repair ranged from 12 to 30 months (mode 17 months). All the palatoplasties were done either by a senior surgeon or a resident surgeon. The chi square test was used to assess whether the development of postoperative fistulas was influenced by sex, extent of cleft (as estimated by the Veau classification), age at repair, and operating surgeon. There were 12 palatal fistulas (7%), 8 of which were at the junction of the hard and soft palate, 3 in the hard palate, and 1 in the soft palate. There was no evidence to suggest that sex or age were associated with their development. Patients whose clefts had been treated by the senior surgeon had fewer fistulas (2/82, 2%) than those by the resident surgeon (10/94, 11%) (p=0.04). The incidences of palatal fistulas in patients with clefts of the hard and soft cleft palate (7/44, 21%), and bilateral cleft lip or palate (2/21,10%), were significantly higher than those in patients with cleft soft palate (1/37, 3%), and unilateral cleft lip or palate (2/74, 3%) (p=0.03). Our results show that palatal fistula after repair is related mainly to the extent of the cleft and the experience of the operating surgeon.

We have tried to clarify some characteristics of the motor encoding processes of shouted and whispered voice as opposed to normal voice. Our corpus consisted of trisyllabic nonsense words. We recorded the activity of three muscles of the buccal area (levator veli palatini, digastric and orbicularis oris inferior) and we analyzed selected duration parameters in the acoustic and electromyographic recordings. Our data revealed that the encoding modalities of the shouted and whispered occurrences differed significantly from those of the normal items. It seems in particular that the extent of the programming process was more reduced in shouted voice than in normal and especially in whispered voice. Furthermore, we suggest that the changes in duration which we observed between the “normal” and “unusual” sequences are not necessarily due to biomechanical differences of force, but could be ascribed to specificities of the motor programs.

In some patients with cleft palate (CP), velopharyngeal insufficiency persists after palatoplasty. In order to determine whether such insufficiency is due to the pathological changes of the levator veli palatini (LVP) muscle, we examined histologically the LVP muscles of 35 patients with CP and of six control patients with congenital microtia. Electromyographic records were obtained of the LVP muscles of 12 patients with CP after palatoplasty.The muscle structures were well preserved in seven of 35 patients with CP. Among the other 28 patients, perimysial fibrosis was observed in 13, variations in fiber caliber in seven and internal nuclei in one, but these findings were also observed in the control group. The incidence of each finding was not significantly different between the two groups. Electromyography revealed the mean action potential during phonation of the sound “ah” to be 825 μV. Effective elevation of the soft palate was correlated with neither the histology nor the action potential of the LVP muscle.Therefore velopharyngeal insufficiency persisting after palatoplasty is considered not to be due to pathological changes in the LVP muscle.

To clarify the incidence of middle ear disease in patients with congenital velopharyngeal insufficiency (CVPI), we observed the shape of the velopharynx by a videofluorography and the movement of the lateral pharyngeal wall and soft palate with a flexible fxberscope. The findings of otoscopy, audiometry, and tympanometry were also recorded.Otitis media with effusion was the most common findings. The shape of the velopharynx had no relation to the incidence of middle ear disease. On the other hand, middle ear diseases were uncommon in CVPI patients with a good mobility of the lateral pharyngeal wall and soft palate. It was thought that the mobility of the velopharyngeal muscles, such as a levator veli palatini, might have some effect on conditions in the middle ear.

Detailed information about the tissue components of the soft palate is needed to construct biomechanical models that are functionally useful. Soft palates were removed from 10 adult cadavers, four males and six females. One-half of each palate was further divided into 10 blocks of equal anterior-to-posterior thickness. The face of each block was sectioned and stained using three different stains, thus providing a sample of 300 histologic slides. Each slide was carefully examined and major anatomic characteristics were noted and recorded. The results indicate that a typical adult soft palate consists of several major tissue layers including: (1) the oral aspect, which is glandular with a zone of adipose tissue located somewhat laterally; (2) the two middle layers are muscular with the more inferior layer consisting mainly of transverse levator veli palatini fibers and the overlying longitudinal layer of musculus uvulae fibers; (3) a superoanterior layer consisting of the tensor veli palatini tendon; and (4) a posteroinferior layer consisting of a mixture of tissue that is primarily glandular. The oral mucosa consists of stratified squamous epithelium with a basement membrane that is reinforced with a dense meshwork of elastic fibers. The nasal mucosa consists of pseudostratified ciliated columnar epithelium anteriorly and stratified squamous epithelium posteroinferiorly. The functional implications of these findings are discussed.

The rate of cleft palate has been reported to be as high as 6.8 per 10,000 live births,1,2 which makes cleft palate the second most common congenital disability in the world. Although corrective surgery has been well described, 15 to 25 percent of cleft palate repairs still require an additional surgical procedure to correct persistent velopharyngeal insufficiency.3,4 Although the variability in both surgical technique and the type of repair may help to explain inconsistent rates of success,5 previous studies have shown that intrinsic differences in cleft palate muscles before surgical intervention could potentially play a significant role in determining surgical outcomes. Cohen et al. observed disorganization in fiber orientation in levator veli palatini muscle of cleft palates.6 Schendel et al. found that isolated human cleft palate muscle contained a mixture of type I and type II fibers; however, they did not compare their results to normal palatal musculature.7 Lindman et al. compared levator veli palatini muscle obtained from cleft palate infants to those obtained from levator veli palatini muscle of normal adults. They observed a larger variation in fiber size, with an overall smaller mean fiber diameter, an increase in the proportion of type II fibers, and an increase in the amount of fast myosin heavy chain composition in the levator veli palatini muscles from infant cleft palates compared with those of normal adults. In the congenital cleft palate model, Weinzweig et al. observed degeneration of myofibrils and Z-bands.8 We hypothesize that intrinsic differences in the levator veli palatini muscle alter the functional state of the muscles and that those differences may play a more crucial role in the differential outcomes following surgery than the surgical procedure itself. Skeletal muscles with predominately fast (type II) fibers are more fatigable and more prone to contraction-induced injury compared with slow (type I) fibers.9,10 Therefore, the increase in fast fibers observed in the cleft muscle may lead to increased fatigability and injury to the levator veli palatini during speech and contribute to the conditions of persistent velopharyngeal inadequacy observed in a portion of cleft palate patients following surgical intervention. Using electromyography to monitor muscle activity, Tachimura et al. observed a decline in muscle activity in the levator veli palatini muscles of repaired cleft palate subjects with velopharyngeal inadequacy compared with normal speakers. They concluded that the subjects with velopharyngeal inadequacy were displaying increased levator veli palatini muscle fatigue during speech compared with subjects who had normal palates.11 However, other explanations, such as the subjects’ willingness to perform the task, may have influenced measures of muscle fatigue. Therefore, we used single permeabilized fibers to study the intrinsic properties of the muscle without extrinsic neuronal and hormonal influences. The congenital cleft goat model has been well characterized by Weinzweig et al.12 According to the authors, the Nicotiana glauca slurry diminishes the movement of the fetal tongue, with prolonged maintenance of the tongue between the palatal shelves during the period of shelf closure. Disruption of palatal shelf closure is believed to be the mechanical mechanism responsible for the resultant palatal clefting. The authors have not observed any direct teratogenic effect of the anabasine on the maxillary musculoskeletal region. The effect of the anabasine on musculoskeletal motion is transient and resolves shortly after administration of the teratogen is completed. Complete clefting of the secondary palate occurs in 97 percent of the fetuses. In all cases, the cleft extended from the posterior aspect of the alveolar ridge to the uvula; the majority of these clefts were bilateral, with complete detachment of the vomer. Morphologically, these clefts were similar to human clefts.12 The purpose of this study was to use the single permeabilized muscle fiber technique to study the intrinsic properties of muscle, such as force, power, and fatigability, specifically, of levator veli palatini muscles obtained from congenitally cleft palates and normal palates of Spanish goats.