| Discussion: |
Discussion: Nasal escape, also know as nasopharygeal reflux or velopharyngeal incompetence, is a condition that can be seen in the first few days of life. Patients with this disorder will tend to nasally aspirate with swallowing. This is due to either VP sphincter anatomic insufficiencies as seen in cleft lip/palate, or neuromuscular incompetence seen in upper or lower motor neuron disease. It may be seen in a normal term infant but most often is seen in patients with disorders of swallowing. When seen in older children, the voice tends to be hypernasal secondary to velopharygeal incompetence.
Prior to performing invasive and expensive tests for nasal escape, clinical examination by a physician may be of great help. Patients with nasal escape have a very difficult time pronouncing high-pressure consonant sounds. By simply asking the patient to count from 60-80 or having them repeat words such as judge, church, push, puppy, or chocolate chip cookie, a physician will be able to hear the hypernasality in their speech and decide whether to proceed with further testing.
Symptoms: Common symptoms seen with nasal escape include hypernasality of speech, nasal emissions characterized by air escape from the nose during speech, and decreased intelligibility of speech. The severity of these symptoms depend on the amount of velopharyngeal incompetence present in the patient. With infants, nasal regurgitation in the form of food and liquid is often a presenting sign of nasal escape. However in older children and adults, recurrent sinus infections may be a sign of nasal escape.
Imaging: As described earlier, if the physician suspects nasal escape based on the clinical test, more invasive tests will be ordered. Nasopharyngeal video endoscopy is the gold standard in diagnosing nasal escape. With this technique, air bubbles will be seen in abnormal locations that would normally be prevented by a tight velopharyngeal closure. Video fluorography is another test that may be used in adjunct with the endoscopy. This technique, however, is rarely used today.
Treatment: Treatment for nasal escape is often a joint effort between an otolaryngologist, prosthodontist, and speech pathologist. In mild cases of nasal escape, speech therapy is usually the only therapy that is needed to correct the characteristic hypernasal speech. In more moderate and severe forms of nasal escape, a provisional palatal lift prosthesis may be warranted. Speech therapy is then used to tell whether the prosthesis is of help to the patient. If it is, a permanent prosthesis will be placed in the patient. If the hypernasal speech is not corrected, prosthetic lift adjustments may be used until satisfactory results are seen, which is then followed by placing a permanent prosthetic.