Voz hipernasal y regurgitación nasal aguda: reporte de un caso clínico y revisión de la literatura / Hypernasal speech and acute nasal regurgitation: a case report and a review of the literature

RESUMEN La voz hipernasal y la regurgitación nasal son síntomas de disfunción velofaríngea. Ésta puede tener múltiples causas: anatómicas, neurológicas o funcionales. Se describe el caso de una paciente de sexo femenino, de 13 años, que se presenta con voz hipernasal y regurgitación nasal aguda. Al examen físico se evidencia inmovilidad del velo del paladar derecho sin otros hallazgos neurológicos. El estudio con resonancia nuclear magnética de cerebro y punción lumbar fueron normales. Se diagnosticó una incompetencia velofaríngea aguda transitoria, de probable etiología viral. La paciente evolucionó de forma favorable con mejoría clínica progresiva. La incompetencia velofaríngea a causa de una paresia o parálisis del nervio vago y/o nervio glosofaríngeo es una causa poco frecuente de disfunción velofaríngea.

ABSTRACT Hypernasal speech and nasal regurgitation are symptoms of velopharyngeal dysfunction. This may have multiple causes, including velopharyngeal incompetence due to paresis or paralysis of the vagus nerve and/or glossopharyngeal nerve. We describe the case of a 13 year-old female patient, with hypernasal speech and acute nasal regurgitation, with a physical examination showing immobility of the right palate with no other neurological findings. Magnetic resonance imaging of the brain and lumbar puncture was normal. Transient acute velopharyngeal incompetence was diagnosed, probably of viral etiology. The patient evolved favorably with progressive clinical improvement. Velopharyngeal incompetence due to paresis or paralysis of the vagus and/or glossopharyngeal nerves is a rare cause of velopharyngeal dysfunction.

A secção cirúrgica do retalho faríngeo pode comprometer a ressonância de fala de indivíduos com fissura labiopalatina? / Could the speech resonance of individuals with cleft lip and palate be affected by complete section of pharyngeal flap?

RESUMO Objetivo Investigar o efeito da cirurgia para secção completa do retalho faríngeo sobre a hipernasalidade de fala. Métodos Foram avaliados 26 indivíduos com fissura de palato±lábio reparada, submetidos à cirurgia de retalho faríngeo para tratamento da insuficiência velofaríngea e que, em função do aparecimento de queixas respiratórias, necessitaram nova cirurgia para secção do retalho. A hipernasalidade foi determinada por meio das avaliações perceptiva e nasométrica da fala 18 meses, em média, após a secção do retalho. Na avaliação perceptiva, a hipernasalidade foi classificada como: 1 = ausente ou 2 = presente e, na nasometria, foi determinada por meio da medida da nasalância durante a leitura de sentenças contendo, exclusivamente, sons orais, considerando-se, como limite de normalidade, o escore de 27% (p ≤ 0,05). Resultados A avaliação perceptiva mostrou que, antes da secção do retalho, oito (31%) indivíduos apresentavam ressonância equilibrada e 18 (69%) apresentavam hipernasalidade. Após a cirurgia, um (4%) paciente permaneceu com ressonância equilibrada e 25 (96%) apresentaram hipernasalidade. De acordo com a nasometria, antes da cirurgia, 13 (57%) indivíduos apresentaram valores de nasalância inferiores a 27%, indicando ausência de hipernasalidade (média = 15±8%) e dez (43%) pacientes apresentaram valores indicativos de hipernasalidade (média = 41±7%). Após a cirurgia, quatro (17%) pacientes permaneceram com valores indicativos de ausência de hipernasalidade (média = 19±10%) e 19 (83%) apresentaram valores de nasalância indicativos de hipernasalidade (média = 45±7%). Diferença entre as avaliações perceptiva e nasométrica da fala não foi observada. Conclusão A cirurgia para secção completa do retalho faríngeo causou deterioração da ressonância de fala, levando ao reaparecimento da hipernasalidade, na maioria dos pacientes estudados.

ABSTRACT Purpose To investigate the effect of complete section of pharyngeal flap on speech hypernasality. Methods The study analyzed twenty-six individuals with repaired cleft palate±lip underwent pharyngeal flap surgery to treat velopharyngeal insufficiency and posteriorly underwent complete section of the flap due to the occurrence of respiratory symptoms. Hypernasality was determined by auditory-perceptual speech assessments and nasometry at 18 months after surgery, on average. Hypernasality was perceptually classified as: 1 = absent or 2 = present and determined by nasalance measurement during reading of sentences containing exclusively oral sounds, considering a cutoff of 27% (p ≤ 0.05). Results Perceptual assessment before section of the flap revealed that eight (31%) individuals showed normal resonance, while 18 (69%) presented hypernasality. After surgery, one (4%) subject remained with normal resonance and 25 (96%) presented hypernasality. According to nasometry, before surgery, 13 (57%) individuals presented nasalance scores lower than 27%, indicative of absence of hypernasality (mean = 15±8%) and ten (43%) presented nasalance scores indicative of hypernasality (mean = 41±7%). After surgery, four (17%) patients remained with scores indicative of absence of hypernasality (mean = 19±10%) and for 19 (83%) the nasalance scores were indicative of hypernasality (mean = 45±7%). There was no difference between perceptual and nasometric speech evaluations. Conclusion Surgery for complete section of pharyngeal flap caused deterioration of speech resonance, leading to the reappearance of hypernasality in most patients in this study.

Puntos de aproximación de pilares en amigdalectomía pediátrica / Pillars´ approach suture points in pediatric tonsillectomy / Pontos de abordagem dos pilares na tonsilectomia pediátrica

INTRODUCCIÓN: A lo largo de los años, varias técnicas de amigdalectomía han sido desarrolladas y modificadas con el fin de reducir su morbimortalidad. Diversos estudios han comparado estas técnicas, no habiendo consenso en cuanto al método con mejores resultados. El objetivo de nuestro trabajo es describir la técnica personal de amigdalectomía y analizar la frecuencia de sangrado y el desarrollo de insuficiencia velopalatina post-quirúrgica en la cirugía con aproximación de pilares. MATERIAL Y MÉTODO: Estudio descriptivo, prospectivo. Se incluyeron pacientes operados de amigdalectomía con amigdalotomo de Daniels, de 3 a 15 años, en el período comprendido desde febrero de 2017 a febrero de 2018, en el sistema de salud Malvinas Argentinas. Se interrogó por sintomatología de sangrado e insuficiencia velopalatina mediante una encuesta de elaboración propia a la semana y al mes post-quirúrgico...

INTRODUCTION: Throughout the years, several tonsillectomy techniques have been developed and modified in order to reduce their morbidity and mortality. Several studies have compared these techniques, and there is no consensus regarding the method with better results. The objective of our study is to describe the personal technique of tonsillectomy and analyze the frequency of bleeding and development of post-surgical velopalatine insufficiency in surgery with abutment approach. MATERIAL AND METHOD: Descriptive, prospective study. We included patients undergoing tonsillectomy with Daniels, from between 3 and 15 years old, from February 2017 to February 2018, in the Malvinas Argentinas hospital. They were interrogated for symptomatology of bleeding and velopalatine insufficiency by through of a self-developed questionnaire one week and one month after surgery…

INTRODUÇÃO: Ao longo dos anos, várias técnicas de amigdalectomia foram desenvolvidas e modificadas para reduzir sua morbidade e mortalidade. Diversos estudos compararam essas técnicas, não havendo consenso em relação ao método com melhores resultados. O objetivo do nosso trabalho é descrever a técnica pessoal de amigdalectomia e analisar a frequência de sangramento e o desenvolvimento de insuficiência velopalatina pós-cirúrgica em cirurgia com abordagem de abutment. MATERIAL E MÉTODO: Estudo descritivo, prospectivo. Foram incluídos pacientes submetidos à tonsilotomia com tonsilectomia de Daniels, de 3 a 15 anos, no período de fevereiro de 2017 a fevereiro de 2018, no sistema de saúde Malvinas Argentinas. Foi interrogado por sintomatologia de hemorragia e insuficiência velopalatine por meio de um questionário autodevelado durante a semana e o mês pós-cirúrgico...

Intensive treatment of speech disorders in robin sequence: a case report

ABSTRACT Purpose To describe the speech of a patient with Pierre Robin Sequence (PRS) and severe speech disorders before and after participating in an Intensive Speech Therapy Program (ISTP). Methods The ISTP consisted of two daily sessions of therapy over a 36-week period, resulting in a total of 360 therapy sessions. The sessions included the phases of establishment, generalization, and maintenance. A combination of strategies, such as modified contrast therapy and speech sound perception training, were used to elicit adequate place of articulation. The ISTP addressed correction of place of production of oral consonants and maximization of movement of the pharyngeal walls with a speech bulb reduction program. Therapy targets were addressed at the phonetic level with a gradual increase in the complexity of the productions hierarchically (e.g., syllables, words, phrases, conversation) while simultaneously addressing the velopharyngeal hypodynamism with speech bulb reductions. Results Re-evaluation after the ISTP revealed normal speech resonance and articulation with the speech bulb. Nasoendoscopic assessment indicated consistent velopharyngeal closure for all oral sounds with the speech bulb in place. Conclusion Intensive speech therapy, combined with the use of the speech bulb, yielded positive outcomes in the rehabilitation of a clinical case with severe speech disorders associated with velopharyngeal dysfunction in Pierre Robin Sequence.

Speech therapy for compensatory articulations and velopharyngeal function: a case report

The objective of this study was to describe the process of intensive speech therapy for a 6-year-old child using compensatory articulations while presenting with velopharyngeal insufficiency (VPI) and a history of cleft lip and palate. The correction of VPI was temporarily done with a pharyngeal obturator since the child presented with very little movement of the pharyngeal walls during speech, compromising the outcome of a possible pharyngeal flap procedure (pharyngoplasty). The program of intensive speech therapy involved 3 phases, each for duration of 2 weeks incorporating 2 daily sessions of 50 minutes of therapy. A total of 60 sessions of intervention were done with the initial goal of eliminating the use of compensatory articulations. Evaluation before the program indicated the use of co-productions (coarticulations) of voiceless plosive and fricative sounds with glottal stops (simultaneous production of 2 places of productions), along with weak intraoral pressure and hypernasality, all compromising speech intelligibility. To address place of articulation, strategies to increase intraoral air pressure were used along with visual, auditory and tactile feedback, emphasizing the therapy target and the air pressure and airflow during plosive and fricative sound productions. After the first two phases of the program, oral place of articulation of the targets were achieved consistently. During the third phase, velopharyngeal closure during speech was systematically addressed using a bulb reduction program with the objective of achieving velopharyngeal closure during speech consistently. After the intensive speech therapy program involving the use of a pharyngeal obturator, we observed absence of hypernasality and compensatory articulation with improved speech intelligibility.

Comparação dos resultados da fala após as cirurgias de retalho faríngeo e veloplastia intravelar para correção da disfunção velofaríngea / Comparison of speech results following pharyngeal flap and intravelar veloplasty for correction of velopharyngeal dysfunction

OBJETIVO: Comparar a fala e o funcionamento velofaríngeo após as técnicas de retalho faríngeo e veloplastia intravelar para a correção da disfunção velofaríngea residual. MÉTODOS: Foi realizado um estudo retrospectivo com análise de 148 casos com fissura labiopalatina operada e submetidos à correção cirúrgica da disfunção velofaríngea, sendo 77 com retalho faríngeo (média de idade: 20,4 anos) e 71 com veloplastia intravelar (média de idade: 16,2 anos). Foram avaliadas a ressonância da fala, a presença de articulações compensatórias, a emissão de ar nasal e a extensão da falha no fechamento velofaríngeo antes e após as duas técnicas. RESULTADOS: Dos 77 casos submetidos ao retalho faríngeo 64 (83 por cento) apresentaram melhora na ressonância, enquanto que dos 71 casos com veloplastia intravelar 48 (68 por cento) revelaram melhora, havendo diferença significativa entre os grupos. No grupo com retalho faríngeo, seis (8 por cento) apresentaram melhora na articulação compensatória e dois (3 por cento) no grupo veloplastia intravelar, enquanto a emissão de ar nasal melhorou em 17 (22 por cento) casos com retalho faríngeo e em 18 (26 por cento) com veloplastia intravelar. Não houve diferença entre os grupos quanto à articulação compensatória e emissão de ar nasal. A falha no fechamento velofaríngeo reduziu em 75 (96 por cento) casos com retalho faríngeo e 46 (66 por cento) com a veloplastia intravelar, havendo diferença entre os grupos. CONCLUSÃO: A técnica de retalho faríngeo mostrou-se mais efetiva na melhora da ressonância e no fechamento velofaríngeo quando comparada à veloplastia intravelar.

PURPOSE: To compare speech and velopharyngeal function after pharyngeal flap and intravelar veloplasty techniques for the correction of residual velopharyngeal dysfunction. METHODS: It was carried out a retrospective study analyzing 148 cases of cleft lip and palate operated and submitted to velopharyngeal dysfunction surgical correction, 77 with pharyngeal flap (mean age: 20.4 years) and 71 with intravelar veloplasty (mean age: 16.2 years). Speech resonance, presence of compensatory articulations, nasal air emission, and velopharyngeal gap size were assessed before and after the use of both techniques. RESULTS: Sixty four (83 percent) of the 77 cases submitted to pharyngeal flap presented resonance improvement, while 48 (68 percent) of the 71 cases with intravelar veloplasty improved, with significant difference between the groups. Six (8 percent) subjects with pharyngeal flap, and two (3 percent) with intravelar veloplasty showed improvement in compensatory articulations, while nasal air emission improved in 17 (22 percent) cases with pharyngeal flap, and 18 (26 percent) with intravelar veloplasty. No significant differences were found between the groups regarding compensatory articulations and nasal air emission. The velopharyngeal gap size reduced in 75 (96 percent) cases with pharyngeal flap, and 46 (66 percent) with intravelar veloplasty, with a significant difference between the groups. CONCLUSION: The pharyngeal flap technique was more effective in improving resonance and velopharyngeal closure, when compared to intravelar veloplasty.

Four novel prosthodontic methods for managing upper airway resistance syndrome: An investigative analysis revealing the efficacy of the new nasopharyngeal aperture guard appliance.

Statement of Problem: Obstructive sleep apnea is the most frequent cause for insomnia in the populace. Snoring is mulled over as the potential factor that can lead the sequel to obstructive sleep apnea. Although the etiology and deterrence measures for snoring are yet to be undoubtedly clarified by our scientific sorority, various means of surgical corrections have been affirmed and put into practice, with a substantial degree of success. Despite this, it is implicit that a noninvasive method of managing obstructive sleep apnea is more relevant for overcoming this condition. Purpose: This manuscript intends to establish how snoring can be controlled prosthodontically by different modalities of scientifically defensible approaches. The most effective among the modalities was affirmed as the investigative analyses of the treatment outcomes with each modality. Novel Methods: Four new methods of managing obstructive sleep apnea - uvula lift appliance, uvula and velopharynx lift appliance, nasopharyngeal aperture guard, and soft palate lift appliance were demonstrated through this article. Clinical Reports: The four new modalities stated and one conventional modality of mandibular advancement appliance for managing obstructive sleep apnea, a total of five types of appliance therapies, were described with case reports for each. Investigation: Five individuals undergoing the appliance therapy were chosen for each modality. The treatment outcome with each modality was examined by analysis of clinical predictors and also by means of standard investigation, with nasal and oral endoscopic analyses. Result: Among the five types of appliance therapies, the nasopharyngeal aperture guard provided the best treatment outcome in terms of clinical predictors and endoscopic analyses. Conclusion: Nasopharyngeal aperture guard, the novel method stated in this article is the better modality for managing obstructive sleep apnea, among the five different appliance therapies.

Nasoendoscopy of velopharynx before and during diagnostic therapy

Nasoendoscopy is an important tool for assessing velopharyngeal function. The purpose of this study was to analyze velar and pharyngeal wall movement and velopharyngeal gap during nasoendoscopic evaluation of the velopharynx before and during diagnostic therapy. Nasoendoscopic recordings of 10 children with operated cleft lip and palate were analyzed according to the International Working Group Guidelines. Ratings of movement of velum and pharyngeal walls, and size, location and shape of gaps were analyzed by 3 speech-language pathologists (SLPs). Imaging was obtained during repetitions of the syllable /pa/ during a single nasoendoscopic evaluation: (a) before diagnostic therapy, and (b) after the children were instructed to impound and increase intraoral air pressure (diagnostic therapy). Once the patients impounded and directed air pressure orally, the displacement of the velum, right, left and posterior pharyngeal walls increased 40, 70, 80, and 10%, respectively. Statistical significance for displacement was found only for right and left lateral pharyngeal walls. Reduction in gap size was observed for 30% of the patients and other 40% of the gaps disappeared. Changes in gap size were found to be statistically significant between the two conditions. In nasoendoscopic assessment, the full potential of velopharyngeal displacement may not be completely elicited when the patient is asked only to repeat a speech stimulus. Optimization of information can be done with the use of diagnostic therapy’s strategies to manipulate VP function. Assuring the participation of the SLP to conduct diagnostic therapy is essential for management of velopharyngeal dysfunction.

Evaluation of palatal prosthesis for the treatment of velopharyngeal dysfunction / Avaliação de pacientes portadores de disfunção velofaríngea tratados com prótese de palato

O trabalho avaliou a efetividade do tratamento da disfunção velofaríngea com prótese de palato. A amostra consistiu em 48 pacientes, com idades variando entre 8 e 74 anos (X = 31,47 16,03), sendo 42 com insuficiência velofaríngea devido à fissura palatina congênita operada ou não, 2 com insuficiência velofaríngea devido à ressecção total ou parcial do palato (casos que tiveram câncer) e 4 com incompetência velofaríngea devido à paralisia total ou parcial do palato mole. Os resultados do questionário mostraram que: (1) a maioria dos pacientes preferiu se alimentar usando a prótese (81,2 por cento); (2) a maioria relatou melhora da fala com a prótese (85,4 por cento); (3) a prótese ficou estável para a maioria dos pacientes, tanto na alimentação (75 por cento), quanto na fala (91,7 por cento); (4) a maior parte dos pacientes (79,2 por cento) sentiram-se confortável em usar a prótese; (5) a estética com a prótese foi satisfatória para a maioria dos pacientes (97,9 por cento); (6) a qualidade de vida da maioria dos pacientes (85,4 por cento), melhorou com o uso da prótese.

Videonasofaringoscopía para retroalimentación del habla en pacientes con paladar hendido / Videonasopharingoscopy for visual biofeedback during speech in cleft palate patients

Propósito: Estudiar el uso de la videonasofaringoscopía como un instrumento para la retro-alimentación visual durante el habla en pacientes con paladar hendido reparado quirúrgicamente y con insuficiencia velofaríngea residual. Material y Métodos: Diecisiete pacientes con paladar hendido fueron seleccionados al azar para el estudio. Todos los pacientes mostraron insuficiencia velofaríngea (IVF), articulación compensatoria (AC) y movimiento negativo de las paredes faríngeas laterales (MNPFL) durante el habla. Nueve pacientes recibieron terapia del lenguaje para corregir la AC. Ocho pacientes recibieron terapia del lenguaje y videonasofaringoscopía como un instrumento para retro-alimentación visual del esfinter velofaríngeo. Resultados: Después de 12 semanas, el MNPFL se modificó en los pacientes que recibieron terapia del lenguaje y retro-alimentación visual. En contraste, el MNPFL se encontró presente en ocho de nueve pacientes que recibieron terapia del lenguaje. Posteriormente, estos pacientes también recibieron retro-alimentación visual y el MNPFL se corrigió en todos los caos. Después de seis meses, todo los diecisiete pacientes habían corregido al AC durante el habla aislada. A todos los pacientes se les practicó un colgajo faríngeo hecho a la medida. La IVF se corrigió en forma completa en quince casos. En los dos casos restantes en los que la IVF continuó presente en forma postoperatoria, el tamaño del defecto esfinter velofaríngeo se redujo significativamante. En estos dos pacientes, la retro-alimentación visual fue posterior a la cirugía para mejorar el movimiento de las paredes faríngeas laterales (PFL) hacia el borde del colgajo. Después de dieciocho meses desde el inicio de la terapia de lenguaje, todos los pacientes presentaban resonancia nasal y articulación normal durante el habla conectada. Conclusiones: La videonasofaringoscopía es una herramienta útil para mejorar la IVF en pacientes con MNPFL

Prótese de elevaçäo palatina: recurso protético na incompetência velofaríngica / Palatal lift appliance: a prosthetic approach to velopharyngeal incompetence

Os autores tecem consideraçöes relativas aos quadros de inadequaçäo do esfíncter velofaríngico, diferenciando as condiçöes de insuficiência e de incompetência velofaríngica. Abordam os aspectos de diagnóstico e planejamento terapêutico na incompetência velofaríngica e situam a prótese de elevaçäo palatina como possível modalidade terapêutica. Apresentam os aspectos técnicos relativos à confecçäo, instalaçäo, readaptaçäo e ao controle da prótese. Concluem a respeito de sua eficácia frente à incompetência velofaríngica, ressaltando suas vantagens, como a possibilidade de readaptaçöes sucessivas e a reversibilidade

O esfíncter velofaríngeo / Velopharyngeal sphincter

Descreve os aspectos morfológicos e funcionais do esfíncter veloparíngeo, as causas responsáveis pelas alteraçöes da funçäo velofaríngea e sua sintomatologia. Mostraa importância do diagnóstico endoscópio, radiológico e aerodinâmico para uma adequada indicaçäo terapêutica

Funçäo velofaríngea: consideraçöes na avaliaçäo e no tratamento fonoaudiológico / Velopharyngeal function: speech valuation and therapy

O trabalho apresenta dados específicos da avaliaçäo da funçäo velofaríngea que devem ser considerados importantes para que se obtenha, além da definiçäo correta da conduta, um esclarecimento mais objetivo do prognóstico do quadro e do momento adequado para a realizaçäo de cada procedimento terapêutico no tratamento dos vários quadros de falha da funçäo velofaríngea. Apresenta, também, os pontos a serem considerados na fonoterapia e na cirurgia secundária de correçäo da funçäo velofaríngea

Avaliaçäo imediata da prótese obturadora faríngica na fala e voz de pacientes portadores de insuficiência velofaríngica / Imediate evaluation of \"speech\" prosthesis on the speech and voice of patients with velopharyngeal insufficience

Os autores realizam uma avaliçäo dos efeitos imediatos da prótese obturadora faríngica na fala e voz de 10 pacientes portadores de fissura palatina já submetidos à cirurgia plástica reparadora, mas que apresentavam insuficiência velofaríngica. A observaçäo dos dados permitiu concluir que a prótese obturadora faríngica eliminou a hipernasalidade e promoveu uma reduçäo quantitativa do escape de ar nasal durante o sopro e a fala, melhorando a qualidade da voz

Velopharyngeal incompetence: an easy prosthetic approach.

Various techniques are in use to correct palato pharyngeal defects. More important is its repair or closure of the defect and restoration of the function. Correction of such defect by means of prosthesis with speech bulb carries important place as surgical intervention can be avoided or delayed to the limit it is desired so. The method described here is simple and can be used as a part of transitary therapeutic treatment which can be replaced by permanent metallic appliance later on.

Avaliaçäo e tratamento da incompetência velofaríngea: tendências atuais no Japäo / Evaluation and treatment of velopharyngeal incompetence: present trends in Japan

The present article describes the approach developed at the Cleft Palate Clinic of Kyoto University Hospital, aiming at introducing assessment and treatment for velopharyngeal function currently in use in Japan. A multi-view approach with the main emphasis given to the fluorocideography and to the nasopharyngofiberscopy permits accurate analysis and evaluation of dynamic velopharyngeal gesture and facilitates the selection of adequated treatment. The article describes the surgical treatment, the speech therapy procedures, and presentes a case study reporting the therapeutic approach to the articulation disorders combined with sligth velopharyngeal incompetence