Laryngeal resistance in individuals with marginal velopharyngeal closure

OBJETIVO: Verificar se pacientes com disfunção velofaríngea marginal modificam a resistência laríngea como uma estratégia para alcançar o fechamento velofaríngeo completo durante a fala. MÉTODOS: Foram avaliados 19 pacientes com fissura de palato operada, de ambos os sexos com idade entre 12 e 47 anos, com fechamento velofaríngeo marginal e 18 indivíduos sem fissura (grupo controle), de ambos os sexos, com idade entre 14 e 35 anos. A resistência laríngea (R), pressão aérea intra-oral (Po) e fluxo oro-nasal (Vº) foram obtidos por meio de avaliação aerodinâmica utilizando-se o sistema PERCI-SARS durante a produção da sílaba /pa/, com e sem a oclusão das narinas. RESULTADOS: Os valores médios de resistência laríngea (R), pressão aérea intra-oral (Po) e fluxo oro-nasal (Vº), no grupo com fechamento velofaríngeo marginal, foram de, respectivamente, 34,8±10,8 cmH2O/L/seg, 4,8±1,4 cmH2O, 144,8±34,0 mL/s, sem a oclusão das narinas e de 34,0±14,3 cmH2O/L/seg, 4,8±1,1 cmH2O, 150,9±38,7 mL/s com a oclusão das narinas. No grupo controle, os valores médios foram 39,2±13,4 cmH2O/L/seg, 4,8±0,8 cmH2O, 133,9±50,2 mL/s, respectivamente para as mesmas variáveis. Não houve diferença estatisticamente significante (p<0,05) entre os valores médios de resistência laríngea (R), pressão aérea intra-oral (Po) e fluxo oro-nasal (Vº) dos grupos estudados. CONCLUSÃO: Esses resultados mostraram que os pacientes com fechamento velofaríngeo marginal estudados não modificaram a resistência laríngea.PURPOSE: To verify whether patients with marginal velopharyngeal dysfunction modify the laryngeal resistance as a strategy to achieve complete velopharyngeal closure during speech. METHODS: Nineteen patients of both genders with repaired cleft palate with marginal velopharyngeal closure and ages varying from 12 to 47 years, and 18 patients of both genders without cleft palate (control group), with ages between 14 and 35 years were assessed. Laryngeal resistance (R), intraoral air pressure (Po) and the oronasal airflow (Vº) were obtained through an aerodynamics evaluation using the PERCI-SARS system during the production of the syllable /pa/, with and without nasal occlusion. RESULTS: Mean values of laryngeal resistance (R), intraoral air pressure (Po) and oronasal airflow (Vº), for the group with marginal velopharyngeal dysfunction, were, respectively, 34.8±10.8 cmH2O/L/sec, 4.8±1.4 cmH2O, 144.8±34.0 mL/s without nasal occlusion, and 34.0±14.3 cmH2O/L/sec, 4.8±1.1 cmH2O, 150.9±38.7 mL/s with nasal occlusion. In the control group, the mean values were 39.2±13.4 cmH2O/L/sec, 4.8±0.8 cmH2O, 133.9±50.2 mL/s, respectively, for the same variables. There was no statistically significant difference (p<0.05) between the groups regarding mean values of laryngeal resistance (R), intraoral air pressure (Po) and oronasal airflow (Vº). CONCLUSION: These results showed that the patients with marginal velopharyngeal closure studied did not modify laryngeal resistance.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES

Impact of interjudge agreement on perceptual judgment of hypernasality

Objective: To investigate the effect of perceptual interjudge agreement of hypernasality on velopharyngeal (VP) closure prediction. Methods: Two logistic regression models were developed and compared in order to verify the effect of interjudge agreement of perceptual hypernasality evaluating on models results. The models were built aiming to verify the possibility of predicting the VP closure by using the following characteristics: rating of VP closure (adequate, borderline, inadequate), determined by the pressure-flow technique, degree of hypernasality (absent, mild, moderate, severe), and the presence/absence of nasal air emission and nasal rustle determined perceptually by three speech pathologists. In the first model 100 speech samples with a moderate agreement rate of hypernasality (kappa coefficient) were used. In the second model 43 speech samples with a perfect agreement among judges were included. The Qui-square test was used to compare the models (p&#8804;5%). Results: In the first model, 65% (65/100) of the samples were rated in the correct VP closure category, with 93% (42/45) adequate and 35% (23/35) inadequate. However, the borderline VP closure was not predicted. The second model rated 72% (31/43) in the correct category, with 95.5% (21/22) adequate VP closure, 45.5% (5/11) in the borderline VP closure and 50% (5/10) inadequate. The data analysis showed that, although there was no significant difference (p=0.526) between the two models, the second one showed a higher proportion of 7% accuracy than the first model, and also it has predicted the borderline VP closure. Conclusion: These results showed the importance of high index of interjudge agreement when using subjective parameters of speech evaluation, especially when compared to an instrumental evaluation

Effect of intravelar veloplasty on nasality in patients with velopharyngeal insufficiency

OBJETIVO: verificar o efeito da palatoplastia secundária realizada com veloplastia intravelar sobre a nasalidade e nasalância dos pacientes com fissura de palato reparada e insuficiência velofaríngea (IVF) e comparar os resultados entre estes pacientes, de acordo com o grau de fechamento velofaríngeo aferido na nasofaringoscopia. MÉTODO: estudo prospectivo com 40 pacientes de ambos os sexos, com idades entre 4 e 48 anos, com fissura de palato reparada e IVF residual, avaliado 3 dias antes e 8 meses após a palatoplastia, em média, divididos em dois grupos: um com 25 pacientes com falhas pequenas (grupo I) e outro com 15 pacientes com falhas médias a grandes (grupo II) no fechamento velofaríngeo. A hipernasalidade foi avaliada perceptivamente e nasalância foi avaliada por meio da nasometria. Diferenças entre grupos e etapas foram consideradas significativas ao nível de 5%. O estudo foi aprovado pelo Comitê de Ética para Pesquisa com Seres Humanos da Instituição. RESULTADOS: após a cirurgia, verificou-se redução da hipernasalidade em 84% dos pacientes do grupo I e em 73% dos pacientes do grupo II. Redução da nasalância foi observada em 52% dos casos do grupo I e em 43% dos pacientes do grupo II. CONCLUSÃO: a palatoplastia secundária com veloplastia intravelar levou à melhora da nasalidade na maioria dos pacientes analisados. Os resultados também demonstraram que a cirurgia foi mais efetiva nos pacientes que apresentavam falhas pequenas no fechamento velofaríngeo.PURPOSE: to check the effect of secondary palatoplasty performed with intravelar veloplasty on the nasality and nasalance of patients with repaired cleft palate and velopharyngeal insufficiency (VPI) and compare the outcome among these patients, according to the degree of velopharyngeal closure as analyzed by nasopharyngoscopy. METHOD: prospective study with 40 patients of both genders, aged from 4 to 48 years, with repaired cleft palate and residual VPI, evaluated for 3 days before and 8 months after palatoplasty, on average, divided into two groups: one with 25 patients with minor defect (group I) and the other with 15 patients with medium to large defect (group II) in velopharyngeal closure. Hypernasality was evaluated perceptually and nasalance was assessed by nasometry. Differences between groups and stages were considered to be significant at the 5% level. The local Ethics Committee for Human Research approved the study. RESULTS: after surgery, we observed a reduction of hypernasality in 84% of the patients from group I, and in 73% of the patients from group II. Reduction of nasalance scores were observed in 52% of the group I cases and in 43% of the group II. CONCLUSION: secondary palatoplasty performed with intravelar veloplasty led to improvement in nasality in most of the analyzed patients. The results further demonstrated that surgery was more effective in patients with minor defects in velopharyngeal closure

Speech, hearing and swallowing in Richieri-Costa Pereira syndrome clinical report

Background: Richieri-Costa and Pereira (1992) described a autosomal recessive condition involving acrofacial dysostosis, often associated with Robin sequence. Phenotypic findings include facial, skeletal, genetic, laryngeal and auditory anomalies, with no specific reports regarding hearing, speech or swallowing. Purpose: To describe speech, hearing and swallowing in a patient with Richieri-Costa Pereira syndrome (RCPS). Clinical report: 8-year-old boy with cleft palate and mandible, supported by the institution since 2 months, requiring tracheotomy and gastrostomy. Palatoplasty was performed at 2 years. At age 4, mandibular osteogenic distraction was performed and tracheotomy removed. Epiglottis agenesis was confirmed at 6 years. Gastrostomy was removed when he was 7 years old and is currently with exclusive oral intake. Speech was assessed since age 2, with articulatory mistakes due to anatomical limitations and later dysphonia was also observed. He underwent some periods of speech therapy and in the last assessment no impairment of speech intelligibility was observed, despite the presence of nasal rustle in some phonemes. The first hearing evaluation (tonal audiometry and immitance measures) was performed when the patient was 5 years old, and repeated one year later with similar results: mild conductive hearing loss in the left ear. Two years later, hearing evaluation revealed normal hearing with a type A tympanometric curve bilaterally. Conclusion: Speech and hearing follow-ups showed initial impairment in speech intelligibility and hearing sensitivity, which improved with speech therapy, surgical reconstructive procedures and structural growing. Swallowing was impaired due to larynx malformations, but a compensatory mechanism was developed for airway protection

Speech resonance after septoplasty in a patient with bilateral cleft lip and palate

Purpose: The nasal airway is an important regulator of the pressures generated in speech when velopharyngeal function is altered. Patients with cleft palate often have nasal obstruction and increased nasal resistance, which can compensate a possible velopharyngeal dysfunction (VPD) and mask hypernasality. Clinical report: A 16 yearold patient, male, underwent nasometric and rhinomanometric assessment before and one year after septoplasty and bilateral inferior turbinectomy surgery. Nasometry was used to evaluate the nasalance scores (acoustic correlate of nasality) during the reading of a set of 5 sentences containing predominantly nasal sounds (nasal text) and a set containing exclusively oral sounds (oral text). Rhinomanometry permits the determination of the minimum nasal cross-sectional area (CSA) by the simultaneous measurement of the differential transnasal pressure and nasal air flow during resting breathing. Before surgery, the nasalance values were 40% and 26% in nasal and oral text, respectively, indicating hyponasality. Rhinomanometry showed that the values obtained for nasal area were 0.571cm2 and 0.094cm2 in the right and left sides respectively indicating a reduced nasal CSA of the left side. After surgery, there was an increase in nasalance to 55% in the nasal text and to 40% in the oral text, indicating hypernasality. Rhinomanometry indicated that nasal area were 0.237cm2 and 0.287cm2, in the right and left sides respectively. Conclusion: The surgery resulted in an increase of the nasal area and improving nasal patency. However, hypernasality was demonstrated. These results confirm what has already been reported by Warren et al (1992) in stating that in the presence of VPD "a good nose for breathing is often a bad nose for speech"

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: Institutional outcomes assessment and the role of the Laboratory of Physiology

The Laboratory of Physiology provides support for the diagnosis of functional disorders associated with cleft lip and palate and also conducts studies to assess, objectively, the institutional outcomes, as recommended by the World Health Organization. The Laboratory is conceptually divided into three units, namely the Unit for Upper Airway Studies, Unit for Stomatognathic System Studies and the Unit for Sleep Studies, which aims at analyzing the impact of different surgical and dental procedures on the upper airways, stomatognathic system and the quality of sleep of individuals with cleft lip and palate. This paper describes the main goals of the Laboratory in the assessment of procedures which constitute the basis of the rehabilitation of cleft lip and palate, i.e., Plastic Surgery, Orthodontics and Maxillofacial Surgery and Speech Pathology

Nasopharyngeal dimensions and respiratory complaints of individuals with velopharyngeal insufficiency submitted to pharyngeal flap surgery

Objetivos: Investigar o efeito da cirurgia de retalho faríngeo (CRF) sobre as dimensões internas nasais de pacientes com insuficiência velofaríngea (IVF), a curto e longo prazo, e, correlacionar esses achados com o aparecimento de queixas respiratórias após a cirurgia. Modelo/Pacientes: Estudo prospectivo em 58 pacientes com fissura palatina operada e IVF, avaliados 2 dias antes (PRE) e, 5 (POS1) e 14 meses (POS2) após a cirurgia, em média, divididos em 2 grupos: um queixas respiratórias (CQ) em POS2 e outro, sem queixas (SQ). Diferenças entre grupos e etapas foram consideradas significantes ao nível de 5%. Local: Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, USP, Bauru. Intervenções: CRF de pedículo superior. Variáveis: Queixas (respiração oral, ronco e dificuldade respiratória durante o sono) e área de secção transversa mínima nasal (AN) e nasofaríngea (ANF) avaliada por rinomanometria. Resultados: Queixas respiratórias foram observadas em 55% dos pacientes em POS1 e 36% em POS2. Observou-se na rinomanometria posterior: 1) redução significativa da AN média em POS1 e POS2, relativamente ao PRE, em ambos os grupos. Não foram observadas variações significativas na rinomanometria anterior; 2) AN média do grupo CQ significantemente menor que a do grupo SQ em POS2; 3) redução da AN mais pronunciada no grupo CQ. Medidas da ANF confirmaram esses achados. Conclusões: A curto prazo, a CRF levou à redução significativa da dimensão nasofaríngea em proporção expressiva de pacientes, parte dos quais passaram a apresentar queixas respiratórias; a longo prazo, esse efeito atenuou-se sem, contudo, desaparecer por completo.Objectives: To investigate the short- and long-term effect of pharyngeal flap surgery (PFS) on the internal nasal dimensions of patients with velopharyngeal insufficiency (VPI) and to correlate the findings with the onset of respiratory complaints (RC) after surgery. Model/Patients: Prospective study in 58 patients with repaired cleft palate and VPI, evaluated, on average, 2 days before (PRE), 5 (POST1) and 14 months (POST2) after surgery, divided into 2 groups: one consisting of patients with RC (WRC) at POST2 and the other without RC (WtRC). Differences between groups and stages were considered to be significant at the 5% level. Site: Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, Brazil. Interventions: Superiorly based PFS. Variables: RC (oral respiration, snoring and respiratory difficulty during sleep), and minimal nasal (NA) and nasopharyngeal (NPA) cross-sectional area assessed by rhinomanometry. Results: RC were observed in 55% of patients at POST1 and 36% at POST2. Posterior rhinomanometry showed: 1) a significant reduction of mean NA at POST1 and POST2 compared to PRE, in both groups. No significant changes were observed by anterior rhinomanometry; 2) significantly lower mean NA in the WC group compared to the WtC group at POST2; 3) more pronounced reduction in NA values in the WC group. NPA measurements confirmed these findings. Conclusions: In the short term, PFS led to a significant reduction in the nasopharyngeal dimensions in a significant proportion of patients, part of whom started to present RC; in the long term, this effect was attenuated but did not fully disappear