Spauwen, Paulus Hubertus Maria

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   University of GroningenHearing speech and language after surgery for velopharyngeal incompetenceSpauwen, Paulus Hubertus MariaIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:1985Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Spauwen, P. H. M. (1985). Hearing speech and language after surgery for velopharyngeal incompetence.s.n.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 21-06-2022SIJMMARY AND CONCLUSIONSCHAPTER 1: Commencing with a review of the literature it appears that noconsensus exists concerning the effects of a pharyngoplasty on the hearing.The divergent results are due to the variety of criteria employed for theselection of patients, methods and definitions of hearing pathology.The present study has been performed to answer the following questions;- Are there, from a theoretical point of view, valid arguments for supposingthat a relationship exists between a pharyngoplasty and the changes in theEustachian tube function?- What is the actual influence of a pharyngoplasty on the hearing and thespeech/language development?CHAPTER 2: The indication for performing a pharyngoplasty has beenformulated as the patient's inability to close the velopharyngeal apertureduring connected speech. This condition is called velopharyngeal incompe-tence and is based upon anatomical and functional defects leading to nasalresonance, nasal escape as well as delayed speech and language development.Two groups of children are at risk of developing velopharyngeal incompe-tence: children, who have undergone a palatoplasty and children with anintact, but congenital short or badly functioning soft palate. The diagnosticprocedures are discussed together with the compensatory mechanisms, ofwhich adenoidal hypertrophy and the increased contractions of thevelopharyngeal muscles are the most important.CHAPTER 3: Data from the literature focused on the hearing pathology inpatients with velopharyngeal incompetence lead to the conclusion that 50percent of these patients have hearing problems as opposed to five percent ofthe normal population. The commonest type of hearing pathology is bilateralserous otitis media accompanied by an average conductive hearing loss of 30dB. The influences of the basic pathology causing velopharyngeal incompe-tence and the type of any preceding treatment are discussed.CHAPTER 4: The immediate cause of serous otitis media is defectiveEustachian tube function. Children with velopharyngeal incompetence areparticularly at risk of developing serous otitis media. This can be due to theanatomical and functional defects in the Eustachian tube and its surroundingmuscles and also to reflux of the pharyngeal contents. The disturbed balancet25between the levator veli palatini muscle and the Eustachian tube cartilageappears to be the decisive factor for producing Eustachian tube dysfunction.CHAPTER 5: The general principles of the surgical treatment forvelopharyngeal incompetence are discussed and focused on the Groningenmodification of the inferiorly based pharyngoplasty. This operation allows aconsiderable reduction in the velopharyngeal aperture and a posterior retrac-tion of the soft palate.CHAPTER 6: The immediate effects of a pharyngoplasty on thevelopharyngeal structures may improve Eustachian tube function. Firstly,reduction in the oro-nasal leakage provides better protection of theEustachian tube orifices from velopharyngeal contents. Secondly, posteriorretraction of the soft palate may cause retropositioning of the levator sling,restoring an effective interplay between levator sling contraction and move-ments of the Eustachian tube cartilases.CHAPTER 7: To confirm the hypothetical relationship between a pharyngealflap and hearing, an investigation on 51 patients with velopharyngeal incom-petence was performed. Patient selection and methods employed are de-scribed. The occurrence of bilateral chronic serous otitis media is stressed asthe definite criterion for hearing pathology.CHAPTER 8: In the presentation of the investigation results, the relation-ships between the hearing and the speech/language development are de-scribed. Possible coherences with the fundamental pathology, the age, theperformance of an adenoidectomy and the logopaedic treatment are analyzed.CHAPTER 9: Data from our investigation are compared with the data fromthe literature and are discussed in accordance with the previously formulatedaims of the study, leading to the following CONCLUSIONS:THE HEARING- Approximately half of the patients with velopharyngeal incompetence,particularly if associated with a cleft palate, had bilateral chronic serousotitis media with average air-bone gaps of 33 dB as opposed to five percentof normal children.- Attacks of suppurative otitis media occurred in 35 percent of patients withvelopharyngeal incompetence as opposed to five percent of normal child-ren.126IIttrchian tube cartilagean tube dysfunction.3ical treatment ford on the Groningenis operation allows ard a posterior retrac-yngoplasty on thebe function. Firstly,protection of theSecondly, posteriorof the levator sling,ntraction and move-etween a pharyngeallopharyngeal incom-s employed are de-media is stressed asresults, the relation-evelopment are de-rology, the age, thertment are analyzed.C with the data from'eviously formulated)NS:geal incompetence,eral chronic serousosed to five percentent of patients withnt of normal child-Bilateral chronic serous otitis media occurred most frequently in childrenunder six years of age. The early school years showed a change in thepattern of the obstinate bilateral chronic serous otitis media, as is also seenin normal children.Bilateral chronic serous otitis media appeared to be related to insufficientarticulation. Routine expert examination of the hearing and the speech/language development at an early age appears to be justified.A 65 percent decrease in the bilateral chronic serous otitis media wasdemonstrated within three months of performing the pharyngoplasty, mostfrequently in children older than six years of age. This emphasizes thetendency for hearing improvement during the early school years.The most obvious explanation for the decreased incidence of bilateralchronic serous otitis after pharyngoplasty appears to be1) The retropositioning of the levator muscle sling, facilitating the liftingaction of this sling on the Eustachian tube cartilages as well as thedilation of the membranous wall by the dilator tubae muscle.2) The reduced oro-nasal eakage.The reduction in the adenoid growth at the nasopharyngeal end of theEustachian tube and the improvement of middle ear ventilation related to ahigher frequency of swallowing remain hypothetical.THE VELOPHARYNGEAL INCOMPETENCE. SPEECH ANDLANGUAGESevere velopharyngeal incompetence tended to occur mostly in cleft palatechildren under six years of age and was associated with insufficient articula-tion and language production.A striking decrease in the velopharyngeal incompetence after apharyngoplasty was found, causing an immediate reduction in the nasalityand nasal escape in almost all these patients. An improvement in thearticulatory skills and language production in an increasing number ofpatients was noticed over a period of time. Children, who showed adecrease in the velopharyngeal incompetence from severe to normal weremost likely to demonstrate improved language production.The correct choice between logopaedic or surgical treatment forvelopharyngeal incompetence appears to be difficult. Particularly indubious cases, the selection of treatment based upon anatomical-functionaland developmental considerations hould incline towards surgical treat-ment, especially as the bilateral hearing acuity may also be favoured.t2'1THE TYPE OF CLEFTIn this study, the ratio of cleft palate to congenital short palate is 2:1.Patients with a congenital short palate were represented more frequentlythan in other studies. Adequate and active management with respect o thediagnosis and the treatment may be responsible for this difference and mayhave influenced the referral patterns.The cleft palate children demonstrated a significantly more frequent inci-dence of velopharyngeal incompetence and bilateral chronic serous otitismedia as opposed to the children with a congenital short palate.An average delay of more than three years was noticed between the onsetof speech problems and the surgical treatment in children with a congenitalshort palate.Both children with a cleft lip and palate and those with an isolated cleftpalate were equally at risk of developing speech and hearing problems. Theextent of the cleft did not appear to influence the final action of the levatorsling on the Eustachian tube.ADENOIDECTOMYIn the patients with velopharyngeal incompetence an adenoidectomy failedto produce a decrease in the frequency of the bilateral chronic serous otitismedia.Recurrent adenoidal hypertrophy appeared to be infrequent in childrenwith velopharyngeal incompetence.THE AGEChildren with velopharyngeal incompetence under six years of age tendedto demonstrate more severe nasality and nasal escape and were more likelyto develop insufficient articulation, insufficient language production andbilateral chronic serous otitis media. After a pharyngoplasty, they showedthe most obvious improvement in the nasality and nasal escape, but weremore resistant o the improvement in their bilateral chronic serous otitismedia.FINAL CONCLUSIONA PHARYNGOPLASTY APPEARS TO PRODUCE MANYFAVOURABLE RESULTS. ALMOST ALL CHILDREN WITHVELOPHARYNGEAL INCOMPETENCE SHOW A DECREASE INTHE NASALITY AND NASAL ESCAPE. MANY CHILDREN SHOWtzg[@ short palate is 2:1.hfrnted more frequentlyErotwithrespect to the&isdifference andmayffiiffnore frequent inci-*.dronic serous otitisBltuort pdate.ffid between the onsetfifrcn with a congenital| 41.:*ryith an isolated cleftfuaringproblems. The{d,action of the levatort  j i .ilthadenoidectomy failedd chronic serous otitisinfrequent in childrent .:i+;ffi,yeatr of age tendedfundwere more likelyffpge production andfrEllasty, they showedffiI escape, but wereffionic serous otitisiá7'.i{*yïfr.* t ;4&tlTPDUCE MANYSflLDREN wrrHfr|, DECREASE rN'#HILDREN SHOWAN IMPROVEMENT IN THEIR BILATERAL CHRONIC SEROUSOTITIS MEDIA. OVER A PERIOD OF TIME, AN INCREASINGNUMBER OF CHILDREN SHOW IMPROVEMENT IN THEIR AR-TICULATORY SKILLS AND/OR LANGUAGE PRODUCTION. INA SELECTED GROUP, TÏfi POSITIVE EFFECTS ON THE SPEECHAND LANGUAGE DEVELOPMENT AS WELL AS ON THEBILATERAL HEARING ACUITY JUSTIFIES PERFORMING APHARYNGOPLASTY AT AN EARLY AGE SO PROVIDING THECHILD WITH THE TOOLS FOR DEVELOPING NORMAL SPEECHAND LANGUAGE.I29

Hearing speech and language after surgery for velopharyngeal incompetence

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Hearing speech and language after surgery for velopharyngeal incompetence

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