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Clinical use of the bulb obturator to facilitate normal speech in velopharyngeal incompetence
548
British Journal of Plastic Surgery
years, conducted by the principal speech therapist at that time. The data collected for the survey pertained to each child’s medical condition, linguistic abilities and social background, including parental attitude towards the child. The current investigation seeks to address certain issues arising from the survey. These include attention to the extent to which an individual’s medical and social history has predictive/prognostic value for later life. By identifying developmental patterns and problems incurred by having a cleft, it will be possible to make recommendations for improved clinical practice, such as early parent education and teenage counselling (where necessary). Having traced 207 of the 561 individuals involved in the original survey, a postal questionnaire was sent out. A 67% response has been obtained to date, which includes 7 respondents who will be studied separately as their mothers completed the questionnaire for them. Questions related to personal details, education, employment, speech and appearance and experiences of having a cleft palate (with or without cleft lip).
As the data are currently being analysed, discussion of the findings would be premature at this stage. However, the following frequency counts were presented (see Table). The subsequent plan is to undertake an in-depth examination of the hospital records of the ex-patients. This information is expected to supplement the existing data base. Personal interviews will then be conducted with a selection of the questionnaire respondents. Table How the respondents perceive their feelings about having a cleft to have changed since their school days
No Problems Perceived Increased Self-Confidence Now Lack of Self-Confidence Now No Change of Feeling Perceived No Response Total
3 56 6 57 5
3.49; 44.19$ 4.75; 44.9% 3.9%
127
loo.oO;
Velopharyngeal Incompetence of sudden onset: A Case Report T. Sweeney and M. J. Earley Departments of Speech Therapy and Plastic Surgery, The Children’s Hospital, Temple Street, Dublin This paper presents a case report of a nine year old boy with sudden onset of velopharyngeal incompetence of unknown etiology. The patient noticed velopharyngeal incompetence while blowing a flute. There was subsequent deteriorationof speech followed by nasal regurgitation of fluids and soft food. Initial team assessment indicated assymmetric elevation of the soft palate, absent gag reflex and hypernasal speech. E.N.T. and neurological investigations showed no abnormality. Speech assessment indicated weak consonant production, moderate nasal emission on sounds and moderate/severe hypernasality. Videofluoroscopy indicated poor movement of the soft palate with incomplete velopharyngeal closure. Possible Diagnoses : 1. Post viral mononeuritis-most likely diagnosis 2. Degenerative neurological disease; this was not supported by M.R.I. and E.E.G. assessments and the disorder was not progressive. 3. Psychological disorder was ruled out due to the unilateral problem. Anxiety and depression were noted to be secondary to speech deterioration.
Management
included speech therapy and review
of velopharyngeal function. Speech therapy focused on production of sounds reducing nasal emission and maintaining intra-oral air pressure. The Exeter Nasal Anemometer was used for visual feedback during therapy. He responded extremely well to this approach and learned to eliminate nasal emission on words and sentences. A Palatal Training Appliance was fitted to improve elevation of the soft palate and therapy continued using the appliance and the Nasal Anemometer. Present speech status is mildly hypernasal with minimal nasal emission in a structured speech situation; however, there is limited carryover to normal conversational speech; conversational speech is inconsistently hypernasal with nasal emission on sounds. Review of velopharyngeal function in March ‘91 using Nasendoscopy and Videofluoroscopy indicated persistent asymmetric failure of velopharyngeal closure. Soft palate movement improved using Palatal Training Appliance; however, velopharyngeal closure was incomplete. Final diagnosis is that of acquired unilateral paralysis of the soft palate of unknown aetiology. A lateral Hynes/Orticochea procedure is recommended.
Clinical use of the bulb obturator to facilitate normal speech in velopharyngeal incompetence P. J. Lax Child De~eIopment and ~ehab~i~tation Center, Portland, Oregon 97.201 USA A management strategy for velopharyngeal incompetence used at the Oregon cleft palate clinic is described.
The strategy employs a temporary speech bulb obturator, which improves the ability of the pre-school
Craniofacial Society Abstracts
549
child to impound air. Criteria, rationale, fabrication, drawbacks and effectiveness of the bulb obturator are presented. Candidates for a bulb obturator appliance will have the following speech ratings : objectionable hypernasality. moderate to severe nasal emission and/or moderate to severe velopharyngeal incompetence. These ratings are based on the child’s speech sample, interpreted by the clinician using a nasal listening tube. cold mirror, nasal flutter test and listener judgement. The bulb appliance assists speech at a critical learning period by improving valve function, while allowing sufficient air passage for breathing and phonatilon of the nasal consonants. It is viewed as a temporary appliance because lateral wall stimulation will permit periodic reductions of the bulb over time. This stimulation can also prove beneficial to the surgeon, who will have a smaller defect to repair if a child cannot become independent of the appliance.
The appliance is fabricated by the dentist in stages to allow adaption. Increments are added to the bulb until obturation is confirmed by a speech assessment. Speech therapy continues with the obturator. Drawbacks, such as dental caries, orthodontic coordination, non-compliance of the child or family, and the necessity of a dentist-speech clinician team, are discussed. The acquisition of good articulation in the preschool child is the goal of the Oregon obturator program. Forty percent (40%) will become independent of the appliance, while maintaining adequate velopharyngeal function. Another fifty percent (50%) will undergo successful pharyngoplasties. Children with non cleft velopharyngeal incompetence or lesser cleft problems have a better prognosis th.an bilateral cleft lip and palate children and those with neuromuscular problems.
Complications of Goode’s Tympanostomy tubes in the cleft palate patient A. J. N. Prichard,
J. Marshall,
R. S. A. Thomas
and T. M. Milward
Depts of Otolur.~wgology und Plastic Surgery. Lricrstrr Royal I@mary,
To prevent persistent otitis media with effusion in those patients with cleft palate, the placement of long term tymp~inostomy tubes with simultaneous repair of the soft palate is highly desirable. A retrospective analysis of the complications of middle ear ventilation by 327 Goode’s tubes over a ten year period is presented--61 tubes were simultaneously inserted during cleft palate repair. For those with cleft palate the mean period of ventilation before removal or extrusion was 28.4 months Spontaneous extrusion occurred with 13.11;
Lcicrster, LEl 5U’U’
of tubes. Otorrhoea was found in 46.1”, and perforation in 25.69, of ears. The incidence of perforation occurred significantly more often in those who had the tube removed (P < 0.05). Perforation was significantly more likely to occur in the cleft palate patient (PI 0.01). although the otorrhoea rate was reduced (P < 0.001). To avoid such complications avoidance of Goode’s T-tubes to maintain middle ear ventilation is required. The use of alternative tubes, such as the Shah PermaVent. is suggested.
Three dimensional changes in cleft palate patients before and after surgery J. P. Moss, D. R. James, A. McCance Orthodrwtic Department,
and W. R. Fright
Uniwrsity College Hospital, London
Two dimensional analysis of the soft tissues in the midline has been available for some time, but only recently has a method of recording the face in three dimensions been possible (Moss et al., 1989). In assessing the results of the treatment of Cleft Palate patients the changes which are most interesting are those in, the soft tissues as these are the parts that the patient and others see, Although the teeth and jaws are important for function the aesthetics depend on the changes in the soft tissues. In this study three questions were investigated :----What changes occur in the soft tissues as a result of surgery? How do the faces
of cleft palate patients compare with the normal population? At the end of surgery do the cleft palate patients resemble a normal patient‘?
Material 17 patients with a unilateral cleft, 6 patients with a bilateral cleft and 6 patients with a secondary cleft were scanned using a laser scanner before and after surgery. 10 normal females and 10 normal males were also scanned to provide a comparison.
British Journal of Plastic Surgery
years, conducted by the principal speech therapist at that time. The data collected for the survey pertained to each child’s medical condition, linguistic abilities and social background, including parental attitude towards the child. The current investigation seeks to address certain issues arising from the survey. These include attention to the extent to which an individual’s medical and social history has predictive/prognostic value for later life. By identifying developmental patterns and problems incurred by having a cleft, it will be possible to make recommendations for improved clinical practice, such as early parent education and teenage counselling (where necessary). Having traced 207 of the 561 individuals involved in the original survey, a postal questionnaire was sent out. A 67% response has been obtained to date, which includes 7 respondents who will be studied separately as their mothers completed the questionnaire for them. Questions related to personal details, education, employment, speech and appearance and experiences of having a cleft palate (with or without cleft lip).
As the data are currently being analysed, discussion of the findings would be premature at this stage. However, the following frequency counts were presented (see Table). The subsequent plan is to undertake an in-depth examination of the hospital records of the ex-patients. This information is expected to supplement the existing data base. Personal interviews will then be conducted with a selection of the questionnaire respondents. Table How the respondents perceive their feelings about having a cleft to have changed since their school days
No Problems Perceived Increased Self-Confidence Now Lack of Self-Confidence Now No Change of Feeling Perceived No Response Total
3 56 6 57 5
3.49; 44.19$ 4.75; 44.9% 3.9%
127
loo.oO;
Velopharyngeal Incompetence of sudden onset: A Case Report T. Sweeney and M. J. Earley Departments of Speech Therapy and Plastic Surgery, The Children’s Hospital, Temple Street, Dublin This paper presents a case report of a nine year old boy with sudden onset of velopharyngeal incompetence of unknown etiology. The patient noticed velopharyngeal incompetence while blowing a flute. There was subsequent deteriorationof speech followed by nasal regurgitation of fluids and soft food. Initial team assessment indicated assymmetric elevation of the soft palate, absent gag reflex and hypernasal speech. E.N.T. and neurological investigations showed no abnormality. Speech assessment indicated weak consonant production, moderate nasal emission on sounds and moderate/severe hypernasality. Videofluoroscopy indicated poor movement of the soft palate with incomplete velopharyngeal closure. Possible Diagnoses : 1. Post viral mononeuritis-most likely diagnosis 2. Degenerative neurological disease; this was not supported by M.R.I. and E.E.G. assessments and the disorder was not progressive. 3. Psychological disorder was ruled out due to the unilateral problem. Anxiety and depression were noted to be secondary to speech deterioration.
Management
included speech therapy and review
of velopharyngeal function. Speech therapy focused on production of sounds reducing nasal emission and maintaining intra-oral air pressure. The Exeter Nasal Anemometer was used for visual feedback during therapy. He responded extremely well to this approach and learned to eliminate nasal emission on words and sentences. A Palatal Training Appliance was fitted to improve elevation of the soft palate and therapy continued using the appliance and the Nasal Anemometer. Present speech status is mildly hypernasal with minimal nasal emission in a structured speech situation; however, there is limited carryover to normal conversational speech; conversational speech is inconsistently hypernasal with nasal emission on sounds. Review of velopharyngeal function in March ‘91 using Nasendoscopy and Videofluoroscopy indicated persistent asymmetric failure of velopharyngeal closure. Soft palate movement improved using Palatal Training Appliance; however, velopharyngeal closure was incomplete. Final diagnosis is that of acquired unilateral paralysis of the soft palate of unknown aetiology. A lateral Hynes/Orticochea procedure is recommended.
Clinical use of the bulb obturator to facilitate normal speech in velopharyngeal incompetence P. J. Lax Child De~eIopment and ~ehab~i~tation Center, Portland, Oregon 97.201 USA A management strategy for velopharyngeal incompetence used at the Oregon cleft palate clinic is described.
The strategy employs a temporary speech bulb obturator, which improves the ability of the pre-school
Craniofacial Society Abstracts
549
child to impound air. Criteria, rationale, fabrication, drawbacks and effectiveness of the bulb obturator are presented. Candidates for a bulb obturator appliance will have the following speech ratings : objectionable hypernasality. moderate to severe nasal emission and/or moderate to severe velopharyngeal incompetence. These ratings are based on the child’s speech sample, interpreted by the clinician using a nasal listening tube. cold mirror, nasal flutter test and listener judgement. The bulb appliance assists speech at a critical learning period by improving valve function, while allowing sufficient air passage for breathing and phonatilon of the nasal consonants. It is viewed as a temporary appliance because lateral wall stimulation will permit periodic reductions of the bulb over time. This stimulation can also prove beneficial to the surgeon, who will have a smaller defect to repair if a child cannot become independent of the appliance.
The appliance is fabricated by the dentist in stages to allow adaption. Increments are added to the bulb until obturation is confirmed by a speech assessment. Speech therapy continues with the obturator. Drawbacks, such as dental caries, orthodontic coordination, non-compliance of the child or family, and the necessity of a dentist-speech clinician team, are discussed. The acquisition of good articulation in the preschool child is the goal of the Oregon obturator program. Forty percent (40%) will become independent of the appliance, while maintaining adequate velopharyngeal function. Another fifty percent (50%) will undergo successful pharyngoplasties. Children with non cleft velopharyngeal incompetence or lesser cleft problems have a better prognosis th.an bilateral cleft lip and palate children and those with neuromuscular problems.
Complications of Goode’s Tympanostomy tubes in the cleft palate patient A. J. N. Prichard,
J. Marshall,
R. S. A. Thomas
and T. M. Milward
Depts of Otolur.~wgology und Plastic Surgery. Lricrstrr Royal I@mary,
To prevent persistent otitis media with effusion in those patients with cleft palate, the placement of long term tymp~inostomy tubes with simultaneous repair of the soft palate is highly desirable. A retrospective analysis of the complications of middle ear ventilation by 327 Goode’s tubes over a ten year period is presented--61 tubes were simultaneously inserted during cleft palate repair. For those with cleft palate the mean period of ventilation before removal or extrusion was 28.4 months Spontaneous extrusion occurred with 13.11;
Lcicrster, LEl 5U’U’
of tubes. Otorrhoea was found in 46.1”, and perforation in 25.69, of ears. The incidence of perforation occurred significantly more often in those who had the tube removed (P < 0.05). Perforation was significantly more likely to occur in the cleft palate patient (PI 0.01). although the otorrhoea rate was reduced (P < 0.001). To avoid such complications avoidance of Goode’s T-tubes to maintain middle ear ventilation is required. The use of alternative tubes, such as the Shah PermaVent. is suggested.
Three dimensional changes in cleft palate patients before and after surgery J. P. Moss, D. R. James, A. McCance Orthodrwtic Department,
and W. R. Fright
Uniwrsity College Hospital, London
Two dimensional analysis of the soft tissues in the midline has been available for some time, but only recently has a method of recording the face in three dimensions been possible (Moss et al., 1989). In assessing the results of the treatment of Cleft Palate patients the changes which are most interesting are those in, the soft tissues as these are the parts that the patient and others see, Although the teeth and jaws are important for function the aesthetics depend on the changes in the soft tissues. In this study three questions were investigated :----What changes occur in the soft tissues as a result of surgery? How do the faces
of cleft palate patients compare with the normal population? At the end of surgery do the cleft palate patients resemble a normal patient‘?
Material 17 patients with a unilateral cleft, 6 patients with a bilateral cleft and 6 patients with a secondary cleft were scanned using a laser scanner before and after surgery. 10 normal females and 10 normal males were also scanned to provide a comparison.