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Muscular and functional changes following adenotonsillectomy in children
International Journal of Pediatric Otorhinolaryngology 79 (2015) 537–540
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Muscular and functional changes following adenotonsillectomy in children Dandara de A. Bueno a, Taı´s H. Grechi a, Luciana V.V. Trawitzki a, Wilma T. Anselmo-Lima b, Cla´udia M. Felı´cio a, Fabiana C.P. Valera b,* a b
Speech Therapy Course, Medical School of Ribeira˜o Preto, University of Sa˜o Paulo, Ribeira˜o Preto, Sa˜o Paulo State, Brazil Otorhinolaryngology Division, Medical School of Ribeira˜o Preto, University of Sa˜o Paulo, Ribeira˜o Preto, Sa˜o Paulo State, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 November 2014 Received in revised form 15 January 2015 Accepted 19 January 2015 Available online 28 January 2015
Background: It is recognized that adenotonsillar hypertrophy leads to muscular and functional changes in face, and that adenotonsillectomy is associated to improvement in this condition. However, the ideal interval one should wait until this spontaneous recovery is not well defined, neither if this recovery is expected to be complete or partial. Objective: To compare the muscular and functional changes in face of children prior and after adenotonsillectomy in a monthly evaluation. Methods: 8 children aged from 4 to 6 years were prospectively studied. All patients underwent adenotonsillectomy, and were assessed before and monthly-after surgery up to 6 months, through the Protocol of Orofacial Myofunctional Evaluation with Scores (OMES). Results: There was a progressive improvement in OMES score in all measured parameters, including the ‘‘mobility’’ and ‘‘posture’’ sub-tests; this improvement was significant at the first month after surgery. The sub-test ‘‘function’’ was not affected by surgery. Improvement continued from the first to the sixth month after surgery, although it was not significant between these two periods. Additionally, all parameters remained altered after the final evaluation at six months. There was a significant correlation between the improvement in ‘‘mobility’’ sub-test and in total score of OMES. Conclusion: We observed a partial recovery in facial muscular and functional changes following adenotonsillectomy, particularly during the first month after surgery. This improvement was especially observed in the ‘‘mobility’’ and ‘‘posture’’ sub-tests. We conclude that waiting for a spontaneous muscular and functional facial recovery during the first month post-operatively seems reasonable. Nevertheless, after this period, if the patient fails to achieve recovery, it may be advised that this child should undergo myofunctional therapy. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Adenotonsillectomy Myofunctional Evolution Mouth breathing Therapy Muscular
1. Introduction Mouth breathing during childhood is associated to sleep breathing diseases [1]. The main causes for mouth breathing are adenotonsillar hypertrophy and allergic rhinitis, and both conditions are frequently concomitant [2]. Adenotonsillectomy is one of the most common surgery performed in children, and its main objective is to reestablish nasal breathing, ultimately improving
* Corresponding author. Tel.: +55 16 3602 2862/+55 16 3602 2863; fax: +55 16 36022860. E-mail addresses: [email protected], [email protected] (Fabiana C.P. Valera). http://dx.doi.org/10.1016/j.ijporl.2015.01.024 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
quality of life and, hopefully, facial myofunctional status after surgery [3]. Several craniofacial modifications have been reported in chronic mouth breathing children, such as maxillary and mandibular retraction [2,4,5], vertical rotation in mandible [6], long face [5–7], maxillary atresia [2,4,7] and posterior cross-bite [7]. In general, these changes are more apparent in older children [4–6]. In a previous study performed by our group [8], we have observed palatal atresia and dolichofacial pattern in children from three to six years, but in general the craniofacial changes were subtler in this stage than in scholar children. We suggested that craniofacial changes depended on time and amount of breathing disturbance. Myofunctional changes, however, are already evident in preschool children [8]. The main muscular changes observed in
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D.A. Bueno et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 537–540
mouth-breathing children in literature are: mouth opened [2], protruded tongue or tongue in floor of mouth and diminished tonicity in masseter, buccinator and tongue [5,8–10]. These changes compromise mastication and deglutition. As a consequence, these children prefer soft and liquid food, help deglutition with liquids and usually show impaired mouth sealing during mastication, interposition of tongue during phonation and deglutition and head movement during deglutition [5,8]. Moreover, the mouth-breathing children have a significantly inferior mastication time than nasal breathers [11], damaging the quality of this function. The myofunctional changes associated to adenotonsillar hypertrophy are established in literature [2,5,8,10–12]. Although, myofunctional recovery is usually assumed, few studies report whether there is spontaneous recovery in these changes after adenotonsillectomy. The improvement after surgery does not seem to be constant, neither uniform: some children with severe myofunctional changes before surgery may improve spontaneously, while others persist with impaired myofunctional pattern after surgery despite they presented a less damaged pattern preoperatively. Yet, there still is a debate on who should be referred to a speech therapy evaluation after surgery, and when this evaluation should take place. The objective of this study is to evaluate and to compare the myofunctional parameters in patients with adenotonsillar hypertrophy before and up to six months after surgery (in a monthlyprogram), using a validated protocol. 2. Methods This is a prospective study with patients aged four to six years and with adenotonsillectomy indication due to respiratory breathing impairment associated with adenotonsillar hypertrophy. These children were evaluated at the Mouth Breathing Outpatient Clinic from Clinics Hospital—Medical School of Ribeira˜o Preto— University of Sa˜o Paulo. Children with genetic syndromes, severe facial changes/malocclusions, and previous adenotonsillectomy, orthodontic treatment or orofacial therapy were excluded. After their parents have signed the informed consent, the patients had their myofunctional parameters evaluated according the Protocol of Orofacial Myofunctional Evaluation with Scores (OMES), proposed by Felı´cio and Ferreira [12]. This protocol comprises pre-determined scores and it allows to clinically assessing: 1. Appearance and posture of stomatognathic components. The scores were attributed individually for facial symmetries, cheeks, tongue, lips, mandible and hard palate, using a 3-point scale from 1 (severe alteration) to 3 (normal). A score of 18 points indicates absence of alterations in this sub-item. 2. Mobility of lips, tongue, mandible and cheeks. In the analysis, separate movements of each component, precise and without tremors, were considered to be normal and the score 3 was assigned. For insufficient ability and tremors the score assigned was 2, and 1 when observed severe inability. A total score of 57 points indicates the best performance during mobility tasks. 3. Functions: breathing mode, deglutition and mastication. A score of 25 points indicates absence of alterations in this sub-item. Briefly, breathing mode was observed throughout the evaluation and was classified as nasal (score = 3), oronasal mild (score = 2) or oronasal severe (score = 1). During deglutition, the parameters evaluated were: tongue and lips functions, as well as deglutition efficiency for both liquid and soft food consistence, being considered the ability of transferring the bolus from mouth to the oropharynx. A 3-point scale was used (normal = 3, mild dysfunction = 2, severe dysfunction = 1).
Also, compensatory movements were observed and its absence was scored 1 and its presence was scored zero. During mastication, the patient was oriented to eat a slice of bread, in his habitual pattern. The mastication type (trituration) was classified by the percentage of chewing strokes occurring on each side of the oral cavity and the following scores were attributed to it: bilateral and alternate (score = 4); simultaneously bilateral (score = 3); unilateral preference, with masticatory strokes occurring on the same side of the oral cavity 66–94% of the times (score = 2); chronic unilateral, when the masticatory strokes occurred on the same side 95–100% of the time (score = 1); anterior when the masticatory strokes occurred in the region of the incisors and canines or when the patient did not perform the function (score = 1). The association of body movements and the eventual food escape absence was assigned as 1 and its presence as zero. A total OMES score of 100 indicates total absence of orofacial myofunctional disorder [12,13]. The values obtained from OMES protocol were: (1) total OMES; (2) sub-item ‘‘posture OMES’’; (3) sub-item ‘‘mobility OMES’’; and (4) sub-item ‘‘function OMES’’. After surgery, children were reassessed once a month during the first six months of follow-up. The child was always evaluated by the same two speech therapists, and the mean value of each parameter was considered. They were aware of which child and to what group he/she belonged when they analyzed the parameters. The exam was recorded for future reassessment. OMES values were compared between times of evaluation using paired Student’s t test, being considered significant the difference when P < 0.05. To evaluate in which parameter the improvement was more pronounced, we correlated the improvement of each sub-item to the improvement in total OMES score. For this purpose, we developed the improvement index (DOMES), when
D OMES ¼ OMES ð6th month of follow-upÞ OMES ðbefore surgeryÞ The same index was applied for each sub-item assessed: D ‘‘posture OMES’’, D ‘‘mobility OMES’’ and D ‘‘function OMES’’. The D total OMES was correlated to each D OMES sub-item (posture, mobility and function) by Spearman correlation test, and it was considered statistically significant when P < 0.05. This study was approved by local IRB—Ethics Committee in Research of Clinical Hospital of Medical School of Ribeira˜o Preto— University of Sa˜o Paulo (process no. 5693/2010). 3. Results Twenty-one children were initially assessed, all of them having undergone adenotonsillectomy. Only 13 were re-evaluated at the first month of follow-up, and a total of eight children finished all the seven evaluations. At the moment of surgery, mean age of the children who underwent to all evaluations was 4.9 years, and all of them had body mass index lower than 18.5 kg/m2. At the first evaluation, the main alterations observed, among the 21 children initially studied were: absence of lip sealing (mild in 66.7% and severe in 33.3% of cases); interposition of tongue during rest (100%) and during deglutition (in 76.2% of children); and altered mastication (76.2%). Among the eight children who completed the whole study, there was a significant spontaneous improvement after surgery, as observed by OMES protocol (68.5 6.39 before surgery vs. 74.5 5.29 at the first month after surgery, P < 0.01, IC95%: 2.23; 9.76). The improvement persisted after this period, reaching the score
D.A. Bueno et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 537–540
value of 79.62 6.43 at the sixth month after surgery, but this difference was not significant when compared to the first month period (P NS, IC95%: 1.37; 11.62) (Fig. 1). The same pattern was observed for ‘‘posture OMES’’,: there was a significant improvement after the first month of surgery (11.50 1.19 before surgery vs. 13.25 1.75 at the first month after surgery, P < 0.01, IC95%: 0.58;2.91). After this period, the improvement lost significance, reaching to 13.87 1.45 at the sixth month after surgery (Fig. 2). The same pattern was also observed for ‘‘mobility OMES’’. The mean value of 38.00 5.55 before surgery reached up to 41.37 4.71 at the first month after surgery (P < 0.05, IC95%: 0.34; 6.40); from this period on this improvement lost significance, reaching the value of 45.62 5.87 at the sixth month following surgery (Fig. 3).
539
‘‘Function OMES’’ was not influenced by surgery: there was no significant difference in scores between evaluations (19.00 2.13 before surgery vs. 19.87 1.88 at the first month of follow-up vs. 20.12 1.35 at the sixth month). The correlation between D total OMES and D ‘‘mobility OMES’’ was extremely high and significant (R = 0.90, P < 0.005) (Fig. 4). For the other two sub-items, the correlation was not significant (R = 0.44, P = 0.31 for D ‘‘posture OMES’’ and R = 0.38, P = 0.39 for D ‘‘function OMES’’). This result suggests that mobility OMES is the parameter that most influenced total OMES recovery for these children. 4. Discussion
Fig. 2. Evolution in mean values of posture OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
At the present study, we have observed a high prevalence of myofunctional changes in children who underwent adenotonsillectomy due to respiratory disease. An important disturbance in total OMES score, as well as in each sub-item, was present before surgery. These findings are in agreement with several other reports in literature [5,7,8,14], that demonstrated important changes in orofacial muscle functions, leading to important alterations in mastication and deglutition. In this regard, Di Francesco et al. [7] concluded that nasal obstruction should be treated as early as possible in order to improve facial development. The main changes observed prior to surgery were: absence of lips sealing, interposition of tongue between teeth during phonation and deglutition, hard palate atresia and changes during mastication. These results are also in accordance with other findings in literature [2,5,8,10–12] that also reported similar signs and symptoms in mouth breathing children. In general, adenotonsillectomy in children with sleep respiratory disturbances is followed by improvement in respiratory symptoms, in mastication [14], and consequently in quality of life [3]. However, few prospective studies have observed the impact of surgery on myofunctional changes. Only two studies [14,15] applied systematic protocols to evaluate this parameter pre and post-operatively. In both cases, there was myofunctional recovery after surgery, but this improvement was only partial. Both studies determined that myofunctional therapy should be performed if complete recovery was not achieved after this period of evaluation. The present study aimed to evaluate in a monthly-schedule the patients up to six months of follow-up, with the purpose of ascertaining which would be the best moment after surgery to indicate myofunctional therapy. We have observed that adenotonsillectomy is followed by myofunctional improvement, especially due to ‘‘mobility OMES’’; i.e. the movement and tonicity of stomatognathic structures. There was also improvement in the ‘‘posture OMES’’, but it was less intense. However, function
Fig. 3. Evolution in mean values of mobility OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
Fig. 4. Correlation between D total OMES and D mobility OMES, through Spearman test.
Fig. 1. Evolution in mean values of total OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
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sub-item was not significantly changed after surgery, i.e. mastication, deglutition and breathing evaluation at protocol was not influenced by surgery. This result differs from other reports [14,15] and this may be due to the time for the first clinical evaluation (1 month), which was earlier if compared to the other studies. We may presume that posture and mobility recovery would anticipate function recovery. The sub-item that have predominantly influenced myofunctional recovery was ‘‘mobility OMES’’, since this sub-item was highly and significantly correlated to total OMES. It is worthwhile to stress that the most important improvement in OMES protocol occurred during the first month of follow-up. After this period, the improvement was not longer significant. Additionally, the myofunctional recovery did not reach normality, as values at the last evaluation persisted away from maximum OMES values—considered the expected values for children with normal myofunctional feature. According to Lundeborg et al. [14] and Valera et al. [15], the children who have not presented complete myofunctional recovery after these first months of follow-up should benefit from speech therapy. Based on our recent findings, the ideal moment in which therapy should be indicated would be right after the first month after surgery. 5. Conclusion We conclude that there is partial myofunctional compensation after adenotonsillectomy, mostly during the first month after surgery. In the case where complete recovery was not achieved after this period, the child should be referred to myofunctional therapy. Conflict of interest statement None. Financial support CNPq—study sponsorship.
Acknowledgement Nothing to disclose. References [1] S.C. Izu, C.H. Itamoto, M. Pradella-Hallinan, G.U. Pizarro, S. Tufik, S. Pignatari, et al., Obstructive sleep apnea syndrome (OSAS) in mouth breathing children, Braz. J. Otorhinolaryngol. 76 (2010) 552–556. [2] S.M. Motonaga, L.C. Berti, W.T. Anselmo-Lima, Mouth breathing: causes and changes of the stomatolognathic system, Braz. J. Otorhinolaryngol. 66 (2000) 373–379. [3] R.C. Di Francesco, F.S.G. Fortes, C.L. Komatsu, Quality of life improvement in children after adenotonsillectomy, Braz. J. Otorhinolaryngol. 70 (2004) 748–751. [4] D. Bresolin, G.G. Shapiro, P.A. Shapiro, S.W. Dassel, C.T. Furukawa, W.E. Pierson, et al., Facial characteristics of children who breathe through the mouth, Pediatrics 73 (1984) 622–625. [5] F.C. Pereira, S.M. Motonaga, P.M. Faria, M.A.N. Matsumoto, L.V.V. Trawitzki, S.A. Lima, et al., Myofunctional and cephalometric evaluation of mouth breathers, Braz. J. Otorhinolaryngol. 67 (2001) 43–49. [6] F.C.R. Lessa, C. Enoki, M.F.N. Feres, F.C.P. Valera, W.T. Anselmo-Lima, M.A.N. Matsumoto, Breathing mode influence on craniofacial development, Braz. J. Otorhinolaryngol. 71 (2005) 156–160. [7] R.C. Di Francesco, E.G.P. Bregola, L.S. Pereira, R.S. Lima, A obstruc¸a˜o nasal e o diagno´stico ortodoˆntico, R. Dental Press Ortod. Ortop. Facial 11 (2006) 107–113. [8] F.C.P. Valera, L.V.V. Trawitzki, S.E.M. Mattar, M.A.N. Matsumoto, A.M. Elias, W.T. Anselmo-Lima, Muscular, functional and orthodontic changes in pre school children with enlarged adenoids and tonsils, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 761–770. [9] A.P. Bianchini, Z.C.F. Guedes, M.M. Vieira, A study on the relationship between mouth breathing and facial morphological pattern, Braz. J. Otorhinolaryngol. 73 (2007) 500–505. [10] H.O.S.N. Rodrigues, S.R. Faria, F.S.G. De Paula, A.M. Rodrigues, Ocorreˆncia de respirac¸a˜o oral e alterac¸o˜es miofuncionais orofaciais em sujeitos em tratamento ortodoˆntico, Rev CEFAC 7 (2005) 356–362. [11] M.A.S. De Andrade, V. Natalini, R.R. Ramires, L.P. Ferreira, Ana´lise comparativa da mastigac¸a˜o de crianc¸as respiradoras nasais e orais com dentic¸a˜o decidua, Rev CEFAC 9 (2007) 190–198. [12] C.M. Felı´cio, C.L. Ferreira, Protocol of orofacial myofunctional evaluation with scores, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 367–375. [13] C.M. Felı´cio, A.P. Medeiros, M. Oliveira Melchior, Validity of the ‘protocol of orofacial myofunctional evaluation with scores’ for young and adult subjects, J. Oral. Rehabil. 39 (2012) 744–753. [14] I. Lundeborg, A. McAllister, J. Graf, E. Ericsson, E. Hultcrantz, Oral motor dysfunction in children with adenotonsillar hypertrophy effects of surgery, Logoped Phoniatr Vocol 34 (2009) 111–116. [15] F.C.P. Valera, L.V.V. Trawitzki, W.T. Anselmo-Lima, Myofunctional evaluation after surgery for tonsils hypertrophy and its correlation to breathing pattern: a 2 year follow up, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 221–225.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Muscular and functional changes following adenotonsillectomy in children Dandara de A. Bueno a, Taı´s H. Grechi a, Luciana V.V. Trawitzki a, Wilma T. Anselmo-Lima b, Cla´udia M. Felı´cio a, Fabiana C.P. Valera b,* a b
Speech Therapy Course, Medical School of Ribeira˜o Preto, University of Sa˜o Paulo, Ribeira˜o Preto, Sa˜o Paulo State, Brazil Otorhinolaryngology Division, Medical School of Ribeira˜o Preto, University of Sa˜o Paulo, Ribeira˜o Preto, Sa˜o Paulo State, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 November 2014 Received in revised form 15 January 2015 Accepted 19 January 2015 Available online 28 January 2015
Background: It is recognized that adenotonsillar hypertrophy leads to muscular and functional changes in face, and that adenotonsillectomy is associated to improvement in this condition. However, the ideal interval one should wait until this spontaneous recovery is not well defined, neither if this recovery is expected to be complete or partial. Objective: To compare the muscular and functional changes in face of children prior and after adenotonsillectomy in a monthly evaluation. Methods: 8 children aged from 4 to 6 years were prospectively studied. All patients underwent adenotonsillectomy, and were assessed before and monthly-after surgery up to 6 months, through the Protocol of Orofacial Myofunctional Evaluation with Scores (OMES). Results: There was a progressive improvement in OMES score in all measured parameters, including the ‘‘mobility’’ and ‘‘posture’’ sub-tests; this improvement was significant at the first month after surgery. The sub-test ‘‘function’’ was not affected by surgery. Improvement continued from the first to the sixth month after surgery, although it was not significant between these two periods. Additionally, all parameters remained altered after the final evaluation at six months. There was a significant correlation between the improvement in ‘‘mobility’’ sub-test and in total score of OMES. Conclusion: We observed a partial recovery in facial muscular and functional changes following adenotonsillectomy, particularly during the first month after surgery. This improvement was especially observed in the ‘‘mobility’’ and ‘‘posture’’ sub-tests. We conclude that waiting for a spontaneous muscular and functional facial recovery during the first month post-operatively seems reasonable. Nevertheless, after this period, if the patient fails to achieve recovery, it may be advised that this child should undergo myofunctional therapy. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Adenotonsillectomy Myofunctional Evolution Mouth breathing Therapy Muscular
1. Introduction Mouth breathing during childhood is associated to sleep breathing diseases [1]. The main causes for mouth breathing are adenotonsillar hypertrophy and allergic rhinitis, and both conditions are frequently concomitant [2]. Adenotonsillectomy is one of the most common surgery performed in children, and its main objective is to reestablish nasal breathing, ultimately improving
* Corresponding author. Tel.: +55 16 3602 2862/+55 16 3602 2863; fax: +55 16 36022860. E-mail addresses: [email protected], [email protected] (Fabiana C.P. Valera). http://dx.doi.org/10.1016/j.ijporl.2015.01.024 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
quality of life and, hopefully, facial myofunctional status after surgery [3]. Several craniofacial modifications have been reported in chronic mouth breathing children, such as maxillary and mandibular retraction [2,4,5], vertical rotation in mandible [6], long face [5–7], maxillary atresia [2,4,7] and posterior cross-bite [7]. In general, these changes are more apparent in older children [4–6]. In a previous study performed by our group [8], we have observed palatal atresia and dolichofacial pattern in children from three to six years, but in general the craniofacial changes were subtler in this stage than in scholar children. We suggested that craniofacial changes depended on time and amount of breathing disturbance. Myofunctional changes, however, are already evident in preschool children [8]. The main muscular changes observed in
538
D.A. Bueno et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 537–540
mouth-breathing children in literature are: mouth opened [2], protruded tongue or tongue in floor of mouth and diminished tonicity in masseter, buccinator and tongue [5,8–10]. These changes compromise mastication and deglutition. As a consequence, these children prefer soft and liquid food, help deglutition with liquids and usually show impaired mouth sealing during mastication, interposition of tongue during phonation and deglutition and head movement during deglutition [5,8]. Moreover, the mouth-breathing children have a significantly inferior mastication time than nasal breathers [11], damaging the quality of this function. The myofunctional changes associated to adenotonsillar hypertrophy are established in literature [2,5,8,10–12]. Although, myofunctional recovery is usually assumed, few studies report whether there is spontaneous recovery in these changes after adenotonsillectomy. The improvement after surgery does not seem to be constant, neither uniform: some children with severe myofunctional changes before surgery may improve spontaneously, while others persist with impaired myofunctional pattern after surgery despite they presented a less damaged pattern preoperatively. Yet, there still is a debate on who should be referred to a speech therapy evaluation after surgery, and when this evaluation should take place. The objective of this study is to evaluate and to compare the myofunctional parameters in patients with adenotonsillar hypertrophy before and up to six months after surgery (in a monthlyprogram), using a validated protocol. 2. Methods This is a prospective study with patients aged four to six years and with adenotonsillectomy indication due to respiratory breathing impairment associated with adenotonsillar hypertrophy. These children were evaluated at the Mouth Breathing Outpatient Clinic from Clinics Hospital—Medical School of Ribeira˜o Preto— University of Sa˜o Paulo. Children with genetic syndromes, severe facial changes/malocclusions, and previous adenotonsillectomy, orthodontic treatment or orofacial therapy were excluded. After their parents have signed the informed consent, the patients had their myofunctional parameters evaluated according the Protocol of Orofacial Myofunctional Evaluation with Scores (OMES), proposed by Felı´cio and Ferreira [12]. This protocol comprises pre-determined scores and it allows to clinically assessing: 1. Appearance and posture of stomatognathic components. The scores were attributed individually for facial symmetries, cheeks, tongue, lips, mandible and hard palate, using a 3-point scale from 1 (severe alteration) to 3 (normal). A score of 18 points indicates absence of alterations in this sub-item. 2. Mobility of lips, tongue, mandible and cheeks. In the analysis, separate movements of each component, precise and without tremors, were considered to be normal and the score 3 was assigned. For insufficient ability and tremors the score assigned was 2, and 1 when observed severe inability. A total score of 57 points indicates the best performance during mobility tasks. 3. Functions: breathing mode, deglutition and mastication. A score of 25 points indicates absence of alterations in this sub-item. Briefly, breathing mode was observed throughout the evaluation and was classified as nasal (score = 3), oronasal mild (score = 2) or oronasal severe (score = 1). During deglutition, the parameters evaluated were: tongue and lips functions, as well as deglutition efficiency for both liquid and soft food consistence, being considered the ability of transferring the bolus from mouth to the oropharynx. A 3-point scale was used (normal = 3, mild dysfunction = 2, severe dysfunction = 1).
Also, compensatory movements were observed and its absence was scored 1 and its presence was scored zero. During mastication, the patient was oriented to eat a slice of bread, in his habitual pattern. The mastication type (trituration) was classified by the percentage of chewing strokes occurring on each side of the oral cavity and the following scores were attributed to it: bilateral and alternate (score = 4); simultaneously bilateral (score = 3); unilateral preference, with masticatory strokes occurring on the same side of the oral cavity 66–94% of the times (score = 2); chronic unilateral, when the masticatory strokes occurred on the same side 95–100% of the time (score = 1); anterior when the masticatory strokes occurred in the region of the incisors and canines or when the patient did not perform the function (score = 1). The association of body movements and the eventual food escape absence was assigned as 1 and its presence as zero. A total OMES score of 100 indicates total absence of orofacial myofunctional disorder [12,13]. The values obtained from OMES protocol were: (1) total OMES; (2) sub-item ‘‘posture OMES’’; (3) sub-item ‘‘mobility OMES’’; and (4) sub-item ‘‘function OMES’’. After surgery, children were reassessed once a month during the first six months of follow-up. The child was always evaluated by the same two speech therapists, and the mean value of each parameter was considered. They were aware of which child and to what group he/she belonged when they analyzed the parameters. The exam was recorded for future reassessment. OMES values were compared between times of evaluation using paired Student’s t test, being considered significant the difference when P < 0.05. To evaluate in which parameter the improvement was more pronounced, we correlated the improvement of each sub-item to the improvement in total OMES score. For this purpose, we developed the improvement index (DOMES), when
D OMES ¼ OMES ð6th month of follow-upÞ OMES ðbefore surgeryÞ The same index was applied for each sub-item assessed: D ‘‘posture OMES’’, D ‘‘mobility OMES’’ and D ‘‘function OMES’’. The D total OMES was correlated to each D OMES sub-item (posture, mobility and function) by Spearman correlation test, and it was considered statistically significant when P < 0.05. This study was approved by local IRB—Ethics Committee in Research of Clinical Hospital of Medical School of Ribeira˜o Preto— University of Sa˜o Paulo (process no. 5693/2010). 3. Results Twenty-one children were initially assessed, all of them having undergone adenotonsillectomy. Only 13 were re-evaluated at the first month of follow-up, and a total of eight children finished all the seven evaluations. At the moment of surgery, mean age of the children who underwent to all evaluations was 4.9 years, and all of them had body mass index lower than 18.5 kg/m2. At the first evaluation, the main alterations observed, among the 21 children initially studied were: absence of lip sealing (mild in 66.7% and severe in 33.3% of cases); interposition of tongue during rest (100%) and during deglutition (in 76.2% of children); and altered mastication (76.2%). Among the eight children who completed the whole study, there was a significant spontaneous improvement after surgery, as observed by OMES protocol (68.5 6.39 before surgery vs. 74.5 5.29 at the first month after surgery, P < 0.01, IC95%: 2.23; 9.76). The improvement persisted after this period, reaching the score
D.A. Bueno et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 537–540
value of 79.62 6.43 at the sixth month after surgery, but this difference was not significant when compared to the first month period (P NS, IC95%: 1.37; 11.62) (Fig. 1). The same pattern was observed for ‘‘posture OMES’’,: there was a significant improvement after the first month of surgery (11.50 1.19 before surgery vs. 13.25 1.75 at the first month after surgery, P < 0.01, IC95%: 0.58;2.91). After this period, the improvement lost significance, reaching to 13.87 1.45 at the sixth month after surgery (Fig. 2). The same pattern was also observed for ‘‘mobility OMES’’. The mean value of 38.00 5.55 before surgery reached up to 41.37 4.71 at the first month after surgery (P < 0.05, IC95%: 0.34; 6.40); from this period on this improvement lost significance, reaching the value of 45.62 5.87 at the sixth month following surgery (Fig. 3).
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‘‘Function OMES’’ was not influenced by surgery: there was no significant difference in scores between evaluations (19.00 2.13 before surgery vs. 19.87 1.88 at the first month of follow-up vs. 20.12 1.35 at the sixth month). The correlation between D total OMES and D ‘‘mobility OMES’’ was extremely high and significant (R = 0.90, P < 0.005) (Fig. 4). For the other two sub-items, the correlation was not significant (R = 0.44, P = 0.31 for D ‘‘posture OMES’’ and R = 0.38, P = 0.39 for D ‘‘function OMES’’). This result suggests that mobility OMES is the parameter that most influenced total OMES recovery for these children. 4. Discussion
Fig. 2. Evolution in mean values of posture OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
At the present study, we have observed a high prevalence of myofunctional changes in children who underwent adenotonsillectomy due to respiratory disease. An important disturbance in total OMES score, as well as in each sub-item, was present before surgery. These findings are in agreement with several other reports in literature [5,7,8,14], that demonstrated important changes in orofacial muscle functions, leading to important alterations in mastication and deglutition. In this regard, Di Francesco et al. [7] concluded that nasal obstruction should be treated as early as possible in order to improve facial development. The main changes observed prior to surgery were: absence of lips sealing, interposition of tongue between teeth during phonation and deglutition, hard palate atresia and changes during mastication. These results are also in accordance with other findings in literature [2,5,8,10–12] that also reported similar signs and symptoms in mouth breathing children. In general, adenotonsillectomy in children with sleep respiratory disturbances is followed by improvement in respiratory symptoms, in mastication [14], and consequently in quality of life [3]. However, few prospective studies have observed the impact of surgery on myofunctional changes. Only two studies [14,15] applied systematic protocols to evaluate this parameter pre and post-operatively. In both cases, there was myofunctional recovery after surgery, but this improvement was only partial. Both studies determined that myofunctional therapy should be performed if complete recovery was not achieved after this period of evaluation. The present study aimed to evaluate in a monthly-schedule the patients up to six months of follow-up, with the purpose of ascertaining which would be the best moment after surgery to indicate myofunctional therapy. We have observed that adenotonsillectomy is followed by myofunctional improvement, especially due to ‘‘mobility OMES’’; i.e. the movement and tonicity of stomatognathic structures. There was also improvement in the ‘‘posture OMES’’, but it was less intense. However, function
Fig. 3. Evolution in mean values of mobility OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
Fig. 4. Correlation between D total OMES and D mobility OMES, through Spearman test.
Fig. 1. Evolution in mean values of total OMES scores before and up to six months after adenotonsillectomy. Comparison between times through paired Student’s t test.
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sub-item was not significantly changed after surgery, i.e. mastication, deglutition and breathing evaluation at protocol was not influenced by surgery. This result differs from other reports [14,15] and this may be due to the time for the first clinical evaluation (1 month), which was earlier if compared to the other studies. We may presume that posture and mobility recovery would anticipate function recovery. The sub-item that have predominantly influenced myofunctional recovery was ‘‘mobility OMES’’, since this sub-item was highly and significantly correlated to total OMES. It is worthwhile to stress that the most important improvement in OMES protocol occurred during the first month of follow-up. After this period, the improvement was not longer significant. Additionally, the myofunctional recovery did not reach normality, as values at the last evaluation persisted away from maximum OMES values—considered the expected values for children with normal myofunctional feature. According to Lundeborg et al. [14] and Valera et al. [15], the children who have not presented complete myofunctional recovery after these first months of follow-up should benefit from speech therapy. Based on our recent findings, the ideal moment in which therapy should be indicated would be right after the first month after surgery. 5. Conclusion We conclude that there is partial myofunctional compensation after adenotonsillectomy, mostly during the first month after surgery. In the case where complete recovery was not achieved after this period, the child should be referred to myofunctional therapy. Conflict of interest statement None. Financial support CNPq—study sponsorship.
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