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Nasalance scores in pediatric patients after adenoidectomy
International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Nasalance scores in pediatric patients after adenoidectomy Arzu Tuzuner *,1, Sule Demirci 1, Ahmet Akkoc 1, Erhan Arslan 1, Necmi Arslan 1, Etem Erdal Samim 1 Department of Otorhinolaryngology—Head and Neck Surgery, Ministry of Health,Ankara, Training and Research Hospital, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 November 2013 Received in revised form 6 January 2014 Accepted 8 January 2014 Available online 16 January 2014
Objective: Adenoidectomy is one of the most frequently performed operations in childhood. Nasal obstruction and chronic infection are the basic indications for surgery. Nasometer measures both oral and nasal air pressure during loud speech, and calculates their ratio. The aim of this study was to compare the mean nasal values in patients who had adenoidectomy at different ages against a control group. Methods: Eighty children between the ages of three and sixteen that had adenoidectomy in our clinic between 2006 and 2010 were compared against eighty age-matched controls who had not had nasal obstruction in their lifetime and were proven to have open nasal airways on physical examination. Results: Statistical analysis of the data showed that mean nasalance scores were significantly lower in patients who had adenoidectomy before 6 years of age when compared to the ones who had the operation after the age of six. In addition, when we compared the children who had adenoidectomy before 5 years of age and between 5and 6 years of age, we found that their nasalance scores were significantly lower when compared to those who had adenoidectomy after the age of six (p = 0.017 and p = 0.019, respectively). Conclusion: This study has shown that, even when adenoidectomy is performed, hyponasality may continue in clinically symptomatic patients under the age of six, and that there are no determined risk factors other than the early age. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Adenoidectomy Nasal speech Nasometer Craniofacial development
Introduction Nasopharyngeal adenoids are the part of the Waldeyer ring situated at the posterior of the nasal cavity. Diffuse enlargement of this lymphoid tissue is the most frequent cause of nasal obstruction during childhood, and most frequently seen between the ages of 3 and 6 [1,2]. Excessive enlargement of the adenoids can cause disorders such as sleep apnea, sleep-related disorders, an increase in nasal speech and chronic otitis media with effusion due to Eustachian tube dysfunction [3,4]. Although most of the aforementioned disorders improve after adenoidectomy and resolution of nasal obstruction, inhibition of facial skeleton development may result in permanent changes such as a narrower airway and increased vertical facial height. Adenoid or adenotonsillar hypertrophy may cause defects in balance of oropharyngeal, maxillary and mandibular development.
* Corresponding author. Tel.: +90 312 5953556/+90 505 9487932; fax: +90 312 5083166. E-mail addresses: [email protected], [email protected] (A. Tuzuner). 1 The paper was presented as poster. 0165-5876/$ – see front matter ß 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2014.01.010
The hardware and software of Nasometer II was defined by Kay in 1986. Since then, Nasometer has become an international standard for objective evaluation of patients with nasality problems. Nasometer measures oral and nasal air pressure separately during loud speech and calculates their ratio [5,6]. It is a highly sensitive diagnostic method for evaluation of hypo/ hypernasality, and is frequently used for postoperative follow up of cleft lip–palate and velopharyngeal insufficiency patients as well as postoperative evaluation of maxillofacial surgery [7,8]. This study aims to compare nasal resonance averages after adenoidectomy with healthy controls, and determine the demographic data which could affect the differences in nasal speech. Material and methods The study population consisted of eighty children (adenoidectomy age between 3 and 16 years) who had adenoidectomy due to chronic nasal obstruction in Ankara Education and Research Hospital Otorhinolaryngology Clinic between 2006 and 2010, and eighty controls (age ranging between 7 and 18 years) who were admitted to our outpatient clinic with complaints other than chronic nasal obstruction. The inclusion criterion was having adenoidectomy due
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
to chronic nasal obstruction. The patients who had cleft lip–palate, neurological disorders, velopharyngeal insufficiency, Down syndrome, history of maxillary surgery or tonsillectomy, nasal septum deviation, nasal polyps, allergic rhinitis, recurrent adenoids, nonfluent speech or insertion of ventilation tubes in addition to adenoidectomy due to otitis media with effusion were excluded. Before the study was conducted, the approval of Ankara Education and Research Hospital’s Ethics Committee was obtained. Two hundred and ten patients who fulfilled the inclusion criteria were called by phone and the families of 102 patients accepted to be included in the study. Of these patients, four had recurrent adenoid hypertrophy, eight had allergic rhinitis, seven had nasal septal deviation and three had other exclusion criteria, and therefore they were not included in the study. Both study and the control groups had detailed otorhinolaryngologic examinations including nasal endoscopy. Nasalance measurements were done with Nasometer II model 6450 developed by Kay Elemetrics. The voice analysis was performed in a quite room while the patient was in a sitting position, and the Nasometer headset was placed and adjusted so that the separation plate remained perpendicular to the frontal plane of the subject’s face and comfortably stayed above the upper lip. The microphone was placed approximately 5 cm away from the mouth of the subject. The Nasometer was adjusted before testing each subject. The subject then read a standard text including both nasal and oral sounds, and the speech was recorded with a desktop computer which included Realtek AC97 sound card in CSL signal files format (*.nsp). The text consisted of 725 sounds which 81 of them nasal and 644 of them were oral sounds. Nasal/oral ratio values of the text is 0.125 and oral/nasal value is 7.95. All the participants are read the text without assistance. The data were analyzed in the analysis program to obtain mean nasalance scores. Statistical analysis The data were analyzed using SPSS for Windows 11.5 package program. Normality of distribution was determined using Kolmogorov Smirnov test. Descriptive statistics were presented as mean standard deviation or median (minimum–maximum), and the categorical variables were presented as the number of the cases and %. The importance of the difference for the mean ages between the groups was tested using Student’s t test. The similarity of the gender distribution was analyzed using Pearson’s Chi square test. The importance between the groups for the medians of the clinical measurements was analyzed with Mann Whitney U test when the number of the independent groups was two. Kruskal Wallis test was used when the number of the groups was more than two. When the result of the Kruskal Wallis test indicated a statistically significant result, Conover’s non parametric multiple comparison test was used to determine the situations that caused the difference. A p < 0.05 was regarded as statistically significant.
611
Table 1 The demographic characteristics of the patients according to the groups. Variables
Control group (n = 80)
Study group (n = 80)
p
Age (years) Gender Female Male Age at the surgery (years) Age at the surgery <5 years 5–6 years >6 years
11.7 3.0
11.3 2.9
0.470y 0.874z
43 (53.8%) 37 (46.2%) –
44 (55.0%) 36 (45.0%) 6.6 2.7
– – –
17 (21.3%) 28 (35.0%) 35 (43.7%)
y z
– –
Student’s t test. Pearson’s Chi-square test.
Table 2 The clinical measurements of the patients in the control and the study groups. Variables
Control group (n = 80)
Study group (n = 80)
py
MNS*
38 (26–54)
36 (29–57)
0.206
y *
Mann Whitney U test. MNS: Mean nasalance score.
time range for the text was 67.2(37.6–100) s and in control group was 68.7 (47.2–100) s. The difference between control and study group was not statistically significant (p = 0.753). We divided the patients into three groups according to their ages and compared their nasalance scores. We found that the group <5 years of age and the 5–6 years age group had lower nasalance scores when compared to the control group (p = 0.036 and p = 0.041, respectively). The mean nasalance scores of the group <5 years of age and the 5–6 years age group were significantly lower when compared to the >6 years age group (p = 0.017 and p = 0.019, respectively). The mean nasalance scores were similar in the group that had adenoidectomy at an age >6 years and the control group (p = 0.715) (Table 3) (Figs. 1 and 2). Discussion Hyponasality results from an obstruction in the nasal airway. Air that must be released through the nose is released through the mouth. Any pathology causing obstruction such as nasal polyps, nasal septal deviation, upper respiratory tract infection or adenoid hypertrophy, can cause hyponasality [9–12]. Hypernasality can be encountered in children if the risk factors are not determined preoperatively. Even though the postoperative
Table 3 The clinical measurements of the control group and the study group according to the age at the operation.
Results Patient characteristics Control group consisted of 80 subjects and median age was 11.7 3.0 years. Study group involved 80 children who performed adenoidectomy and median age 11.3 2.9 years. The median age of study group at the time of adenoidectomy was 6.6 2.7 years as shown in Table 1. Comparison of nasalance data The nasalance scores of the study and the control groups were not significantly different. (p = 0.206) as seen in Table 2. The mean
Groups
Mean
Control Operation age <5 years Operation age 5–6 years Operation age >6 years py
38 (26–54)a,b 34 (29–50)a,c 35 (30–52)b,d 37 (29–57)c,d 0.029
a The difference between the control and age at operation <5 years groups was statistically significant (p = 0.036). b The difference between the control group and the group with operation age 5–6 years was statistically significant (p = 0.041). c The difference between the operation age <5 years and operation age >6 years groups was statistically significant (p = 0.017). d The difference between operation age 5–6 years and operation age >6 years groups was statistically significant (p = 0.019). y Kruskal Wallis test.
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
612
Control Group
Study Group
Fig. 1. Nasalance mean scores of control and study group.
Fig. 2. Control and study group comparison nasalance mean scores regarding at the operation ages.
changes in nasality are thought to be transient, recovery can occur in a few weeks or can be delayed for 1 year [13,14]. Adenoid hypertrophy is a frequently seen condition in children before adolescence and in the adolescent period. Enlarged adenoid tissue causes mouth breathing during sleep, snoring, frequent awakenings, growth or developmental retardation, frequent upper respiratory tract infections and abnormalities in maxillofacial development. A big adenoid tissue obstructs nasal airflow and causes passage of the air through the mouth instead of the nose, and this ends up with hyponasality. On the other hand, after adenoidectomy, hypernasality and velopharygeal insufficiency can be seen in some high risk patients [11,12]. Wallner et al. investigated [15] the voice changes subjectively after adenotonsillectomy in 1968 for the first time in the literature. The speech pathologist determined voice changes in 26 of 29 patients, and severe and persistent nasality was determined in five of them. In 1991 Andreassen et al. [16] studied aerodynamic,
acoustic and perceptual changes after adenoidectomy in children and determined nasal airway resistance, nasality scores and the perceptual ratio or nasality preoperatively and at postoperative 1st, 3rd and 6th months. They found a significant increase in nasality and a decrease nasal airway resistance, but they could not determine statistically significant differences in the perception measurements. Watterson et al. [17], compared nasalance and hypernasality scores using a sentence made up of nasal consonants in 25 children between the ages of 3 and 13 years in 1998. They determined that nasometer values and specialist opinions agreed in 84% of the cases with hypernasality (sensitivity). The nasometer scores and specialist opinions agreed in 88% of the normal cases (specificity). Dalston et al. [7] investigated 117 craniofacial patients in 1991 and found the sensitivity and specificity of nasalance scores as 0.89 and 0.95 for correct determination of the hypernasal sounds. Andreassen et al. [16] performed a study in 1991 and found an increase in the nasalance scores after adenoidectomy. Williams et al. [18] found an increase in nasalance after tonsillectomy with and without adenoidectomy for nasal voices in 1992. Subramaniam et al. [19] analyzed the effect of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice, and found that preoperative mean nasalance values were higher compared to the healthy children, nasalance tended to decrease in the postoperative period but this was not statistically significant, and the nasalance values were correlated with the degree of the hypertrophy in children with tonsillar hypertrophy. Recurrent adenoids are one of the postoperative reasons for hyponasality, and hyponasality is more frequently seen in cases that have surgery at an early age. Dearking et al. made a cohort study on 8245 patients and found that 163 (3%) of the children needed revision adenoidectomy after a follow up period of 10 years, and early age was a significant risk factor in those cases [20]. In this study, six of seven patients in whom nasometry could not be performed due to recurrent adenoids had adenoidectomy at 5 years of age or earlier. The data obtained in this study showed that mean nasalance scores of children who had adenoidectomy before 5 years of age were lower than the control group than the ones who were operated at a later age. There can be several explanations for this. The first hypothesis claims that the cases experience severe nasal obstruction during the first 4 years of life when maxillofacial development is completed to a large extent (60%) are more prone to persistent changes. To test this hypothesis, a vertically directed growth pattern was analyzed in 66 pediatric patients who had adenoidectomy at an early and a late age (<4 years of age and >4 years of age), and the results were compared with 27 controls who were described as having a clear airway. The study did not show any significant cephalometric differences during a 1 year follow up period; however there was an increase in the vertical growth pattern in the adenoidectomy group when compared to the controls [21]. Zettergren-Wijk et al. compared postoperative 1st, 3rd and 5th year cephalograms of 17 patients who had tonsillectomy and/or adenoidectomy at a mean age of 5.6 1.34 years for obstructive sleep apnea with a healthy control group. At the end of the 5th year, the length of cranial base was found statistically significantly shorter. In addition, when a soft tissue profile was examined, the nose was less pronounced compared to the control group and the length of the cranial base was shorter [22]. The second hypothesis claims that a long obstruction time due to the families’ and the surgeons’ drawbacks in the decision making period causes a disruption of the maxillofacial development in this age group. In this age group, we could not find any data on the permanent effects of the duration of the nasal obstruction and the age of adenoidectomy on craniofacial development and nasopharyngeal airway’s area.
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
Conclusion After adenoidectomy, hypo- or hypernasality can be seen depending on the risk factors. If there is no additional etiology causing velopharyngeal insufficiency, this condition is usually transient. We did not find permanent hypernasality in our study. When we compared the nasality scores of the adenoidectomized patients with the control group, we did not find any differences, and this indicates normal nasality values in these patients. When hyponasality is considered, we found that hyponasality could continue even after adenoidectomy if the patient had the operation at an early age. To explain this finding, long term controlled studies are needed describing preoperative data including the duration of obstruction and the age when obstruction began. References [1] L.M. Wolford, D. Perez, E. Stevao, E. Perez, Airway space changes after nasopharyngeal adenoidectomy in conjunction with Le Fort I osteotomy, J. Oral Maxillofac. Surg. 70 (3) (2012) 665–671. [2] S.E. Mattar, F.C. Valera, G. Faria, M.A. Matsumoto, W.T. Anselmo-Lima, Changes in facial morphology after adenotonsillectomy in mouth-breathing children, Int. J. Paediatr. Dent. 21 (5) (2011) 389–396. [3] F.E. Waleed, A.F. Samia, Samar MF impact of sleep-disordered breathing and its treatment on children with primary nocturnal enuresis, Swiss Med. Wkly. 141 (2011) w13216. [4] M.T. van den Aardweg, A.G. Schilder, E. Herkert, C.W. Boonacker, M.M. Rovers, Adenoidectomy for otitis media in children, Cochrane Database Syst. Rev. 20 (1) (2010) CD007810. [5] K.H. Hong, S. Kwon, S.S. Jung, The assessment of nasality with a nasometer and sound spectrography in patients with nasal polyposis, Otolaryngol. Head Neck Surg. 117 (1997) 343–348. [6] R.M. Dalston, G.S. Neiman, G. Gonzalez-Landa, Nasometric sensitivity and specificity: a cross-dialect and cross-culture study, Cleft Palate Craniofac. J. 30 (1993) 285–291.
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[7] R.M. Dalston, D.W. Warren, E.T. Dalston, Use of nasometry as a diagnostic tool for identifying patients with velopharyngeal impairment, Erratum in: Cleft Palate Craniofac. J. 28 (4) (1991) 446. [8] J. Rieger, J. Wolfaardt, H. Seikaly, N. Jha, Speech outcomes in patients rehabilitated with maxillary obturator prostheses after maxillectomy: a prospective study, Int. J. Prosthodont. 15 (2) (2002) 139–144. [9] C.C. McLean, S.W. Kelly, M.C. Manley, An instrument for the non-invasive objective measurement of velar function during speech, Med. Eng. Phys. 19 (1997) 7–14. [10] D.R. Bone, S.C. McFarlane, The Voice and Voice Therapy, sixth ed., Allyn & Bacon, USA, 2000. [11] S.F. Austin, Movement of the velum during speech and singing in classically trained singers, J. Voice. 11 (1997) 212–221. [12] M. Morrison, L. Rammage, The Management of Voice Disorders, first ed., Chapman & Hall Medical, London, 1994. [13] M.L. Andreassen, H.A. Leeper, D.L. MacRae, I.R. Nicholson, Aerodynamic, acoustic, and perceptual changes following adenoidectomy, Cleft Palate Craniofac. J. 31 (1994) 263–270. [14] J.S. Greene, T.E. Zipfel, M. Harlor, The effect of uvulopalatopharyngoplasty on the nasality of voice, J. Voice. 18 (2004) 423–430. [15] L.J. Wallner, B.J. Hill, W. Waldrop, C. Monroe, Voice changes following adenotonsillectomy. a study of velar function by cinefluorography and video tape, Laryngoscope 78 (1968) 1410–1418. [16] M.L. Andreassen, H.A. Leeper, D.L. MacRae, Changes in vocal resonance and nasalization following adenoidectomy in normal children: preliminary findings, J. Otolaryngol. 20 (4) (1991) 237–242. [17] T. Watterson, K.E. Lewis, C. Deutsch, Nasalance and nasality in low pressure and high pressure speech, Cleft Palate Craniofac. J. 35 (1998) 293–298. [18] R.G. Williams, M. Preece, R. Rhys, R. Eccles, The effect of adenoid and tonsil surgery on nasalance, Clin. Otolaryngol. Allied Sci. 17 (1992) 136–140. [19] V. Subramaniam, P. Kumar, Impact of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice: a comparative study, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 966–969. [20] A.C. Dearking, B.D. Lahr, A. Kuchena, L.J. Orvidas, Factors associated with revision adenoidectomy, Otolaryngol. Head Neck Surg. 146 (6) (2012) 984–990. [21] T. Arun, F. Isik, K. Sayinsu, Vertical growth changes after adenoidectomy, Angle Orthod. 73 (2) (2003) 146–150. [22] L. Zettergren-Wijk, C.M. Forsberg, S. Linder-Aronson, Changes in dentofacial morphology after adeno-/tonsillectomy in young children with obstructive sleep apnea—a 5-year follow-up study, Eur. J. Orthod. 28 (4) (2006) 319–326.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Nasalance scores in pediatric patients after adenoidectomy Arzu Tuzuner *,1, Sule Demirci 1, Ahmet Akkoc 1, Erhan Arslan 1, Necmi Arslan 1, Etem Erdal Samim 1 Department of Otorhinolaryngology—Head and Neck Surgery, Ministry of Health,Ankara, Training and Research Hospital, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 November 2013 Received in revised form 6 January 2014 Accepted 8 January 2014 Available online 16 January 2014
Objective: Adenoidectomy is one of the most frequently performed operations in childhood. Nasal obstruction and chronic infection are the basic indications for surgery. Nasometer measures both oral and nasal air pressure during loud speech, and calculates their ratio. The aim of this study was to compare the mean nasal values in patients who had adenoidectomy at different ages against a control group. Methods: Eighty children between the ages of three and sixteen that had adenoidectomy in our clinic between 2006 and 2010 were compared against eighty age-matched controls who had not had nasal obstruction in their lifetime and were proven to have open nasal airways on physical examination. Results: Statistical analysis of the data showed that mean nasalance scores were significantly lower in patients who had adenoidectomy before 6 years of age when compared to the ones who had the operation after the age of six. In addition, when we compared the children who had adenoidectomy before 5 years of age and between 5and 6 years of age, we found that their nasalance scores were significantly lower when compared to those who had adenoidectomy after the age of six (p = 0.017 and p = 0.019, respectively). Conclusion: This study has shown that, even when adenoidectomy is performed, hyponasality may continue in clinically symptomatic patients under the age of six, and that there are no determined risk factors other than the early age. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Adenoidectomy Nasal speech Nasometer Craniofacial development
Introduction Nasopharyngeal adenoids are the part of the Waldeyer ring situated at the posterior of the nasal cavity. Diffuse enlargement of this lymphoid tissue is the most frequent cause of nasal obstruction during childhood, and most frequently seen between the ages of 3 and 6 [1,2]. Excessive enlargement of the adenoids can cause disorders such as sleep apnea, sleep-related disorders, an increase in nasal speech and chronic otitis media with effusion due to Eustachian tube dysfunction [3,4]. Although most of the aforementioned disorders improve after adenoidectomy and resolution of nasal obstruction, inhibition of facial skeleton development may result in permanent changes such as a narrower airway and increased vertical facial height. Adenoid or adenotonsillar hypertrophy may cause defects in balance of oropharyngeal, maxillary and mandibular development.
* Corresponding author. Tel.: +90 312 5953556/+90 505 9487932; fax: +90 312 5083166. E-mail addresses: [email protected], [email protected] (A. Tuzuner). 1 The paper was presented as poster. 0165-5876/$ – see front matter ß 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2014.01.010
The hardware and software of Nasometer II was defined by Kay in 1986. Since then, Nasometer has become an international standard for objective evaluation of patients with nasality problems. Nasometer measures oral and nasal air pressure separately during loud speech and calculates their ratio [5,6]. It is a highly sensitive diagnostic method for evaluation of hypo/ hypernasality, and is frequently used for postoperative follow up of cleft lip–palate and velopharyngeal insufficiency patients as well as postoperative evaluation of maxillofacial surgery [7,8]. This study aims to compare nasal resonance averages after adenoidectomy with healthy controls, and determine the demographic data which could affect the differences in nasal speech. Material and methods The study population consisted of eighty children (adenoidectomy age between 3 and 16 years) who had adenoidectomy due to chronic nasal obstruction in Ankara Education and Research Hospital Otorhinolaryngology Clinic between 2006 and 2010, and eighty controls (age ranging between 7 and 18 years) who were admitted to our outpatient clinic with complaints other than chronic nasal obstruction. The inclusion criterion was having adenoidectomy due
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
to chronic nasal obstruction. The patients who had cleft lip–palate, neurological disorders, velopharyngeal insufficiency, Down syndrome, history of maxillary surgery or tonsillectomy, nasal septum deviation, nasal polyps, allergic rhinitis, recurrent adenoids, nonfluent speech or insertion of ventilation tubes in addition to adenoidectomy due to otitis media with effusion were excluded. Before the study was conducted, the approval of Ankara Education and Research Hospital’s Ethics Committee was obtained. Two hundred and ten patients who fulfilled the inclusion criteria were called by phone and the families of 102 patients accepted to be included in the study. Of these patients, four had recurrent adenoid hypertrophy, eight had allergic rhinitis, seven had nasal septal deviation and three had other exclusion criteria, and therefore they were not included in the study. Both study and the control groups had detailed otorhinolaryngologic examinations including nasal endoscopy. Nasalance measurements were done with Nasometer II model 6450 developed by Kay Elemetrics. The voice analysis was performed in a quite room while the patient was in a sitting position, and the Nasometer headset was placed and adjusted so that the separation plate remained perpendicular to the frontal plane of the subject’s face and comfortably stayed above the upper lip. The microphone was placed approximately 5 cm away from the mouth of the subject. The Nasometer was adjusted before testing each subject. The subject then read a standard text including both nasal and oral sounds, and the speech was recorded with a desktop computer which included Realtek AC97 sound card in CSL signal files format (*.nsp). The text consisted of 725 sounds which 81 of them nasal and 644 of them were oral sounds. Nasal/oral ratio values of the text is 0.125 and oral/nasal value is 7.95. All the participants are read the text without assistance. The data were analyzed in the analysis program to obtain mean nasalance scores. Statistical analysis The data were analyzed using SPSS for Windows 11.5 package program. Normality of distribution was determined using Kolmogorov Smirnov test. Descriptive statistics were presented as mean standard deviation or median (minimum–maximum), and the categorical variables were presented as the number of the cases and %. The importance of the difference for the mean ages between the groups was tested using Student’s t test. The similarity of the gender distribution was analyzed using Pearson’s Chi square test. The importance between the groups for the medians of the clinical measurements was analyzed with Mann Whitney U test when the number of the independent groups was two. Kruskal Wallis test was used when the number of the groups was more than two. When the result of the Kruskal Wallis test indicated a statistically significant result, Conover’s non parametric multiple comparison test was used to determine the situations that caused the difference. A p < 0.05 was regarded as statistically significant.
611
Table 1 The demographic characteristics of the patients according to the groups. Variables
Control group (n = 80)
Study group (n = 80)
p
Age (years) Gender Female Male Age at the surgery (years) Age at the surgery <5 years 5–6 years >6 years
11.7 3.0
11.3 2.9
0.470y 0.874z
43 (53.8%) 37 (46.2%) –
44 (55.0%) 36 (45.0%) 6.6 2.7
– – –
17 (21.3%) 28 (35.0%) 35 (43.7%)
y z
– –
Student’s t test. Pearson’s Chi-square test.
Table 2 The clinical measurements of the patients in the control and the study groups. Variables
Control group (n = 80)
Study group (n = 80)
py
MNS*
38 (26–54)
36 (29–57)
0.206
y *
Mann Whitney U test. MNS: Mean nasalance score.
time range for the text was 67.2(37.6–100) s and in control group was 68.7 (47.2–100) s. The difference between control and study group was not statistically significant (p = 0.753). We divided the patients into three groups according to their ages and compared their nasalance scores. We found that the group <5 years of age and the 5–6 years age group had lower nasalance scores when compared to the control group (p = 0.036 and p = 0.041, respectively). The mean nasalance scores of the group <5 years of age and the 5–6 years age group were significantly lower when compared to the >6 years age group (p = 0.017 and p = 0.019, respectively). The mean nasalance scores were similar in the group that had adenoidectomy at an age >6 years and the control group (p = 0.715) (Table 3) (Figs. 1 and 2). Discussion Hyponasality results from an obstruction in the nasal airway. Air that must be released through the nose is released through the mouth. Any pathology causing obstruction such as nasal polyps, nasal septal deviation, upper respiratory tract infection or adenoid hypertrophy, can cause hyponasality [9–12]. Hypernasality can be encountered in children if the risk factors are not determined preoperatively. Even though the postoperative
Table 3 The clinical measurements of the control group and the study group according to the age at the operation.
Results Patient characteristics Control group consisted of 80 subjects and median age was 11.7 3.0 years. Study group involved 80 children who performed adenoidectomy and median age 11.3 2.9 years. The median age of study group at the time of adenoidectomy was 6.6 2.7 years as shown in Table 1. Comparison of nasalance data The nasalance scores of the study and the control groups were not significantly different. (p = 0.206) as seen in Table 2. The mean
Groups
Mean
Control Operation age <5 years Operation age 5–6 years Operation age >6 years py
38 (26–54)a,b 34 (29–50)a,c 35 (30–52)b,d 37 (29–57)c,d 0.029
a The difference between the control and age at operation <5 years groups was statistically significant (p = 0.036). b The difference between the control group and the group with operation age 5–6 years was statistically significant (p = 0.041). c The difference between the operation age <5 years and operation age >6 years groups was statistically significant (p = 0.017). d The difference between operation age 5–6 years and operation age >6 years groups was statistically significant (p = 0.019). y Kruskal Wallis test.
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
612
Control Group
Study Group
Fig. 1. Nasalance mean scores of control and study group.
Fig. 2. Control and study group comparison nasalance mean scores regarding at the operation ages.
changes in nasality are thought to be transient, recovery can occur in a few weeks or can be delayed for 1 year [13,14]. Adenoid hypertrophy is a frequently seen condition in children before adolescence and in the adolescent period. Enlarged adenoid tissue causes mouth breathing during sleep, snoring, frequent awakenings, growth or developmental retardation, frequent upper respiratory tract infections and abnormalities in maxillofacial development. A big adenoid tissue obstructs nasal airflow and causes passage of the air through the mouth instead of the nose, and this ends up with hyponasality. On the other hand, after adenoidectomy, hypernasality and velopharygeal insufficiency can be seen in some high risk patients [11,12]. Wallner et al. investigated [15] the voice changes subjectively after adenotonsillectomy in 1968 for the first time in the literature. The speech pathologist determined voice changes in 26 of 29 patients, and severe and persistent nasality was determined in five of them. In 1991 Andreassen et al. [16] studied aerodynamic,
acoustic and perceptual changes after adenoidectomy in children and determined nasal airway resistance, nasality scores and the perceptual ratio or nasality preoperatively and at postoperative 1st, 3rd and 6th months. They found a significant increase in nasality and a decrease nasal airway resistance, but they could not determine statistically significant differences in the perception measurements. Watterson et al. [17], compared nasalance and hypernasality scores using a sentence made up of nasal consonants in 25 children between the ages of 3 and 13 years in 1998. They determined that nasometer values and specialist opinions agreed in 84% of the cases with hypernasality (sensitivity). The nasometer scores and specialist opinions agreed in 88% of the normal cases (specificity). Dalston et al. [7] investigated 117 craniofacial patients in 1991 and found the sensitivity and specificity of nasalance scores as 0.89 and 0.95 for correct determination of the hypernasal sounds. Andreassen et al. [16] performed a study in 1991 and found an increase in the nasalance scores after adenoidectomy. Williams et al. [18] found an increase in nasalance after tonsillectomy with and without adenoidectomy for nasal voices in 1992. Subramaniam et al. [19] analyzed the effect of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice, and found that preoperative mean nasalance values were higher compared to the healthy children, nasalance tended to decrease in the postoperative period but this was not statistically significant, and the nasalance values were correlated with the degree of the hypertrophy in children with tonsillar hypertrophy. Recurrent adenoids are one of the postoperative reasons for hyponasality, and hyponasality is more frequently seen in cases that have surgery at an early age. Dearking et al. made a cohort study on 8245 patients and found that 163 (3%) of the children needed revision adenoidectomy after a follow up period of 10 years, and early age was a significant risk factor in those cases [20]. In this study, six of seven patients in whom nasometry could not be performed due to recurrent adenoids had adenoidectomy at 5 years of age or earlier. The data obtained in this study showed that mean nasalance scores of children who had adenoidectomy before 5 years of age were lower than the control group than the ones who were operated at a later age. There can be several explanations for this. The first hypothesis claims that the cases experience severe nasal obstruction during the first 4 years of life when maxillofacial development is completed to a large extent (60%) are more prone to persistent changes. To test this hypothesis, a vertically directed growth pattern was analyzed in 66 pediatric patients who had adenoidectomy at an early and a late age (<4 years of age and >4 years of age), and the results were compared with 27 controls who were described as having a clear airway. The study did not show any significant cephalometric differences during a 1 year follow up period; however there was an increase in the vertical growth pattern in the adenoidectomy group when compared to the controls [21]. Zettergren-Wijk et al. compared postoperative 1st, 3rd and 5th year cephalograms of 17 patients who had tonsillectomy and/or adenoidectomy at a mean age of 5.6 1.34 years for obstructive sleep apnea with a healthy control group. At the end of the 5th year, the length of cranial base was found statistically significantly shorter. In addition, when a soft tissue profile was examined, the nose was less pronounced compared to the control group and the length of the cranial base was shorter [22]. The second hypothesis claims that a long obstruction time due to the families’ and the surgeons’ drawbacks in the decision making period causes a disruption of the maxillofacial development in this age group. In this age group, we could not find any data on the permanent effects of the duration of the nasal obstruction and the age of adenoidectomy on craniofacial development and nasopharyngeal airway’s area.
A. Tuzuner et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 610–613
Conclusion After adenoidectomy, hypo- or hypernasality can be seen depending on the risk factors. If there is no additional etiology causing velopharyngeal insufficiency, this condition is usually transient. We did not find permanent hypernasality in our study. When we compared the nasality scores of the adenoidectomized patients with the control group, we did not find any differences, and this indicates normal nasality values in these patients. When hyponasality is considered, we found that hyponasality could continue even after adenoidectomy if the patient had the operation at an early age. To explain this finding, long term controlled studies are needed describing preoperative data including the duration of obstruction and the age when obstruction began. References [1] L.M. Wolford, D. Perez, E. Stevao, E. Perez, Airway space changes after nasopharyngeal adenoidectomy in conjunction with Le Fort I osteotomy, J. Oral Maxillofac. Surg. 70 (3) (2012) 665–671. [2] S.E. Mattar, F.C. Valera, G. Faria, M.A. Matsumoto, W.T. Anselmo-Lima, Changes in facial morphology after adenotonsillectomy in mouth-breathing children, Int. J. Paediatr. Dent. 21 (5) (2011) 389–396. [3] F.E. Waleed, A.F. Samia, Samar MF impact of sleep-disordered breathing and its treatment on children with primary nocturnal enuresis, Swiss Med. Wkly. 141 (2011) w13216. [4] M.T. van den Aardweg, A.G. Schilder, E. Herkert, C.W. Boonacker, M.M. Rovers, Adenoidectomy for otitis media in children, Cochrane Database Syst. Rev. 20 (1) (2010) CD007810. [5] K.H. Hong, S. Kwon, S.S. Jung, The assessment of nasality with a nasometer and sound spectrography in patients with nasal polyposis, Otolaryngol. Head Neck Surg. 117 (1997) 343–348. [6] R.M. Dalston, G.S. Neiman, G. Gonzalez-Landa, Nasometric sensitivity and specificity: a cross-dialect and cross-culture study, Cleft Palate Craniofac. J. 30 (1993) 285–291.
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[7] R.M. Dalston, D.W. Warren, E.T. Dalston, Use of nasometry as a diagnostic tool for identifying patients with velopharyngeal impairment, Erratum in: Cleft Palate Craniofac. J. 28 (4) (1991) 446. [8] J. Rieger, J. Wolfaardt, H. Seikaly, N. Jha, Speech outcomes in patients rehabilitated with maxillary obturator prostheses after maxillectomy: a prospective study, Int. J. Prosthodont. 15 (2) (2002) 139–144. [9] C.C. McLean, S.W. Kelly, M.C. Manley, An instrument for the non-invasive objective measurement of velar function during speech, Med. Eng. Phys. 19 (1997) 7–14. [10] D.R. Bone, S.C. McFarlane, The Voice and Voice Therapy, sixth ed., Allyn & Bacon, USA, 2000. [11] S.F. Austin, Movement of the velum during speech and singing in classically trained singers, J. Voice. 11 (1997) 212–221. [12] M. Morrison, L. Rammage, The Management of Voice Disorders, first ed., Chapman & Hall Medical, London, 1994. [13] M.L. Andreassen, H.A. Leeper, D.L. MacRae, I.R. Nicholson, Aerodynamic, acoustic, and perceptual changes following adenoidectomy, Cleft Palate Craniofac. J. 31 (1994) 263–270. [14] J.S. Greene, T.E. Zipfel, M. Harlor, The effect of uvulopalatopharyngoplasty on the nasality of voice, J. Voice. 18 (2004) 423–430. [15] L.J. Wallner, B.J. Hill, W. Waldrop, C. Monroe, Voice changes following adenotonsillectomy. a study of velar function by cinefluorography and video tape, Laryngoscope 78 (1968) 1410–1418. [16] M.L. Andreassen, H.A. Leeper, D.L. MacRae, Changes in vocal resonance and nasalization following adenoidectomy in normal children: preliminary findings, J. Otolaryngol. 20 (4) (1991) 237–242. [17] T. Watterson, K.E. Lewis, C. Deutsch, Nasalance and nasality in low pressure and high pressure speech, Cleft Palate Craniofac. J. 35 (1998) 293–298. [18] R.G. Williams, M. Preece, R. Rhys, R. Eccles, The effect of adenoid and tonsil surgery on nasalance, Clin. Otolaryngol. Allied Sci. 17 (1992) 136–140. [19] V. Subramaniam, P. Kumar, Impact of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice: a comparative study, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 966–969. [20] A.C. Dearking, B.D. Lahr, A. Kuchena, L.J. Orvidas, Factors associated with revision adenoidectomy, Otolaryngol. Head Neck Surg. 146 (6) (2012) 984–990. [21] T. Arun, F. Isik, K. Sayinsu, Vertical growth changes after adenoidectomy, Angle Orthod. 73 (2) (2003) 146–150. [22] L. Zettergren-Wijk, C.M. Forsberg, S. Linder-Aronson, Changes in dentofacial morphology after adeno-/tonsillectomy in young children with obstructive sleep apnea—a 5-year follow-up study, Eur. J. Orthod. 28 (4) (2006) 319–326.