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Open nasal speech following adenoidectomy and tonsillectomy
JOURNAL
OF COMMUNICATION
DISORDERS
7 (1914), 26>261
OPEN NASAL SPEECH FOLLOWING ADENOIDECTOMY AND TONSILLECTOMY LEO VAN GELDER, M.D. Otolaryngological Clinic (Phoniarric Department) ) University of Amsterdam. Netherlati
The. author presents a follow-up report on 33 patients with open nasal speech following adenotonsillectomy (incidence one in 3000 patients) and on 4 cases following adenoidectomy (incidence one in 10,000 patients). Important etiological factors mentioned were: congenital malformation or postoperative lesion of the soft palate, an oblong nasopharyngeal shape, and injury to the posterior pharPredisposing factors were speech defects, hearing disordyngeal wall, with traumatic “notching”. ers, mental disorders, as well as retarded body development, asthenia and dolichocephalia, predominantly in the female sex. Speech-therapy was effective in all cases following adenoidectomy and in 26 cases following adenotonsillectomy; 4 patients were submitted to a push-back operation, and 3 to a velopharyngo-plasty. The average velopharyngeal distances in the non-operative cases measured 5 mm for vowels and 2% mm for consonants; in operative cases 7 mm or more for vowels and 4 mm for consonants (roentgenographic analysis by means of velopharyngography). A final evaluation of the speech results is given after a M-year period of follow-up. A slight nasality (near nasal consonants and in some vowels) was perceivable in the majority of the group, which hardly inlluenced the intellieibilitv of sueech.
Adenoidectomy and Open Nasal Speech Adenoidectomy is mentioned by some authors as a cause of postoperative open nasal speech. According to Froeschels ( 195 1) open nasal speech following adenoidectomy only occurs in cases of “latent preoperative rhinolalia,” in which a velopharyngeal closure is effected upon an adenoid. In these cases open nasal speech manifests itself only postoperatively. Imre (1950) ascribes postoperative open nasal speech to a lesion of the tensor or levator muscle of the soft palate, or to damage caused to Passavant’s ridge on the posterior wall of the pharynx. Open nasal speech following adenoidectomy is a rare condition, notwithstanding the fact that an adenoidectomy is the most frequently applied surgical procedure in Western medicine (concerning more than 40% of the population of Westem Europe). Four cases of persistent open nasal speech following adenoidectomy could be observed in our phoniatric department during the last 15 years. It may be estimated that prolonged open nasal speech following adenoidectomy occurs in one out of 10,000 operations. A roentgenogram (velopharyngogram) was made in order to analyse velar length and mobility and to decide upon the necessity of logopedic or operative therapy. The roentgenographical procedure was described in some earlier publi0 American Elsevier Publishing Company,
Inc.,
1974
263
264
LEO VAN GELDER
cations. By this method, initiated by Borel, a positive contrast substance (barium or iodine in oily or watery solution) is administered along the intranasal and intraoral route. The lateral roentgenograms of this series demonstrated an incompetent soft palate, though sufficient in length and mobility; moreover, we observed a large nasopharyngeal space of oblong or oval shape in the anteroposterior direction. This nasopharyngeal anomaly may be considered of primary importance’in open nasal speech following adenoidectomy. In one patient a rectangular, traumatic notch was visible in the posterior-superior angle of the nasopharynx. Velopharyngeal closure during speech could be observed in all four patients in emitting the consonant s. The fact that roentgenological analysis demonstrates the possibility of a velopharyngeal closure, although for a special group of speech sounds (usually for the fricative group of consonants like s and f), underlines the prognostical significance of this type of roentgenograms. In all our cases Passavant’s ridge could be observed on the roentgenograms. Speech therapy was advised; assessment of the speech after 8 years (in 1965) showed satisfactory results without operative procedures. Tonsillectomy
and Open Nasal Speech
While Imhofer (1932) and Gerlings (1934) held that open nasal speech following tonsillectomy would always be of a temporary nature, this statement is not confirmed by recent reports in the literature and by our own experience. Mrs. Borel-Maisonny (1950), in a 25year logopedic practice in Paris, observed 36 cases, all with a preoperative dysfunction of the soft palate, either organic or functional. Guns (1954) on 15,000 cases of adenotonsillectomy, described 30 cases belonging to the preoperative group, and 38 cases with lesions of the soft palate following tonsillectomy. Some Personal
Observations
Number. Out of 10,000 patients in our own practice, four children could be reported with a prolonged open nasal speech following tonsillectomy. Besides these, 29 patients from other clinics could be submitted to a phoniatric and roentgenological examination. Gut of these 33 cases, 25 were girls and 2 were adult young men, 4 had delayed speech development, 1 had mental retardation, 3 had a nasopharyngeal dysplasia (extremely wide nasopharynx) and 3 had a velopalatal hypoplasia (submucous cleft and congenital short palate). Age. The age at which the child was submitted to an adenotonsillectomy varied from % to 10 years; the average age was 4.2 years. Sof Palate. The mobility of the soft palate was examined both by visual inspection and by roentgenogram. The length of the soft palate was described as
OPEN NASAL
relatively
SPEECH FOLLOWING
ADENOIDECTOMY
short in 10 cases at inspection
AND TONSILLECTOMY
and in 18 cases if measured
265
by roent-
genogram . Velopharyngeal Distances. The variations of the velopharyngeal distances were as follows: for vowels (ee, u): between 3 and 11 mm, average 5 mm; and for consonants (s): between 1 and 6 mm, average 241 mm. The experiments of Passavant, Rousselot, Bjork and Nylen should be recalled in this respect, demonstrating that “nasality” is brought about with a velopharyngeal insufficiency that is exceeding 6 mm. Passavant’s Ridge. Pharyngeal action could be observed from the roentgenogram in eight cases, usually with the aspect of a small bar. Nusopharynr. Different configurations of the nasopharynx were seen: Percentage Shape Oblong or oval Spherical Small High and shallow
70% 15% 10% 5%
It is evident that an oblong and deep configuration (dysplastic, infantile type) prevails in this group of patients. It may be assumed that, with an adenoidectomy in an oblong nasopharynx, the horizontal movement of the adenotome may go too far and create an angular notch, whereas in a shallow nasopharynx the vertical movement may be harmful to Passavant’s ridge. Five patients demonstrated a distinct “traumatic notch” in the posterior-superior angle of the nasopharynx: these had an oblong shape of the nasopharynx. Bending of the head in a forward direction renders this notch more visible. General Conclusions (1) Prolonged open nasal speech following adenotonsillectomy, in our experience, occurred in one out of 3000 patients. (2) In 33 patients with this disturbance, the following etiological factors may be enumerated: (a) congenital malformation or postoperative lesion of the soft palate; (b) oblong configuration of the nasopharynx, lesion of nasopharyngeal wall (Passavant’s ridge, levators, tensors); (c) delayed or defective speech development; (d) hearing disturbance; (e) psychoneurotic behavior, mental retardation. Postoperative open nasal speech appeared to be found especially in patients with an infantile, asthenic habit and dolichocephalic skull. The predominating number of girls was remarkable (about 75%). (3) With our roentgenographic analysis we found: in 70% of all cases an oblong nasopharyngeal configuration; in 20% a lesion of the nasopharynx; and
266
LEO VAN GELDER
in 60% a shortened soft palate or a diminished velar mobility. The average velopharyngeal distance found was: for vowels 5 mm (3-l 1 mm); and for consonants 2% mm( l-6 mm). We may remark that in routine examinations of the throat one can neither determine the nasopharyngeal shape nor the presence of a lesion in the nasopharynx. In 30% of our cases a lesion of the soft palate or of its pillars could be observed by visual inspection. (4) The prognosis of the postoperative open nasal speech may be reliably made up by determining the velopharyngeal distances, which can be measured on the roentgenogram some months following the tonsillectomy. With velopharyngeal distances of maximally 7 mm for vowels and 4 mm for consonants the prognosis in a few cases may still be favorable after speech-therapy; in patients with a velopharyngeal distance of 5 mm for vowels and 2?4 mm for consonants speech-therapy usually gave more satisfactory results. (5) With greater velopharyngeal distances than the above mentioned, if intensive speech-therapy has failed, an operative therapy is indicated. From our series of 33 patients seven (21%) were submitted to an operative procedure: a pushback operation was performed upon 4 patients and a velopharyngoplasty upon 3 patients. Of the last group two had a submucous cleft. (6) A roentgenological velopharyngogram is desirable when an adenoidecto my or a tonsillectomy has to be performed in cases of: (a) preoperative open nasal speech; (b) delayed speech development, dyslalia; (c) cleft plate (both open and repaired), cleft uvula; and (d) scarring of the soft palate of the pillars or of the uvula. (7) In a brief follow up report covering 15 years of observation some conclusions may be drawn from our series concerning somatic development, psychosocial level, aspects of velopharyngeal function, nasopharyngeal shape and speech development. The majority of our cases showed a slight retardation in somatic development (asthenic, short figures) while from a psychosocial point of view generally a more mature state was achieved. In one third of the group some traces of scarring and shortening of the soft palate and pillars were still present, while in most cases the nasopharyngeal cavity had been preserving its spacious, oblong configuration from infancy into adolescence. A slight assimilation-nasality (near nasal consonants and some vowels) was perceivable in the majority of the group; it hardly diminished the intelligibility of speech. References Calnan, J. The mobility of the soft palate: radiological 1961, 14, 33. Croatto, L., & Croatto-Martinolli, C. Physiopathologie 11, 124-166.
and statistical
study. Brir. J. Plast Surg.,
du voile du palais. Folk phoniur, 1959,
OPEN
NASAL
SPEECH
FOLLOWING
ADENOIDECTOMY
AND TONSILLECTOMY
267
Froeschels, E. Lehrbuch der Sprachheilkunde (Leipzig 1913). Froeschels, E. Post-operative hyperrhinolalia. Amer. Med. Ass. Arch., Orohyng, 1951,54, 140. Gelder, L. van, De open neusspraak, pathogenese en diagnostiek. Ned. T. Geneesk, 1957, 101, 1005-1011. Gelder, L. van, Het zachte gehemelte bij de spraak. Thesis, Amsterdam. Haarlem: De Erven F. Bohn N.V., 1965. Gelder, L. van, Speech pathology in Holland. In R.W. Rieber and R.S. Brubaker (eds.), Speech Purhology. Amsterdam: North-Holland, 1966, pp. 480-501. Gerlings, P.G., De kliniek der tonsillectomie. Thesis, Amsterdam, 1934. Guns, F., Rhinolalie, voix et chirurgie du nasopharynx. Cadern. cienr. Lisboa, 1954. p. 639. Imre, V., Hyperrhinolalia postoperativa. Proc. VIII Intern. Speech and Voice Therapy Conf. 1950. Basel: Karger, 1951, pp. 49-51. MacMillan, A.S., & Kelemen, G., Radiography of the supraglottic speech organs. Amer. Med. Ass. Arch. Otolaryng., 1952, 55, 671-688. Ommen, B. van, De behandeling van de open neusspraak (protetisch en chirurgisch). Ned. T. Geneesk, 1957, 101,1011-1017. Tameaud, J. La chirurgie et la voix. Ann. O.R.L. (Uruguay), 1955, 83-94. Tameaud, J., & Seeman, M. La voix et la parole. Paris: Maloine, 1950. Weder, A., Die Sludersche Methode. Forts&r. H.N.O. Basel: Karger, 1964, Vol. 11, pp. 142172.
OF COMMUNICATION
DISORDERS
7 (1914), 26>261
OPEN NASAL SPEECH FOLLOWING ADENOIDECTOMY AND TONSILLECTOMY LEO VAN GELDER, M.D. Otolaryngological Clinic (Phoniarric Department) ) University of Amsterdam. Netherlati
The. author presents a follow-up report on 33 patients with open nasal speech following adenotonsillectomy (incidence one in 3000 patients) and on 4 cases following adenoidectomy (incidence one in 10,000 patients). Important etiological factors mentioned were: congenital malformation or postoperative lesion of the soft palate, an oblong nasopharyngeal shape, and injury to the posterior pharPredisposing factors were speech defects, hearing disordyngeal wall, with traumatic “notching”. ers, mental disorders, as well as retarded body development, asthenia and dolichocephalia, predominantly in the female sex. Speech-therapy was effective in all cases following adenoidectomy and in 26 cases following adenotonsillectomy; 4 patients were submitted to a push-back operation, and 3 to a velopharyngo-plasty. The average velopharyngeal distances in the non-operative cases measured 5 mm for vowels and 2% mm for consonants; in operative cases 7 mm or more for vowels and 4 mm for consonants (roentgenographic analysis by means of velopharyngography). A final evaluation of the speech results is given after a M-year period of follow-up. A slight nasality (near nasal consonants and in some vowels) was perceivable in the majority of the group, which hardly inlluenced the intellieibilitv of sueech.
Adenoidectomy and Open Nasal Speech Adenoidectomy is mentioned by some authors as a cause of postoperative open nasal speech. According to Froeschels ( 195 1) open nasal speech following adenoidectomy only occurs in cases of “latent preoperative rhinolalia,” in which a velopharyngeal closure is effected upon an adenoid. In these cases open nasal speech manifests itself only postoperatively. Imre (1950) ascribes postoperative open nasal speech to a lesion of the tensor or levator muscle of the soft palate, or to damage caused to Passavant’s ridge on the posterior wall of the pharynx. Open nasal speech following adenoidectomy is a rare condition, notwithstanding the fact that an adenoidectomy is the most frequently applied surgical procedure in Western medicine (concerning more than 40% of the population of Westem Europe). Four cases of persistent open nasal speech following adenoidectomy could be observed in our phoniatric department during the last 15 years. It may be estimated that prolonged open nasal speech following adenoidectomy occurs in one out of 10,000 operations. A roentgenogram (velopharyngogram) was made in order to analyse velar length and mobility and to decide upon the necessity of logopedic or operative therapy. The roentgenographical procedure was described in some earlier publi0 American Elsevier Publishing Company,
Inc.,
1974
263
264
LEO VAN GELDER
cations. By this method, initiated by Borel, a positive contrast substance (barium or iodine in oily or watery solution) is administered along the intranasal and intraoral route. The lateral roentgenograms of this series demonstrated an incompetent soft palate, though sufficient in length and mobility; moreover, we observed a large nasopharyngeal space of oblong or oval shape in the anteroposterior direction. This nasopharyngeal anomaly may be considered of primary importance’in open nasal speech following adenoidectomy. In one patient a rectangular, traumatic notch was visible in the posterior-superior angle of the nasopharynx. Velopharyngeal closure during speech could be observed in all four patients in emitting the consonant s. The fact that roentgenological analysis demonstrates the possibility of a velopharyngeal closure, although for a special group of speech sounds (usually for the fricative group of consonants like s and f), underlines the prognostical significance of this type of roentgenograms. In all our cases Passavant’s ridge could be observed on the roentgenograms. Speech therapy was advised; assessment of the speech after 8 years (in 1965) showed satisfactory results without operative procedures. Tonsillectomy
and Open Nasal Speech
While Imhofer (1932) and Gerlings (1934) held that open nasal speech following tonsillectomy would always be of a temporary nature, this statement is not confirmed by recent reports in the literature and by our own experience. Mrs. Borel-Maisonny (1950), in a 25year logopedic practice in Paris, observed 36 cases, all with a preoperative dysfunction of the soft palate, either organic or functional. Guns (1954) on 15,000 cases of adenotonsillectomy, described 30 cases belonging to the preoperative group, and 38 cases with lesions of the soft palate following tonsillectomy. Some Personal
Observations
Number. Out of 10,000 patients in our own practice, four children could be reported with a prolonged open nasal speech following tonsillectomy. Besides these, 29 patients from other clinics could be submitted to a phoniatric and roentgenological examination. Gut of these 33 cases, 25 were girls and 2 were adult young men, 4 had delayed speech development, 1 had mental retardation, 3 had a nasopharyngeal dysplasia (extremely wide nasopharynx) and 3 had a velopalatal hypoplasia (submucous cleft and congenital short palate). Age. The age at which the child was submitted to an adenotonsillectomy varied from % to 10 years; the average age was 4.2 years. Sof Palate. The mobility of the soft palate was examined both by visual inspection and by roentgenogram. The length of the soft palate was described as
OPEN NASAL
relatively
SPEECH FOLLOWING
ADENOIDECTOMY
short in 10 cases at inspection
AND TONSILLECTOMY
and in 18 cases if measured
265
by roent-
genogram . Velopharyngeal Distances. The variations of the velopharyngeal distances were as follows: for vowels (ee, u): between 3 and 11 mm, average 5 mm; and for consonants (s): between 1 and 6 mm, average 241 mm. The experiments of Passavant, Rousselot, Bjork and Nylen should be recalled in this respect, demonstrating that “nasality” is brought about with a velopharyngeal insufficiency that is exceeding 6 mm. Passavant’s Ridge. Pharyngeal action could be observed from the roentgenogram in eight cases, usually with the aspect of a small bar. Nusopharynr. Different configurations of the nasopharynx were seen: Percentage Shape Oblong or oval Spherical Small High and shallow
70% 15% 10% 5%
It is evident that an oblong and deep configuration (dysplastic, infantile type) prevails in this group of patients. It may be assumed that, with an adenoidectomy in an oblong nasopharynx, the horizontal movement of the adenotome may go too far and create an angular notch, whereas in a shallow nasopharynx the vertical movement may be harmful to Passavant’s ridge. Five patients demonstrated a distinct “traumatic notch” in the posterior-superior angle of the nasopharynx: these had an oblong shape of the nasopharynx. Bending of the head in a forward direction renders this notch more visible. General Conclusions (1) Prolonged open nasal speech following adenotonsillectomy, in our experience, occurred in one out of 3000 patients. (2) In 33 patients with this disturbance, the following etiological factors may be enumerated: (a) congenital malformation or postoperative lesion of the soft palate; (b) oblong configuration of the nasopharynx, lesion of nasopharyngeal wall (Passavant’s ridge, levators, tensors); (c) delayed or defective speech development; (d) hearing disturbance; (e) psychoneurotic behavior, mental retardation. Postoperative open nasal speech appeared to be found especially in patients with an infantile, asthenic habit and dolichocephalic skull. The predominating number of girls was remarkable (about 75%). (3) With our roentgenographic analysis we found: in 70% of all cases an oblong nasopharyngeal configuration; in 20% a lesion of the nasopharynx; and
266
LEO VAN GELDER
in 60% a shortened soft palate or a diminished velar mobility. The average velopharyngeal distance found was: for vowels 5 mm (3-l 1 mm); and for consonants 2% mm( l-6 mm). We may remark that in routine examinations of the throat one can neither determine the nasopharyngeal shape nor the presence of a lesion in the nasopharynx. In 30% of our cases a lesion of the soft palate or of its pillars could be observed by visual inspection. (4) The prognosis of the postoperative open nasal speech may be reliably made up by determining the velopharyngeal distances, which can be measured on the roentgenogram some months following the tonsillectomy. With velopharyngeal distances of maximally 7 mm for vowels and 4 mm for consonants the prognosis in a few cases may still be favorable after speech-therapy; in patients with a velopharyngeal distance of 5 mm for vowels and 2?4 mm for consonants speech-therapy usually gave more satisfactory results. (5) With greater velopharyngeal distances than the above mentioned, if intensive speech-therapy has failed, an operative therapy is indicated. From our series of 33 patients seven (21%) were submitted to an operative procedure: a pushback operation was performed upon 4 patients and a velopharyngoplasty upon 3 patients. Of the last group two had a submucous cleft. (6) A roentgenological velopharyngogram is desirable when an adenoidecto my or a tonsillectomy has to be performed in cases of: (a) preoperative open nasal speech; (b) delayed speech development, dyslalia; (c) cleft plate (both open and repaired), cleft uvula; and (d) scarring of the soft palate of the pillars or of the uvula. (7) In a brief follow up report covering 15 years of observation some conclusions may be drawn from our series concerning somatic development, psychosocial level, aspects of velopharyngeal function, nasopharyngeal shape and speech development. The majority of our cases showed a slight retardation in somatic development (asthenic, short figures) while from a psychosocial point of view generally a more mature state was achieved. In one third of the group some traces of scarring and shortening of the soft palate and pillars were still present, while in most cases the nasopharyngeal cavity had been preserving its spacious, oblong configuration from infancy into adolescence. A slight assimilation-nasality (near nasal consonants and some vowels) was perceivable in the majority of the group; it hardly diminished the intelligibility of speech. References Calnan, J. The mobility of the soft palate: radiological 1961, 14, 33. Croatto, L., & Croatto-Martinolli, C. Physiopathologie 11, 124-166.
and statistical
study. Brir. J. Plast Surg.,
du voile du palais. Folk phoniur, 1959,
OPEN
NASAL
SPEECH
FOLLOWING
ADENOIDECTOMY
AND TONSILLECTOMY
267
Froeschels, E. Lehrbuch der Sprachheilkunde (Leipzig 1913). Froeschels, E. Post-operative hyperrhinolalia. Amer. Med. Ass. Arch., Orohyng, 1951,54, 140. Gelder, L. van, De open neusspraak, pathogenese en diagnostiek. Ned. T. Geneesk, 1957, 101, 1005-1011. Gelder, L. van, Het zachte gehemelte bij de spraak. Thesis, Amsterdam. Haarlem: De Erven F. Bohn N.V., 1965. Gelder, L. van, Speech pathology in Holland. In R.W. Rieber and R.S. Brubaker (eds.), Speech Purhology. Amsterdam: North-Holland, 1966, pp. 480-501. Gerlings, P.G., De kliniek der tonsillectomie. Thesis, Amsterdam, 1934. Guns, F., Rhinolalie, voix et chirurgie du nasopharynx. Cadern. cienr. Lisboa, 1954. p. 639. Imre, V., Hyperrhinolalia postoperativa. Proc. VIII Intern. Speech and Voice Therapy Conf. 1950. Basel: Karger, 1951, pp. 49-51. MacMillan, A.S., & Kelemen, G., Radiography of the supraglottic speech organs. Amer. Med. Ass. Arch. Otolaryng., 1952, 55, 671-688. Ommen, B. van, De behandeling van de open neusspraak (protetisch en chirurgisch). Ned. T. Geneesk, 1957, 101,1011-1017. Tameaud, J. La chirurgie et la voix. Ann. O.R.L. (Uruguay), 1955, 83-94. Tameaud, J., & Seeman, M. La voix et la parole. Paris: Maloine, 1950. Weder, A., Die Sludersche Methode. Forts&r. H.N.O. Basel: Karger, 1964, Vol. 11, pp. 142172.