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The role of the speech pathologist in velopharyngeal inadequacy
336
British Journal
of Oral and 4laxillofacial
Surgery
examination. light and scanning electron microscope investigations. changes to temporomandibular joint structures were detected in vitro after irradiation with an Erbium:YhG laser system (Carl BAASFL Lasertec: wavelength 2.94 urn. max. cncrgy 2.5 J, max. repetition rate I I IIL, max. average power 15 W). Porcine mandibular joints were used (~24 h post mortem). Within this study. an attempt vvas made to couple the Erbium:YAG laser beam to a new type of libre system. The results and the potential benefits of such a system for clinical arthroscopic applications regarding the temporomandibular joint arc to be discussed. The results suggest that development of a llexiblc delivery system for the ErbiunnYAG laser seems likely in the future. Extensive research is. however, still necessary in this field and has already been initiated.
Consensus viea on the role of fine needle aspiration cytology in the & II. Hussaitl. management uf salivary gland lumps. 34. Mdhk
Department of Oral & Maxillofacial <;uy’s Hospital. London.
Surgery.
UMDS.
I:loor 24;
Needle biopsy was reported as early as 1847 and despite a recent renaissance, it has not obtained universal acceptance amongst suricons. The present study was undertaken to dctemnne the role of I’XAC in the management of salivary gland lumps. The literature was reviewed and a surgical consensus sought from 29 senior head and neck surgeons in USA. Furopc. Australia and the UK. In a review of 2685 articles FNAB was used principally in breast (19X), endomctrial (15%) and liver (14%) disease. Only I%I of the articles related to salivary glands. A review of I I salivary gland studies involving 2178 lesions indicated that, for differentiating benign from malignant disease. FNAC was accurate in 93% casts. The surgical consensus indicated that 14% of respondents did not use the technique, 34% used it routinely to forewarn of possible nerve damage and 52% used it selcctivcly when it was suspL%tcd that the lesion was non neoplastic and surgery could be avoided. FNAC dots not influence the surgical management of the clinically benign tumour and therefore its selective use. when non ncoplastic disease is suspcctcd. would appear to bc the logical application of the technique in the parotid gland.
A comparison of methods for repair of lingual nerve defects. EC G. S&h & I? I’. Rohinsm. Department of Oral and Maxillofacial Surgery. University of Shehield, UK. Repair of a defect in the lingual ncrvc after removal of a damaged scgmcnt may be achieved by stretching the nerve ends togcthcr under tension. or by insertion of a graft. As repair under tension may lead to intraneural fibrosis. and ncrvc grafts may result in donor site morbidity. recent studies have suggested the use of autologous free/e-thawed muscle grafts. The present laboratory study has compared functional recovcry following these three methods. In anaesthetised adult cats the lingual nerve was sectioned, a 4 mm segment of nerve excised, and the defect repaired either by direct apposition with epincurial sutures under tension, insertion of a 4 mm sural nerve graft or insertion of a 4 mm frcczcthawed muscle (masseter) graft (6 animals in each group). After 6 months. recovery of the regenerated tibres was evaluated by measuring salivary flow rates (sccretomotor librcs) and tongue surface tcmpcraturc changes (vasomotor librcs) during clcctrical stimulation of the repaired ncrvcs, and recording integrated whole ncrvc activity and single unit activity from the chorda tympani (gustatory, thcrmoscnsitive and mcchanoscnsitivc fibrcs) and lingual branch of the trigeminal nerve (mechanosensitive and thcrmosensitive fibres). When compared with the other groups. recovery was better after repair under tension; salivary flow rates were higher. conduction velocities faster and the mcchanosensitivc fibrcs had lower force thresholds. There was little diffcrcrence bctwecn the two grafted groups. This study suggests that short lingual nerve defects should be repaired by direct apposition under tension, but if a graft is nwcssary frozen muscle is as eJTective as sural nerw. Supported by the Wellcome Trust.
I‘he efficacy uf late lingual nerve repair.
Smid~. Department of Shcliicld. I:K.
I? P. Robinson
of Oral and Maxillofacial
Surgery.
& K. G. University
‘There is increasing cvidcnce indicating that the repair of lingual nerves damaged during third molar surgery is bcnelicial, although the outcome is variable, Repair is often delayed excessively whilst spontaneous recovery is awaited and this delay may prejudice the prognosis. We have. therefore, studied the level of sensory recovery in IO consecutive patients who had undergone excision of the damaged nerve segment and direct apposition of the cut ends by 5 8: %O cpineurial sutures. after a delay of 7-32 months (mean 18 months) from the initial injury. Recovery was assessed I2 24 months (mean 18 months) after repair. Pre-operatively none of the patients could detect light touch stimuli in the denervated area vvith a 20117X wn Frey hair, whereas 5;lO could detect most or all stimuli after repair. Pin-prick (up to 150 my) was detected in 5~10 pre-operatively and in 8:‘lO after repair, but with raised thrcsho’lds in 4. Two-point discrimination thresholds decreased in 7!lO and in 3 of those became the same as on the uninjured side. Constant current electrical stimuli (up to 500 pA) were detected in 2.‘lO pm-operatively and 9/10 post-repair. Taste stimuli (1 M NaCI; I Xl Sucrose; 0.4 M Acetic acid; 0.1 M Quinine) were dctcctcd in I.:10 pre-operatively and on some occasions in j/IO post-repair. Patients’ subjective assessment of the value of the operation (scale O-JO) ranged from 3-10 (median 7). These results demonstrate that significant and worthwhile recovery occurs in most patients after late lingual nerve repair.
Failed pharygoplast! and subsequent management. L. MO, .!I. .Irrmes & D. Sell. The Hospital for Sick Children, Great Ormond Street;
l.ondon. During the past 100 years more than 40 different surgical procedurcs have been described in an attempt to correct velopharyngcal dysfunction (VPD). Of these, posterior pharyngeal wall flaps and muscle transfers from the lateral pharyngeal walls arc the two types of pharyngoplasty that have stood the test of time. Fach of thcsc procedures yield generally wry satisfactory results in about 70% of patients. .4 study of 18 patients with persistent VPD following pharyngoplasty was undertaken in an attempt to identify the causes of surgical fdilurc. The primary diagnosis in one of the patients was congenital VPD, while the rcmaindcr had a repaired cleft palate. A posterior pharyngcal flap was used in I2 cases (of which I I wrc superiorly based) and the remainder rcceivcd some form of muscle transfer. An analysis of the causes of failure identilicd three main factors: incorrect case sclcction. poor surgical design and poor surgical tcchniquc. Subsequent management of the persistent VPD included nasendoscopy biofeedback therapy, prosthodontics and revisional surgery. The indications for and the results of the various trcatmcnt modalities are presented. with particular reference to the revisional surgical tcchniqucs employed.
The role of the speech pathologist in velopharyngerl inadequacy. D. Se//. The Hospital for Sick Children, Great Ormond Street. London. Given that speech performance reflects the bchaviour of the velopharyngeal mechanism, the speech and language therapist has a central role in the managcmcnt of speech defects related to vclopharyngeal function. The remit of the speech and language therapist includes assessment. diagnosis, treatment. audit and research. This paper examines selected issues and controvcrsics in each of thcsc arcas in speech disorders associated with velopharyngeal inadequacy. For example. a critical review of the literature reveals the limitations of many studies. and highlights the mistakes made in measuring speech outcome. Guidelines for assessment, recording. and documentation for both routine clinical purposes, audit and research are proposed. Based on an audit of a consccutivc series of patients referred vvith suspected disorders of velopharyngeal function between 1990 to present day at the Hospital for Sick Children. Great Ormond Street, and the results of a recent questionnairc of I;K surgeons’ practice. this paper discusses those issues of particular rclcvancc to the speech and language therapist and the surpcon, including the timing of surgery in relation to age
British Journal
of Oral and 4laxillofacial
Surgery
examination. light and scanning electron microscope investigations. changes to temporomandibular joint structures were detected in vitro after irradiation with an Erbium:YhG laser system (Carl BAASFL Lasertec: wavelength 2.94 urn. max. cncrgy 2.5 J, max. repetition rate I I IIL, max. average power 15 W). Porcine mandibular joints were used (~24 h post mortem). Within this study. an attempt vvas made to couple the Erbium:YAG laser beam to a new type of libre system. The results and the potential benefits of such a system for clinical arthroscopic applications regarding the temporomandibular joint arc to be discussed. The results suggest that development of a llexiblc delivery system for the ErbiunnYAG laser seems likely in the future. Extensive research is. however, still necessary in this field and has already been initiated.
Consensus viea on the role of fine needle aspiration cytology in the & II. Hussaitl. management uf salivary gland lumps. 34. Mdhk
Department of Oral & Maxillofacial <;uy’s Hospital. London.
Surgery.
UMDS.
I:loor 24;
Needle biopsy was reported as early as 1847 and despite a recent renaissance, it has not obtained universal acceptance amongst suricons. The present study was undertaken to dctemnne the role of I’XAC in the management of salivary gland lumps. The literature was reviewed and a surgical consensus sought from 29 senior head and neck surgeons in USA. Furopc. Australia and the UK. In a review of 2685 articles FNAB was used principally in breast (19X), endomctrial (15%) and liver (14%) disease. Only I%I of the articles related to salivary glands. A review of I I salivary gland studies involving 2178 lesions indicated that, for differentiating benign from malignant disease. FNAC was accurate in 93% casts. The surgical consensus indicated that 14% of respondents did not use the technique, 34% used it routinely to forewarn of possible nerve damage and 52% used it selcctivcly when it was suspL%tcd that the lesion was non neoplastic and surgery could be avoided. FNAC dots not influence the surgical management of the clinically benign tumour and therefore its selective use. when non ncoplastic disease is suspcctcd. would appear to bc the logical application of the technique in the parotid gland.
A comparison of methods for repair of lingual nerve defects. EC G. S&h & I? I’. Rohinsm. Department of Oral and Maxillofacial Surgery. University of Shehield, UK. Repair of a defect in the lingual ncrvc after removal of a damaged scgmcnt may be achieved by stretching the nerve ends togcthcr under tension. or by insertion of a graft. As repair under tension may lead to intraneural fibrosis. and ncrvc grafts may result in donor site morbidity. recent studies have suggested the use of autologous free/e-thawed muscle grafts. The present laboratory study has compared functional recovcry following these three methods. In anaesthetised adult cats the lingual nerve was sectioned, a 4 mm segment of nerve excised, and the defect repaired either by direct apposition with epincurial sutures under tension, insertion of a 4 mm sural nerve graft or insertion of a 4 mm frcczcthawed muscle (masseter) graft (6 animals in each group). After 6 months. recovery of the regenerated tibres was evaluated by measuring salivary flow rates (sccretomotor librcs) and tongue surface tcmpcraturc changes (vasomotor librcs) during clcctrical stimulation of the repaired ncrvcs, and recording integrated whole ncrvc activity and single unit activity from the chorda tympani (gustatory, thcrmoscnsitive and mcchanoscnsitivc fibrcs) and lingual branch of the trigeminal nerve (mechanosensitive and thcrmosensitive fibres). When compared with the other groups. recovery was better after repair under tension; salivary flow rates were higher. conduction velocities faster and the mcchanosensitivc fibrcs had lower force thresholds. There was little diffcrcrence bctwecn the two grafted groups. This study suggests that short lingual nerve defects should be repaired by direct apposition under tension, but if a graft is nwcssary frozen muscle is as eJTective as sural nerw. Supported by the Wellcome Trust.
I‘he efficacy uf late lingual nerve repair.
Smid~. Department of Shcliicld. I:K.
I? P. Robinson
of Oral and Maxillofacial
Surgery.
& K. G. University
‘There is increasing cvidcnce indicating that the repair of lingual nerves damaged during third molar surgery is bcnelicial, although the outcome is variable, Repair is often delayed excessively whilst spontaneous recovery is awaited and this delay may prejudice the prognosis. We have. therefore, studied the level of sensory recovery in IO consecutive patients who had undergone excision of the damaged nerve segment and direct apposition of the cut ends by 5 8: %O cpineurial sutures. after a delay of 7-32 months (mean 18 months) from the initial injury. Recovery was assessed I2 24 months (mean 18 months) after repair. Pre-operatively none of the patients could detect light touch stimuli in the denervated area vvith a 20117X wn Frey hair, whereas 5;lO could detect most or all stimuli after repair. Pin-prick (up to 150 my) was detected in 5~10 pre-operatively and in 8:‘lO after repair, but with raised thrcsho’lds in 4. Two-point discrimination thresholds decreased in 7!lO and in 3 of those became the same as on the uninjured side. Constant current electrical stimuli (up to 500 pA) were detected in 2.‘lO pm-operatively and 9/10 post-repair. Taste stimuli (1 M NaCI; I Xl Sucrose; 0.4 M Acetic acid; 0.1 M Quinine) were dctcctcd in I.:10 pre-operatively and on some occasions in j/IO post-repair. Patients’ subjective assessment of the value of the operation (scale O-JO) ranged from 3-10 (median 7). These results demonstrate that significant and worthwhile recovery occurs in most patients after late lingual nerve repair.
Failed pharygoplast! and subsequent management. L. MO, .!I. .Irrmes & D. Sell. The Hospital for Sick Children, Great Ormond Street;
l.ondon. During the past 100 years more than 40 different surgical procedurcs have been described in an attempt to correct velopharyngcal dysfunction (VPD). Of these, posterior pharyngeal wall flaps and muscle transfers from the lateral pharyngeal walls arc the two types of pharyngoplasty that have stood the test of time. Fach of thcsc procedures yield generally wry satisfactory results in about 70% of patients. .4 study of 18 patients with persistent VPD following pharyngoplasty was undertaken in an attempt to identify the causes of surgical fdilurc. The primary diagnosis in one of the patients was congenital VPD, while the rcmaindcr had a repaired cleft palate. A posterior pharyngcal flap was used in I2 cases (of which I I wrc superiorly based) and the remainder rcceivcd some form of muscle transfer. An analysis of the causes of failure identilicd three main factors: incorrect case sclcction. poor surgical design and poor surgical tcchniquc. Subsequent management of the persistent VPD included nasendoscopy biofeedback therapy, prosthodontics and revisional surgery. The indications for and the results of the various trcatmcnt modalities are presented. with particular reference to the revisional surgical tcchniqucs employed.
The role of the speech pathologist in velopharyngerl inadequacy. D. Se//. The Hospital for Sick Children, Great Ormond Street. London. Given that speech performance reflects the bchaviour of the velopharyngeal mechanism, the speech and language therapist has a central role in the managcmcnt of speech defects related to vclopharyngeal function. The remit of the speech and language therapist includes assessment. diagnosis, treatment. audit and research. This paper examines selected issues and controvcrsics in each of thcsc arcas in speech disorders associated with velopharyngeal inadequacy. For example. a critical review of the literature reveals the limitations of many studies. and highlights the mistakes made in measuring speech outcome. Guidelines for assessment, recording. and documentation for both routine clinical purposes, audit and research are proposed. Based on an audit of a consccutivc series of patients referred vvith suspected disorders of velopharyngeal function between 1990 to present day at the Hospital for Sick Children. Great Ormond Street, and the results of a recent questionnairc of I;K surgeons’ practice. this paper discusses those issues of particular rclcvancc to the speech and language therapist and the surpcon, including the timing of surgery in relation to age