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Videonasopharyngoscopy as an instrument for visual biofeedback during speech in cleft palate patients
International Journal of Pediatric Otorhinolaryngology 41 (1997) 291 – 298
Videonasopharyngoscopy as an instrument for visual biofeedback during speech in cleft palate patients Antonio Ysunza a,*, MaCarmen Pamplona a, Tatiana Femat a, Ivonne Mayer a, Manuel Garcı´a-Velasco b a
Phoniatrics Department, Hospital Gea Gonza´lez, 4899 Calzada Tlalpan, Mexico D.F. 14000, Mexico b Plastic Surgery Department, Hospital Gea Gonza´lez, 4899 Calzada Tlalpan, Mexico D.F. 14000, Mexico Received 8 December 1996; received in revised form 7 July 1997; accepted 9 July 1997
Abstract Videonasopharyngoscopy was used as an instrument for visual biofeedback during speech in cleft palate patients. Seventeen cleft palate patients were randomly selected for the study. All patients showed velopharyngeal insufficiency (VPI), compensatory articulation (CA) and negative movement of lateral pharyngeal walls (NMLPW) during speech. Nine patients received speech therapy for correcting CA. Eight patients received speech therapy and underwent videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter. After 12 weeks, NMLPW was modified in the patients receiving speech therapy and visual biofeedback. In contrast, NMLPW was still present in eight out of nine patients receiving only speech therapy. These patients received visual biofeedback and NMLPW was corrected in all cases. After six months, all 17 patients had corrected CA during isolated speech. All patients received a tailor-made pharyngeal flap. VPI was completely corrected in 15 cases. In the two cases in which VPI was still present postoperatively, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used postoperatively for increasing lateral pharyngeal walls (LPW) motion towards the borders of the flap. After 18 months since the onset of speech therapy all the patients had normal nasal resonance and normal articulation during connected speech. © 1997 Elsevier Science Ireland Ltd. * Corresponding author. 0165-5876/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 0 9 6 - 7
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A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
Keywords: Videonasopharyngoscopy; Biofeedback; Velopharyngeal insufficiency; Speech
1. Introduction Surgical treatment of cleft palate corrects velopharyngeal insufficiency (VPI) in 80– 90% of the cases [14,15,18,19]. However, even in the best conditions 10–20% of cleft palate patients will show VPI after surgical palate closure. These cases will require a second surgery for achieving complete velopharyngeal closure during speech. Furthermore, the final speech outcome in cleft palate patients depend on articulation as much as correct nasal resonance balance for normality. Certain articulation disorders are generally regarded as compensatory behaviors secondary to VPI [7,10,16,18,19]. In cases of cleft palate, nasal resonance is corrected by physical management of the velopharyngeal sphincter, this is accomplished either by surgery or prosthetic appliances. However, compensatory articulation (CA) disorders associated with poor velopharyngeal function appear to be slightly influenced by physical management of the velopharyngeal sphincter [7,10,18,19]. These disorders require speech therapy since they include dysfunction, not only of the velopharyngeal sphincter, but the entire vocal tract. Hence, the best approach appears to be to correct CA, before surgery for VPI is indicated [7,18]. Several authors have described the use of videonasopharyngoscopy and multiview-videofluoroscopy for the study of patients with VPI [3,5,7,10,14,15,18]. These procedures are widely accepted as state-of-the-art techniques for the direct visual assessment of velopharyngeal movements during speech. Golding-Kushner et al. [5], described the standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy. In this paper, the movement of the lateral pharyngeal walls (LPW) away from each other during speech, was described. This movement is recorded as negative and has been associated with CA [5,7,18] (See Figs. 1 and 2). A tailor-made velopharyngeal flap is widely accepted as a reliable approach for correcting VPI [1,5,15]. When a velopharyngeal flap is performed, complete velopharyngeal closure during speech is achieved through the movement of the LPW towards the borders of the flap occluding both ports. Hence, if negative movement of lateral pharyngeal walls (NMLPW) is present, velopharyngeal closure is practically impossible. Since NMLPW is associated with CA, the correction of CA patterns may change this movement. The use of videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter during speech was described several years ago [11,13]. The finding that subjects were able to change velopharyngeal valving pattern implied the role of learning in velopharyngeal valving and a degree of physiological plasticity in the velopharyngeal sphincter. Hence, visual biofeedback of the velopharyngeal sphincter provides additional information for the patient and the speech pathologist. This procedure may be useful during speech therapy aimed at correcting CA. Moreover, this procedure may help the patient to modify NMLPW.
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293
Fig. 1. Videonasopharyngoscopy: degree of lateral pharyngeal wall (LPW) displacement as described by Golding-Kushner et al. [4]. The opposite lateral wall represents 1.0. The left lateral wall moves 0.15 (distance ratio) toward the right LPW. PPW: posterior pharyngeal wall.
The purpose of this paper is to study whether videonasopharyngoscopy may be used as an instrument for visual biofeedback of the velopharyngeal movements during speech in cleft palate patients and whether it may be useful for correcting NMLPW in association with CA.
Fig. 2. Videonasopharyngoscopy: the lateral pharyngeal walls move outward resulting in a rating of −0.1 (negative movement) as described by Golding-Kushner et al. [4]. PPW, posterior pharyngeal wall.
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2. Material and methods All cleft palate patients at the Cleft Palate Clinic of the Hospital Gea Gonza´lez in Me´xico City, from January 1994 to December 1995, were studied. In order to qualify for the study group for this paper, the patients had to meet the following criteria: 1. Total unilateral cleft of primary and secondary palate (UCLP) [6]. These patients were non-syndromic and their UCLP was not associated with any congenital anomalies, thus ruling out extraneous factors which could influence speech and language development and learning. In other words, the patients had to be normal in all respects other than the UCLP. 2. Cleft palate width had to be grades I or II [2]. 3. Surgical repair of the UCLP had to be performed according to the surgical routine of the Cleft Palate Clinic as reported previously [14]. This routine includes: surgical repair of the lip and primary palate between 1–3, months and surgical repair of the secondary palate between 12–18 months with a push-back palatoplasty [17], and simultaneous posterior pillars pharyngoplasty [9]. 4. The patients had to show VPI after surgical correction of the cleft palate as demonstrated by clinical assessment, and videonasopharyngoscopy, and multi-view videofluoroscopy [7,14,15]. 5. The patients with post-operative fistulae were excluded from the study group. 6. The patients had to show consistent CA in association with VPI. 7. The patients had to show NMLPW as demonstrated by videonasopharyngoscopy, in other words, LPW had to show outward displacement during speech [4]. 8. Speech therapy had to be indicated between 11 and 13 years of age. This age group was selected in order to assure adequate compliance during biofeedback sessions. 9. Language development had to be within normal limits as demonstrated by a battery of age-appropriate standardized language tests [8]. 10. Normal hearing had to be demonstrated by behavioral pure tone audiometry. All the patients had to be able to receive speech therapy, three sessions per week (group 1) and eventually, two additional sessions per week for videonasopharyngoscopic visual biofeedback (group 2). The patients were randomly divided into two groups. Those included in the first group received speech therapy aimed at correcting CA. The patients from the second group also received speech therapy aimed at correcting CA. In addition, videonasopharyngoscopy was used as an instrument for visual biofeedback of the velopharyngeal movements. Biofeedback sessions were received twice a week. The technique for videonasopharyngoscopy has been reported previously [5,13,18]. During the biofeedback sessions, the examiner, the speech pathologist and the patient observed and identified the anatomical structures at rest and during speech. Once the patient
A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
295
was completely aware of the structures and movements, several attempts were made to modify NMLPW during speech. Specific phonemes samples which have been described previously [18] were used. The age of the patients selected for the study allowed adequate compliance in all cases. Each session was : 25 min in length. The examiner and speech pathologist were the same in all cases (first and second authors). The speech pathologist in charge of therapy in the other group of patients without biofeedback was the same in all cases (second author). Speech therapy was received three times a week in sessions of : 60 min in length. Both groups of patients received speech therapy with the same speech pathologist, the frequency and methods [18] were the same. The only difference between the two groups was that one group of patients received additional biofeedback sessions, whereas the other group of patients received only speech therapy. All patients were followed until CA had been corrected during isolated speech. At this point in time, a new videonasopharyngoscopy was performed in order to assess LPW motion. If LPW motion was normal, the patient underwent additional videonasopharyngoscopy and multi-view videofluoroscopy for pre-operative surgical planning. These patients were operated according to the findings of the direct visualization of the velopharyngeal sphincter. All patients received a tailor-made pharyngeal flap. It should be pointed out that posterior pillar pharyngoplasty as described by SanVenero Roselli [9] is not a sphincter pharyngoplasty. This type of pharyngoplasty has been used simultaneously with a push-back palatoplasty in our center for several years [9,14,15,17–19]. Furthermore, tailor-made flaps have been performed routinely in our center in patients with previous posterior pillar pharyngoplasty without complications or technical difficulties [15]. Postoperative results were assessed by videonasopharyngoscopy and multi-view videofluoroscopy.
3. Results Revision was done on 593 cleft palate cases. It should be pointed out that our center receives patients from social environments with several socio-economical limitations. Hence, only a reduced number of patients met all the criteria mentioned herein. The purpose of these criteria was to keep the groups of patients as homogeneous [12] as possible in order to make adequate comparisons. From these patients, only 17 were able to comply with the complete protocol and were finally included in the study group. Nine patients were randomly selected and were included in the first group whereas eight patients were included in the second group. Speech therapy was initiated at a median age of 11 years and 9 months in the first group. Patients from the second group initiated speech therapy at a median age of 11 years and 11 months (Table 1). After 12 weeks, NMLPW had been modified in the patients receiving speech therapy and visual biofeedback. In contrast, in eight of the nine patients receiving only speech therapy, outward displacement of LPW was still present, despite CA had been partially improved. Only one patient had modified LPW motion (Table 2). In the eight patients with persistent NMLPW, visual biofeedback was incorpo-
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Table 1
Total of patients Median age
Group 1 speech therapy
Group 2 speech therapy and biofeedback
9 11 years 9 months
8 11 years 11 months
All patients showed negative movement of lateral pharyngeal walls as demonstrated by videonasopharyngoscopy.
rated into speech therapy sessions. After a few more weeks all patients had been able to modify LPW motion during speech. After six months, all 17 patients had completely corrected CA during isolated speech. During the following months, all patients received a tailor-made pharyngeal flap and VPI was completely corrected in 15 out of 17 cases. In the two cases with postoperative VPI, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used for the second time. Six months later, LPW motion had been improved, achieving complete closure of both ports of the pharyngeal flap during speech. Speech therapy was continued after surgery in all patients and after one more year, articulation was completely normal during connected speech in all cases.
4. Discussion CA significantly reduces velopharyngeal motion and it may produce aberrant movements of the velopharyngeal sphincter such as NMLPW. Several studies have reported that the relative degree of movement of the velum, LPW and posterior pharyngeal wall (PPW) varies from individual to individual [3,5,7,12,13,15,18]. The normal inward displacement of LPW during speech is the result of the action of the superior pharyngeal constrictor muscle [4]. However, it is not clear how the outward displacement of LPW during speech is produced. This movement usually Table 2
Modification of NLPWM Persistent NLPWM Total
Group 1 speech therapy
Group 2 speech therapy and biofeedback
1
8
9
8 9
0 8
8 17
A Fisher exact test demonstrated that visual biofeedback significantly improved lateral pharyngeal wall motion in patients from group 2. NLPWM, negative lateral pharyngeal wall motion. PB0.05.
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appears in association with CA patterns [18,19]. None of the muscles of the velopharyngeal sphincter appears to be responsible for this aberrant displacement. A possible explanation is a passive displacement in response to air pressure at the vocal tract. Videonasopharyngoscopy allows a direct view of the movements of the velopharyngeal sphincter during connected speech. The possibility existed that a videonasopharyngoscopic biofeedback technique could improve inadequate velopharyngeal valving. It seemed possible to change NMLPW motion prior to pharyngeal flap surgery, thereby improving the prognosis of surgery. From the results of this study, it appears evident that the use of videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter is a safe and reliable procedure for helping cleft palate patients to modify aberrant LPW motion associated with CA. Ysunza and Pamplona [18], demonstrated that correction of compensatory patterns of articulation increases velopharyngeal sphincter motion. In this study, the correction of CA patterns was able to modify NMLPW in only one out of nine cases. In contrast, when videonasopharyngoscopy was used as an instrument for visual biofeedback of the velopharyngeal sphincter in addition to speech therapy, all the patients treated with this procedure were able to modify NMLPW in a short period of time. After a tailor-made pharyngeal flap was performed, two patients with postoperative VPI were successfully treated with visual biofeedback increasing LPW motion postoperatively. It is possible that patients younger than 11 years of age could have been able to receive visual biofeedback. It is also possible that a greater number of patients may improve LPW motion as a result of adequate speech therapy without visual biofeedback. However, as mentioned herein, our center receives patients with severe socio-economical limitations and selection of the age of the patients for this study was made based upon previous experience in our center which had demonstrated that several patients younger than 11 years of age were not able to cooperate for the biofeedback procedure [15,18]. Nonetheless, the small number of patients included in this study does not allow us to draw any definite conclusions. Although all the patients included in this small group required surgery for VPI, the possibility exists that sometimes speech therapy with videonasopharyngoscopy as an instrument for visual biofeedback may correct VPI without surgery.
References [1] R.V. Argamaso, R.J. Shprintzen, The role of lateral pharyngeal wall movement in pharyngeal flap surgery, Plast. Reconstr. Surg. 66 (1989) 214 – 219. [2] M.J. Converse, Cleft lip and palate craniofacial deformities, in: M.J. Converse (Ed.), Plastic Surgery, Saunders, Philadelphia, PA, 1977, pp. 2508 – 2070. [3] C.B. Croft, R.J. Shprintzen, S.J. Rakoff, Patterns of velopharyngeal valving in normal and cleft palate subjects: A multiview videofluoroscopic and nasendoscopic study, Laryngoscope 91 (1981) 265–271.
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[4] B. Fritzell, The velopharyngeal muscles in speech, Acta Otolaryngol. 250 (Suppl.) (1969) 1 – 81. [5] K. Golding-Kushner, et al., Standardization for the reporting of videonasopharyngoscopy and multi-view videofluoroscopy. A report from an international working group, Cleft Palate J. 27 (1990) 337–347. [6] D.A. Kernahan, R.B. Stark, A new classification for cleft lip and palate, Plast. Reconstr. Surg. 22 (1958) 435–443. [7] M.C. Pamplona, A. Ysunza, M. Guerrero, I. Mayer, M. Garcı´a-Velasco, Surgical correction of velopharyngeal insufficiency with and without compensatory articulation, Int. J. Pediatr. Otorhinolaryngol. 36 (1996) 53–59. [8] E. Rangel et al., Baterı´a de evaluacio´n de la lengua espan˜ola (BELE) para nin˜os mexicanos de 3 a 11 an˜os, Me´xico SEP-DGEE, pp. 1– 83. [9] G. SanVenero Roselli, Divisione palatina sua cura chirurgica, in: G. SanVenero Roselli (Ed.), Divisione Palatina, Luigi Pozzi, Roma, 1934, pp. 268 – 275. [10] R.J. Shprintzen, K.L. Golding-Kushner, Evaluation of velopharyngeal insufficiency, Otolaryngol. Clin. North Am. 22 (1989) 519–536. [11] R.J. Shprintzen, G.N. McCall, M.L. Skolnik, A new therapeutic technique for the treatment of velopharyngeal incompetence, J. Speech Hear. Disord. 40 (1975) 69 – 83. [12] R.J. Shprintzen, Fallibility of clinical research, Cleft Palate-Craniofac. J. 28 (1991) 136 – 140. [13] V.L. Siegel-Sadewitz, R.J. Shprintzen, Nasopharyngoscopy of the normal velopharyngeal sphincter: an experiment of biofeedback, Cleft Palate J. 19 (1982) 194 – 200. [14] I. Trigos, A. Ysunza, A comparison of palatoplasty with and without primary pharyngoplasty, Cleft Palate J. 25 (1988) 163–166. [15] I. Trigos, A. Ysunza, M. Garcı´a-Velasco, Seleccio´n del procedimiento quiru´rgico para corregir IVF basados en la actividad motora del esfı´nter velofarı´ngeo, Cirugı´a Pla´stica Ibero Latino Americana. 19 (1993) 149–157. [16] J.E. Trost-Cardamone, Speech anatomy physiology and pathology, in: D. Kernahan, S. Rosenthal (Eds.), Cleft Lip and Palate: A System of Management. Williams and Wilkins, Baltimore, 1990, pp. 127–140. [17] W.E. Wardill, Palate repair technique, Br. J. Plast. Surg. 16 (1937) 127 – 135. [18] A. Ysunza, M.C. Pamplona, Change in velopharyngeal valving after speech therapy in cleft palate patients: a videonasopharyngoscopic and multi-view videofluoroscopy study, Int. J. Pediatr. Otorhinolaryngol. 24 (1992) 45–54. [19] A. Ysunza, I. Trigos, N. Baldizon, Sustituciones articulatorias gruesas en el diagno´stico y tratamiento de la I.V.F., Bol. Med. Hosp. Infant. Mex. 44 (1987) 81 – 86.
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Videonasopharyngoscopy as an instrument for visual biofeedback during speech in cleft palate patients Antonio Ysunza a,*, MaCarmen Pamplona a, Tatiana Femat a, Ivonne Mayer a, Manuel Garcı´a-Velasco b a
Phoniatrics Department, Hospital Gea Gonza´lez, 4899 Calzada Tlalpan, Mexico D.F. 14000, Mexico b Plastic Surgery Department, Hospital Gea Gonza´lez, 4899 Calzada Tlalpan, Mexico D.F. 14000, Mexico Received 8 December 1996; received in revised form 7 July 1997; accepted 9 July 1997
Abstract Videonasopharyngoscopy was used as an instrument for visual biofeedback during speech in cleft palate patients. Seventeen cleft palate patients were randomly selected for the study. All patients showed velopharyngeal insufficiency (VPI), compensatory articulation (CA) and negative movement of lateral pharyngeal walls (NMLPW) during speech. Nine patients received speech therapy for correcting CA. Eight patients received speech therapy and underwent videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter. After 12 weeks, NMLPW was modified in the patients receiving speech therapy and visual biofeedback. In contrast, NMLPW was still present in eight out of nine patients receiving only speech therapy. These patients received visual biofeedback and NMLPW was corrected in all cases. After six months, all 17 patients had corrected CA during isolated speech. All patients received a tailor-made pharyngeal flap. VPI was completely corrected in 15 cases. In the two cases in which VPI was still present postoperatively, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used postoperatively for increasing lateral pharyngeal walls (LPW) motion towards the borders of the flap. After 18 months since the onset of speech therapy all the patients had normal nasal resonance and normal articulation during connected speech. © 1997 Elsevier Science Ireland Ltd. * Corresponding author. 0165-5876/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 0 9 6 - 7
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A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
Keywords: Videonasopharyngoscopy; Biofeedback; Velopharyngeal insufficiency; Speech
1. Introduction Surgical treatment of cleft palate corrects velopharyngeal insufficiency (VPI) in 80– 90% of the cases [14,15,18,19]. However, even in the best conditions 10–20% of cleft palate patients will show VPI after surgical palate closure. These cases will require a second surgery for achieving complete velopharyngeal closure during speech. Furthermore, the final speech outcome in cleft palate patients depend on articulation as much as correct nasal resonance balance for normality. Certain articulation disorders are generally regarded as compensatory behaviors secondary to VPI [7,10,16,18,19]. In cases of cleft palate, nasal resonance is corrected by physical management of the velopharyngeal sphincter, this is accomplished either by surgery or prosthetic appliances. However, compensatory articulation (CA) disorders associated with poor velopharyngeal function appear to be slightly influenced by physical management of the velopharyngeal sphincter [7,10,18,19]. These disorders require speech therapy since they include dysfunction, not only of the velopharyngeal sphincter, but the entire vocal tract. Hence, the best approach appears to be to correct CA, before surgery for VPI is indicated [7,18]. Several authors have described the use of videonasopharyngoscopy and multiview-videofluoroscopy for the study of patients with VPI [3,5,7,10,14,15,18]. These procedures are widely accepted as state-of-the-art techniques for the direct visual assessment of velopharyngeal movements during speech. Golding-Kushner et al. [5], described the standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy. In this paper, the movement of the lateral pharyngeal walls (LPW) away from each other during speech, was described. This movement is recorded as negative and has been associated with CA [5,7,18] (See Figs. 1 and 2). A tailor-made velopharyngeal flap is widely accepted as a reliable approach for correcting VPI [1,5,15]. When a velopharyngeal flap is performed, complete velopharyngeal closure during speech is achieved through the movement of the LPW towards the borders of the flap occluding both ports. Hence, if negative movement of lateral pharyngeal walls (NMLPW) is present, velopharyngeal closure is practically impossible. Since NMLPW is associated with CA, the correction of CA patterns may change this movement. The use of videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter during speech was described several years ago [11,13]. The finding that subjects were able to change velopharyngeal valving pattern implied the role of learning in velopharyngeal valving and a degree of physiological plasticity in the velopharyngeal sphincter. Hence, visual biofeedback of the velopharyngeal sphincter provides additional information for the patient and the speech pathologist. This procedure may be useful during speech therapy aimed at correcting CA. Moreover, this procedure may help the patient to modify NMLPW.
A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
293
Fig. 1. Videonasopharyngoscopy: degree of lateral pharyngeal wall (LPW) displacement as described by Golding-Kushner et al. [4]. The opposite lateral wall represents 1.0. The left lateral wall moves 0.15 (distance ratio) toward the right LPW. PPW: posterior pharyngeal wall.
The purpose of this paper is to study whether videonasopharyngoscopy may be used as an instrument for visual biofeedback of the velopharyngeal movements during speech in cleft palate patients and whether it may be useful for correcting NMLPW in association with CA.
Fig. 2. Videonasopharyngoscopy: the lateral pharyngeal walls move outward resulting in a rating of −0.1 (negative movement) as described by Golding-Kushner et al. [4]. PPW, posterior pharyngeal wall.
294
A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
2. Material and methods All cleft palate patients at the Cleft Palate Clinic of the Hospital Gea Gonza´lez in Me´xico City, from January 1994 to December 1995, were studied. In order to qualify for the study group for this paper, the patients had to meet the following criteria: 1. Total unilateral cleft of primary and secondary palate (UCLP) [6]. These patients were non-syndromic and their UCLP was not associated with any congenital anomalies, thus ruling out extraneous factors which could influence speech and language development and learning. In other words, the patients had to be normal in all respects other than the UCLP. 2. Cleft palate width had to be grades I or II [2]. 3. Surgical repair of the UCLP had to be performed according to the surgical routine of the Cleft Palate Clinic as reported previously [14]. This routine includes: surgical repair of the lip and primary palate between 1–3, months and surgical repair of the secondary palate between 12–18 months with a push-back palatoplasty [17], and simultaneous posterior pillars pharyngoplasty [9]. 4. The patients had to show VPI after surgical correction of the cleft palate as demonstrated by clinical assessment, and videonasopharyngoscopy, and multi-view videofluoroscopy [7,14,15]. 5. The patients with post-operative fistulae were excluded from the study group. 6. The patients had to show consistent CA in association with VPI. 7. The patients had to show NMLPW as demonstrated by videonasopharyngoscopy, in other words, LPW had to show outward displacement during speech [4]. 8. Speech therapy had to be indicated between 11 and 13 years of age. This age group was selected in order to assure adequate compliance during biofeedback sessions. 9. Language development had to be within normal limits as demonstrated by a battery of age-appropriate standardized language tests [8]. 10. Normal hearing had to be demonstrated by behavioral pure tone audiometry. All the patients had to be able to receive speech therapy, three sessions per week (group 1) and eventually, two additional sessions per week for videonasopharyngoscopic visual biofeedback (group 2). The patients were randomly divided into two groups. Those included in the first group received speech therapy aimed at correcting CA. The patients from the second group also received speech therapy aimed at correcting CA. In addition, videonasopharyngoscopy was used as an instrument for visual biofeedback of the velopharyngeal movements. Biofeedback sessions were received twice a week. The technique for videonasopharyngoscopy has been reported previously [5,13,18]. During the biofeedback sessions, the examiner, the speech pathologist and the patient observed and identified the anatomical structures at rest and during speech. Once the patient
A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
295
was completely aware of the structures and movements, several attempts were made to modify NMLPW during speech. Specific phonemes samples which have been described previously [18] were used. The age of the patients selected for the study allowed adequate compliance in all cases. Each session was : 25 min in length. The examiner and speech pathologist were the same in all cases (first and second authors). The speech pathologist in charge of therapy in the other group of patients without biofeedback was the same in all cases (second author). Speech therapy was received three times a week in sessions of : 60 min in length. Both groups of patients received speech therapy with the same speech pathologist, the frequency and methods [18] were the same. The only difference between the two groups was that one group of patients received additional biofeedback sessions, whereas the other group of patients received only speech therapy. All patients were followed until CA had been corrected during isolated speech. At this point in time, a new videonasopharyngoscopy was performed in order to assess LPW motion. If LPW motion was normal, the patient underwent additional videonasopharyngoscopy and multi-view videofluoroscopy for pre-operative surgical planning. These patients were operated according to the findings of the direct visualization of the velopharyngeal sphincter. All patients received a tailor-made pharyngeal flap. It should be pointed out that posterior pillar pharyngoplasty as described by SanVenero Roselli [9] is not a sphincter pharyngoplasty. This type of pharyngoplasty has been used simultaneously with a push-back palatoplasty in our center for several years [9,14,15,17–19]. Furthermore, tailor-made flaps have been performed routinely in our center in patients with previous posterior pillar pharyngoplasty without complications or technical difficulties [15]. Postoperative results were assessed by videonasopharyngoscopy and multi-view videofluoroscopy.
3. Results Revision was done on 593 cleft palate cases. It should be pointed out that our center receives patients from social environments with several socio-economical limitations. Hence, only a reduced number of patients met all the criteria mentioned herein. The purpose of these criteria was to keep the groups of patients as homogeneous [12] as possible in order to make adequate comparisons. From these patients, only 17 were able to comply with the complete protocol and were finally included in the study group. Nine patients were randomly selected and were included in the first group whereas eight patients were included in the second group. Speech therapy was initiated at a median age of 11 years and 9 months in the first group. Patients from the second group initiated speech therapy at a median age of 11 years and 11 months (Table 1). After 12 weeks, NMLPW had been modified in the patients receiving speech therapy and visual biofeedback. In contrast, in eight of the nine patients receiving only speech therapy, outward displacement of LPW was still present, despite CA had been partially improved. Only one patient had modified LPW motion (Table 2). In the eight patients with persistent NMLPW, visual biofeedback was incorpo-
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A. Ysunza et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 291–298
Table 1
Total of patients Median age
Group 1 speech therapy
Group 2 speech therapy and biofeedback
9 11 years 9 months
8 11 years 11 months
All patients showed negative movement of lateral pharyngeal walls as demonstrated by videonasopharyngoscopy.
rated into speech therapy sessions. After a few more weeks all patients had been able to modify LPW motion during speech. After six months, all 17 patients had completely corrected CA during isolated speech. During the following months, all patients received a tailor-made pharyngeal flap and VPI was completely corrected in 15 out of 17 cases. In the two cases with postoperative VPI, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used for the second time. Six months later, LPW motion had been improved, achieving complete closure of both ports of the pharyngeal flap during speech. Speech therapy was continued after surgery in all patients and after one more year, articulation was completely normal during connected speech in all cases.
4. Discussion CA significantly reduces velopharyngeal motion and it may produce aberrant movements of the velopharyngeal sphincter such as NMLPW. Several studies have reported that the relative degree of movement of the velum, LPW and posterior pharyngeal wall (PPW) varies from individual to individual [3,5,7,12,13,15,18]. The normal inward displacement of LPW during speech is the result of the action of the superior pharyngeal constrictor muscle [4]. However, it is not clear how the outward displacement of LPW during speech is produced. This movement usually Table 2
Modification of NLPWM Persistent NLPWM Total
Group 1 speech therapy
Group 2 speech therapy and biofeedback
1
8
9
8 9
0 8
8 17
A Fisher exact test demonstrated that visual biofeedback significantly improved lateral pharyngeal wall motion in patients from group 2. NLPWM, negative lateral pharyngeal wall motion. PB0.05.
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appears in association with CA patterns [18,19]. None of the muscles of the velopharyngeal sphincter appears to be responsible for this aberrant displacement. A possible explanation is a passive displacement in response to air pressure at the vocal tract. Videonasopharyngoscopy allows a direct view of the movements of the velopharyngeal sphincter during connected speech. The possibility existed that a videonasopharyngoscopic biofeedback technique could improve inadequate velopharyngeal valving. It seemed possible to change NMLPW motion prior to pharyngeal flap surgery, thereby improving the prognosis of surgery. From the results of this study, it appears evident that the use of videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter is a safe and reliable procedure for helping cleft palate patients to modify aberrant LPW motion associated with CA. Ysunza and Pamplona [18], demonstrated that correction of compensatory patterns of articulation increases velopharyngeal sphincter motion. In this study, the correction of CA patterns was able to modify NMLPW in only one out of nine cases. In contrast, when videonasopharyngoscopy was used as an instrument for visual biofeedback of the velopharyngeal sphincter in addition to speech therapy, all the patients treated with this procedure were able to modify NMLPW in a short period of time. After a tailor-made pharyngeal flap was performed, two patients with postoperative VPI were successfully treated with visual biofeedback increasing LPW motion postoperatively. It is possible that patients younger than 11 years of age could have been able to receive visual biofeedback. It is also possible that a greater number of patients may improve LPW motion as a result of adequate speech therapy without visual biofeedback. However, as mentioned herein, our center receives patients with severe socio-economical limitations and selection of the age of the patients for this study was made based upon previous experience in our center which had demonstrated that several patients younger than 11 years of age were not able to cooperate for the biofeedback procedure [15,18]. Nonetheless, the small number of patients included in this study does not allow us to draw any definite conclusions. Although all the patients included in this small group required surgery for VPI, the possibility exists that sometimes speech therapy with videonasopharyngoscopy as an instrument for visual biofeedback may correct VPI without surgery.
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