Relating speech and swallow function to dropout in a longitudinal study of head and neck cancer.

The relation between functional outcome and dropout from a 12-month follow-up period was examined in a longitudinal study whose objective was to define and quantify the functional effects of oral surgical resection and reconstruction on speech and swallowing in patients with head and neck cancer. In a group of 150 patients recruited to a surgical study in the Cancer Control Science Program in Head and Neck Cancer Rehabilitation, dropout from all causes and dropout from specific causes (medical, patient, and administrative specific) were assessed in relation to longitudinal speech and swallow function. In univariate analysis, better speech articulation was associated with decreased risk of dropout from all causes and from medical-specific causes. Better swallow performance was associated with decreased risk of medical-specific dropout. Multivariate analysis revealed the following: (1) only articulation function was associated with dropout from all causes; (2) the association of speech articulation function with medical dropout was diminished after adjusting for advanced age and surgical resection variables; (3) the association of speech articulation function became significant for patient-specific dropout after adjusting for advanced age and surgical resection variables and indicated that better function decreased the risk of this type of dropout; and (4) swallowing function was not related to dropout. Patients treated for oral or oropharyngeal cancer who have poorer speech outcomes are more likely to drop out from a longitudinal study. Basing study results on only patients who complete a longitudinal study will understate the level of dysfunction experienced.

Factors related to dropout in a study of head and neck cancer patients after surgery.

The extent and nature of dropout was assessed in a longitudinal study whose objective was to define and quantify the functional effects of oral surgical resection and reconstruction on speech and swallowing function in patients with head and neck cancer. Of 150 patients who were enrolled to be followed up with speech and swallow assessments for 1 year after surgery, 113 (75%) dropped out and 37 (25%) returned to complete the study at the final 12-month evaluation point. In general, those completing the study had a smaller resection than the patients who dropped out before the 12-month evaluation. Fifty percent of the dropout was accounted for by medical reasons, 23% by administrative reasons, and 27% by patient-specific reasons (i.e., reasons known only to the patient). Analysis of the dropout categories revealed that higher cancer stage, larger volume of resection, and having a flap surgical closure versus a primary closure or skin graft increased a patient's chance of dropping out. A larger volume of resection was also related to an increased chance of being a patient-specific dropout. Patients who reported no or low alcohol usage had a greater chance of completing follow-up than being a patient-specific dropout.

Acoustical and physical dynamics of the diatonic harmonica.

The harmonica is arguably the most widely played instrument in the world, yet there is a surprising paucity of published studies of its acoustics or physical dynamics. The typical diatonic harmonica and the physical forces involved in its natural function are described, and simple observations of the harp's functions are reported. The speaking of the reeds, naturally, when producing a bend, and when speaking as an overblow or overdraw is discussed and investigated by simple stopping of the reeds, by videostroboscopic analysis, and by recording vibration of the reeds with displacement gauges. The reeds of the ten hole harmonica can be made to vibrate at varying frequencies depending on the size and shape of the player's vocal tract. Three different modes of speaking from each hole and its pair of reeds are revealed and studied: first, naturally in a closing mode, either blown or drawn; second, as a bend, either blown or drawn, with pitch in the interval between the two notes in the hole; and third, as an overblow or overdraw in an opening mode with a pitch outside the interval between the two natural notes of the hole. This dynamic interaction allows the player to speak with the instrument perhaps as with no other.

Microwave-cured tracheostoma vents.

This article describes a technique of making custom flexible and combined flexible/rigid tracheostoma vents. The combined flexible rigid tracheostoma vent provides a flexible material that is nonirritating in the peristomial region and maintains a patent tracheostoma by the rigidity of the hard acrylic resin section. The flexible tracheostoma vent can be easily inserted and is more comfortable than the rigid commercially available tracheostomy tube. The use of microwave-cured materials permits fabrication during a single visit. The steps involved in the fabrication of the tracheostoma vents are simple and require no elaborate laboratory equipment.

Discovering the voice in the children's museum.

The authors report on a special section of a Children's Museum which is designed to involve the child and parent in actively learning about vocal function. This approach is recommended as an excellent way to promote interest in healthy vocal function.

Oral endoscopy in prosthodontic management of the soft palate defect.

Telescopic oral endoscopy is an effective aid in the construction and modification of a speech aid prosthesis. The method is noninvasive and easy to perform, permits the prosthodontist to achieve the goal of functional effectiveness in prosthesis construction while keeping the weight and size of the pharyngeal extension at a minimum, decreases the number and length of patient visits required for modification, and when coupled to a fiberoptic teaching arm or a video camera and recording system, it becomes an excellent aid in teaching, patient education and orientation, and record keeping.

The influence of perennial allergic rhinitis on facial type and a pilot study of the effect of allergy management on facial growth patterns.

Perennial rhinitis with an allergic component (PRAC) in association with chronic mouthbreathing has been thought to cause skeletal open-bite facial type and narrow transverse facial dimensions. The object of this study was to supply data for this theory and to determine if allergy management would alter the course of facial growth. When a group of children, aged 5 to 10 years, with PRAC was compared with a matched control sample, a significantly larger palatomandibular angle and lower anterior facial height were found for the PRAC group. Transverse cephalometric measurements showed significantly narrower bilateral orbital breadth, bizygomatic, and binasal dimensions (narrower face) of the PRAC patients compared with the control sample. A pilot study of twelve PRAC patients who received 2 1/2 years of allergy management revealed no significant dento-facial dimensional change. This study suggests that PRAC with chronic mouthbreathing can alter the development of the midface. Whether allergy therapy can prevent or change this is as yet uncertain.

Speech considerations in prosthodontic rehabilitation of the glossectomy patient.

A knowledge of normal articulation is needed before the prosthodontist can assess the compensatory articulation used by glossectomy patients. The amount and portion of tongue resected is directly correlated with speech intelligibility. The loss of the tip of the tongue is more critical to intelligibility than a hemiglossectomy. Partial glossectomy speakers can often use the residual tongue stump to perform adaptive movements that approximate normal movements and should be treated as an articulation problem. The compensatory articulation used by the total glossectomy patient was reviewed. The prosthodontic management of patients with partial tongue resection often includes lowering the palatal vault, while the management of the total glossectomy patient usually requires a mandibular tongue prosthesis. These prostheses can be refined with the use of multiview videofluoroscopy, videotaping, and spectrographic analysis.

Effect of certain head and neck tumors and their management on the ventilatory function of the eustachian tube.

A prospective study was carried out which tested three hypotheses: 1) certain tumors of the head and neck that originate in sites other than the nasopharynx may cause middle ear effusion; 2) middle ear effusion is a predictable sequela of radical maxillectomy as well as total or partial resection of the soft palate; and 3) middle ear effusions that follow surgery to remove head and neck lesions are due to disturbances in palatal function, specifically to tensor veli palatini muscle dysfunction. Our results indicate that one fourth of all subjects had some evidence of middle ear abnormality prior to entering into treatment although they were asymptomatic. The treatment process influenced the function of the middle ear, as 79% of the subjects experienced middle ear-eustachian tube dysfunction following treatment, and 23% were found to have developed a perforation of the tympanic membrane or required myringotomy and tube insertion to relieve middle ear effusion. The results of these studies indicate that surgery that is adequate to remove cancer of the maxilla, tonsil, or palate in most cases interferes with the function of the tensor veli palatini muscle, resulting in functional eustachian tube obstruction. The need for attention to and the treatment of middle ear effusion in such patients is emphasized in light of other sensory deficits in this patient population.

Pharyngeal wall motion in prosthetically managed cleft palate adults.

Fiberoptic nasoendoscopy was used to evaluate the activity in the lateral and posterior pharyngeal walls of five adults with cleft palate, each of whom had worn a prosthetic speech appliance for more than 20 years. Activity during speech was greatest in the area of the levator veli palatini muscle and Passavant's ridge, while no gross activity was observed in the area of the auditory tube superiorly. Activity was variable within and between subjects. Apparent medial movement of the auditory tube seemed to be secondary to the influence of the levator muscle on the pharyngeal wall soft tissues.

Prosthodontic rehabilitation for glossectomy patients.

Patients with oral carcinomas often have resection of the tongue, the floor of the mouth, or the bone of the mandible. Postoperatively, these patients encounter chewing, swallowing, and speech problems. Oral rehabilitation through prosthetic management can aid in alleviating these problems. Designs of the prosthesis vary according to patient needs. A "snap-on" tongue prosthesis or palatal augmentation prosthesis can be constructed. Total glossectomy patients require prosthetic intervention on a mandibular framework. Partial glossectomy patients require prosthetic augmentation on a maxillary framework. Through prosthetic management of this type, articulation and resonance are improved, food is more easily directed into the esophagus, tissues are protected and socialization is enhanced through improved appearance.

A comparative study of four methods of evaluating velopharyngeal adequacy.

Forty-eight subjects with repaired palatal clefts were divided into three major groups on the basis of speech symptoms and were examined for velopharyngeal valving integrity by means of the R-D nasal manometer, pressure-flow techniques, the Hunter oral manometer, and videofluoroscopy. Videofluoroscopy appeared to provide data that most nearly agreed with predictions of valving made from speech. The Hunter oral manometer was the least useful of the four techniques.

Identification of otitis media with effusion in children.

In an effort to establish the diagnostic value of otoscopy, tympanometry, and the middle ear (ME) muscle reflex in the identification of otitis media with effusion (OME), the diagnostic findings by these three methods were compared with the findings at myringotomy in 333 children (500 ears). The study showed that even experienced clinicians had some difficulty in identifying those ears with effusion (sensitivity) and had even greater difficulty in making a diagnosis of those ears without an effusion (specificity). However, tympanometry, employing patterns that have been validated with myringotomy findings, was found to be more accurate. On the other hand, assessment of the ME muscle reflex as a diagnostic method was unacceptable due to an extremely low specificity (52%). An algorithm derived from the combination of the three methods had highest sensitivity (97%) and specificity (90%).

Eustachian tube function in an American Indian population.

A comparatively high prevalence of acute and chronic otitis media (OM) has been reported for the native American Indian population. The present study reports data on the function of the eustachian tube (ET) in 25 White Mountain Apache Indians ranging in age from 3 to 36 years. All study subjects had a history of OM and reported to the reservation clinic with tympanic membrane perforations and a dry middle ear (ME). The results of inflation-deflation tests on these subjects indicated that the Indians had lower forced opening pressures than had been measured in a group of Caucasians with perforations secondary to chronic OM. Of the 23 subjects studied, 67% equilibrated applied positive ME pressures and 38% equilibrate negative pressures by swallowing. During forced response testing, the passive resistance of the ET was found to be lower and the active resistance equivalent to that of a group of Caucasians with traumatic perforations and otherwise negative otologic histories. While the ET was predilated in these subjects by constant airflow, active swallowing further dilated the tube in 67% of the subjects, constricted the tube in 25%, and had no effect in 8%. This study indicated that the ET of the American Indian was functionally different from that of Caucasians previously studied and was characterized by comparatively abnormal, low passive tubal resistance which may be considered to facilitate ventilatory function and to impair protective function. The difference may account for the high prevalence of OM with perforation and the low incidence of cholesteatoma in this population.

Effect of decongestant with or without antihistamine on eustachian tube function.

In an attempt to determine the effect of a decongestant with or without an antihistamine on the ventilatory function of the eustachian tube (ET), two separate studies were conducted in 50 children who had had chronic or recurrent otitis media with effusion (OME) and in whom tympanostomy tubes had been inserted previously. The first was a double-blind study that compared the effect of an oral decongestant, pseudoephedrine hydrochloride, with that of a placebo in 22 children who developed an upper respiratory infection (URI) during an observation period. Certain measures of ET function were significantly elevated above baseline values during the URI, which was attributed to intrinsic mechanical obstruction of the ET. It was found that the oral decongestants tended to alter these parameters of ET function in the direction of the baseline (preURI) values. Even though the effect was statistically significant, the favorable changes in measurements of tubal function were only partial and were more prominent on the second day of the trial after the subjects had received four doses of the decongestant. However, the administration of nasal spray of 1% ephedrine appeared to have no apparent effect on ET function in these children. The second study was a double-blind crossover design. In this study of 28 children who did not have a URI, the effect of a decongestant-antihistamine combination (pseudoephedrine hydrochloride and chlorpheniramine maleate) was compared with that of a placebo. When the subjects were given the decongestant-antihistamine medication, there were favorable changes in certain ET function measures which were not observed when they received the placebo. Again, the response differences between the two groups were statistically significant. Even though these two studies indicated that an oral decongestant appeared to affect favorably the ET function of children who had a URI, and that the combination of an oral decongestant and antihistamine had a similar effect on tubal function in children without a URI, an evaluation of the efficacy of these commonly employed medications must await the results of controlled clinical trials in children with OME.

Longitudinal assessment of Eustachian tube function in children.

Eustachian tube function was evaluated in 27 children (32 ears) with tympanostomy tubes at 6-week intervals for 12 to 30 months. Using a modified inflation-deflation test of passive and active ventilatory function, it was found that the ears had persistent functional obstruction. Most ears exhibited no significant change in tubal function throughout the observation period. There was no difference in the ventilatory function when the nasal airway was congested (other than due to purulent upper respiratory tract infection) and not congested. However, significant seasonal effects on Eustachian tube ventilatory function were recorded: function was poorer in the winter than in the summer. No relationship was found between Eustachian tube ventilatory function and the age of the child.

Cefaclor compared with amoxycillin acute otitis media with effusion: a preliminary report.

A double-blind, randomized clinical trial comparing cefaclor with amoxycillin in the treatment of acute otitis media with effusion (OME) in infants and children is being conducted at Children's Hospital of Pittsburgh. Although the randomization code has not yet been broken, the results of treating the first 55 children are reported, since they appear to be of interest. Of the 62 ears with acute OME on which an initial tympanocentesis was performed, 41 positive cultures were isolated from the middle ear aspirates. Of the 10 ears from which Haemophilus influenzae was isolated, one had a type b strain, and of the remaining unencapsulated strains, one was resistant to both penicillin G and ampicillin. In the one ear from which Staphylococcus aureus was isolated, the organism was found to be resistant to ampicillin. However, all of the organisms were sensitive in vitro to cefaclor. In 88% of all subjects observed for the first 2 weeks, the initial symptomatic response was excellent. Six children had persistent signs and symptoms of acute OME and received a second tympanocentesis; however, none of the effusions from the repeat aspiration revealed an organism. An effusion was still present in 97% of the ears after 3 days, in 69% after 2 weeks, and in 48% 6 weeks after initiation of the study. Tympanocentesis did not appear to affect either the initial clinical response or the persistence of effusion. There were no adverse reactions to either drug in this study. Because an apparent increase in the incidence of ampicillin-resistant strains of H. influenzae is being reported, and because of the presence of ampicillin-resistant S. aureus in some ears with acute OME, a new antimicrobial effective against all the common pathogens causing acute middle ear disease would be desirable. In this respect, the preliminary findings of treatment with cefaclor from this study appear promising.

Function of the Eustachian tube related to surgical management of acquired aural cholesteatoma in children.

A group of 12 children with acquired cholesteatoma had the ventilatory function of the Eustachian tube assessed by the inflation-deflation technique. All had varying degrees of functional rather than mechanical obstruction of the Eustachian tube. In these children, the pathogenesis of acquired cholesteatoma appeared to be the result of the following sequence of events: functional Eustachian tube obstruction, high negative middle ear pressure, atelectasis of the tympanic membrane-middle ear, a retraction pocket in either the posterosuperior or attic portion of the tympanic membrane, and adhesive otitis media. Tympanoplasty in these children was not successful. It is suggested that when the middle ear-mastoidectomy cavity is allowed to remain open, then the bony portion of the Eustachian tube should be surgically closed to prevent postoperative reflux of nasopharyngeal secretions.

Tympanometric patterns found in middle ear effusions.

In 120 ears of 67 children with a history of recurrent acute otitis media or otoscopic evidence of persistent middle ear effusion, or both, tympanograms were obtained using an otoadmittance meter and an electro-acoustic impedance bridge. Myringotomy was performed immediately following the tympanometric evaluation confirming the presence or absence of middle ear effusion. The comparison of myringotomy findings with a tympanometric pattern classification revealed 85.8% overall correct association with the presence or absence of a middle ear effusion for both instruments. In 83.3% of the cases, there was agreement in the classification of the tympanogram between the otoadmittance meter and the electro-acoustic bridge.