The Pushback Pharyngeal Flap: An 18-Year Experience.

BACKGROUND: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism. METHODS: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa. RESULTS: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001). CONCLUSIONS: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Speech outcomes following Sommerlad primary palatoplasty: Results of the Ghent University Hospital.

OBJECTIVE AND SUBJECTS: Speech outcomes were described for 16 patients with cleft palate (mean age: 5.4 years) following Sommerlad primary palatoplasty performed by a single surgeon of the Ghent University Hospital. These speech outcomes were compared with those of an age and gender matched control group without cleft palate (mean age: 5.3 years). METHODS: Speech intelligibility/distinctiveness, resonance, nasal airflow and articulation, were perceptually evaluated. Additionally, nasalance values and the NSI 2.0 were determined. RESULTS: In seven patients, speech intelligibility/distinctiveness was disordered. Hypernasality was present in twelve participants, whereas nasal emission and nasal turbulence were perceived in thirteen and five patients respectively. Both perceptual and instrumental speech evaluations were significantly poorer in the patient group in comparison to the control group. CONCLUSIONS: Patients still present with both obligatory and compensatory speech disorders following Sommerlad's palatoplasty. In the future, a Dutch speech assessment protocol will be developed in order to standardize follow-up of these patients and to allow for within-center and inter-center comparisons.

Influence of timing of delayed hard palate closure on articulation skills in 3-year-old Danish children with unilateral cleft lip and palate.

BACKGROUND: Differing results regarding articulation skills in young children with cleft palate (CP) have been reported and often interpreted as a consequence of different surgical protocols. AIMS: To assess the influence of different timing of hard palate closure in a two-stage procedure on articulation skills in 3-year-olds born with unilateral cleft lip and palate (UCLP). Secondary aims were to compare results with peers without CP, and to investigate if there are gender differences in articulation skills. Furthermore, burden of treatment was to be estimated in terms of secondary surgery, hearing and speech therapy. METHODS & PROCEDURES: A randomized controlled trial (RCT). Early hard palate closure (EHPC) at 12 months versus late hard palate closure (LHPC) at 36 months in a two-stage procedure was tested in a cohort of 126 Danish-speaking children born with non-syndromic UCLP. All participants had the lip and soft palate closed around 4 months of age. Audio and video recordings of a naming test were available from 113 children (32 girls and 81 boys) and were transcribed phonetically. Recordings were obtained prior to hard palate closure in the LHPC group. The main outcome measures were percentage consonants correct adjusted (PCC-A) and consonant errors from blinded assessments. Results from 36 Danish-speaking children without CP obtained previously by Willadsen in 2012 were used for comparison. OUTCOMES & RESULTS: Children with EHPC produced significantly more target consonants correctly (83%) than children with LHPC (48%; p < .001). In addition, children with LHPC produced significantly more active cleft speech characteristics than children with EHPC (p < .001). Boys achieved significantly lower PCC-A scores than girls (p = .04) and produced significantly more consonant errors than girls (p = .02). No significant differences were found between groups regarding burden of treatment. The control group performed significantly better than the EHPC and LHPC groups on all compared variables.

[Improving the speech with a prosthetic construction]. / Een prothetische constructie ter verbetering van de spraak.

A 12-year-old boy had problems with his speech due to a defect in the soft palate. This defect was caused by the surgical removal of a synovial sarcoma. Testing with a nasometer revealed hypernasality above normal values. Given the size and severity of the defect in the soft palate, the possibility of improving the speech with speech therapy was limited. At a centre for special dentistry an attempt was made with a prosthetic construction to improve the performance of the palate and, in that way, the speech. This construction consisted of a denture with an obturator attached to it. With it, an effective closure of the palate could be achieved. New measurements with acoustic nasometry showed scores within the normal values. The nasality in the speech largely disappeared. The obturator is an effective and relatively easy solution for palatal insufficiency resulting from surgical resection. Intrusive reconstructive surgery can be avoided in this way.

What more can be done to popularize phonosurgical ideas in everyday handling of vocal folds?

This paper is focused on vocal fold surgery with phonosurgical intent. The aim of this review is to broaden phonosurgical knowledge, spread the ideas of the European Laryngological Society (ELS) on phonosurgery and translate the layered structure and physiology of the vocal fold described in Hirano's classic body-cover model into the graphic illustration of the "fluttering sleeve" created by Dikkers. In numerous countries, where phonosurgery is a relatively novel field of knowledge or still in its infancy, simple patterns and plain associations will serve the best in popularizing sophisticated vocal fold anatomy and preservation surgery and converting it into everyday routine.

Revision laryngeal framework surgery performed by directly pulling the lateral cricoarytenoid muscle.

BACKGROUND: Revision laryngeal framework surgery is usually performed for medialisation laryngoplasty failure, rather than for failure after arytenoid adduction. We describe a new method for revision arytenoid adduction surgery, performed by directly pulling the lateral cricoarytenoid muscle ('lateral cricoarytenoid muscle pull surgery'). METHODS: We describe a case of revision laryngeal framework surgery, present a literature review and describe the advantages of lateral cricoarytenoid muscle pull surgery over the original method of arytenoid adduction using a posterior approach. RESULTS: Medialisation laryngoplasty combined with arytenoid adduction was performed following unilateral vocal fold paralysis from mediastinal surgery, resulting in severe glottic insufficiency. The patient's voice improved after the initial surgery, but had deteriorated 18 months later. Revision surgery was performed using lateral cricoarytenoid muscle pull surgery, and her voice recovered normally in terms of perceptual impression. The post-operative course was uneventful for 10 months following revision surgery. CONCLUSION: To our knowledge, this is the first case of revision arytenoid adduction performed using a lateral cricoarytenoid muscle pull approach. Lateral cricoarytenoid muscle pull surgery should therefore be considered as a new fenestration approach for arytenoid adduction.

Lingual frenectomy and alveolar tap production: an acoustic and perceptual study.

In this phonetic study, productions of the consonant in the stressed syllable position of the word arara as produced by 13 subjects with short and/or anterior lingual frenulum were compared before and after lingual frenectomy. The results from the measurement of the stressed consonant duration and from the identification of the consonant manners of articulation based on the inspection of spectral characteristics are discussed and related to the answers to a perceptual identification test. After surgery, the number of tap productions did not increase, but alveolar productions did. These clinically relevant findings show frenectomy improved tongue mobility, but, as temporal controls were not totally re-established after surgery and 6-month speech therapy sessions, the production of the alveolar tap remained largely unchanged.

The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review.

OBJECTIVE: To systematically review the outcomes of tongue-tie division procedures in patients with ankyloglossia with the goal of (1) deriving clinically oriented insights into the effect of tongue-tie division procedures and (2) identifying needs in knowledge to stimulate further research. DATA SOURCES: Medline, EMBASE, and Cochrane databases were searched without any limitations, for studies published between 1966 and June 2012. REVIEW METHODS: Studies were included (level 4 evidence or above) if subjects of any age had ankyloglossia and underwent tongue-tie release. Outcome measures of interest were any subjective or objective measures of breastfeeding and speech outcomes, or reports of adverse events. RESULTS: In all, 378 abstracts were generated from the literature searches; 20 studies met the criteria for data extraction and analysis. Of those, 15 studies were observational and 5 were randomized controlled trials. Tongue-tie division provided objective improvements in the following: LATCH scores (3 studies); SF-MPQ index (2 studies); IBFAT (1 study); milk production and feeding characteristics (3 studies); and infant weight gain (1 study). Subjective improvements were also noted in maternal perception of breastfeeding (14 studies) and maternal pain scores (4 studies). No definitive improvements in speech function were reported. The only significant adverse events were recurrent tongue-ties that required repeat procedures. CONCLUSION: Ankyloglossia is a well-tolerated procedure that provides objective and subjective benefits in breastfeeding; however, there was a limited number of studies available with quality evidence. There are no significant data to suggest a causative association between ankyloglossia and speech articulation problems. Aspects of ankyloglossia that would benefit from further research are described, and recommendations for tongue-tie release candidacy criteria are provided.

Normative nasalance data in Ugandan english-speaking children.

AIMS: The aim of this study was to obtain normative nasalance values for typically developing Ugandan English-speaking children as a reference point for clinical practice and further research. METHODS: Sixty-nine typically developing Ugandan children (35 males and 34 females, 2.7-13.5 years of age) participated in the study. Nasalance scores were obtained with the Nasometer while children repeated 4 sustained sounds, 14 repeated syllables, 15 sentences (12 oral, 3 nasal) and 2 texts ('Rainbow Passage' and 'Zoo Passage'). Data were analyzed for gender and age dependence. RESULTS: No significant effects of age or gender on nasalance values were obtained; hence, normative values for the overall group were reported. The average nasalance scores for Ugandan English-speaking children were 17 and 64% for the oral and nasal sentences and 33 and 14% for the oronasal and oral text, respectively. CONCLUSION: The normative values are important as a reference point to assess the impact of several surgical procedures and several surgical timing strategies on speech in Uganda.

Impact of tongue reduction on overall speech intelligibility, articulation and oromyofunctional behavior in 4 children with Beckwith-Wiedemann syndrome.

OBJECTIVE: The purpose of this study was to determine the impact of partial glossectomy (using the keyhole technique) on speech intelligibility, articulation, resonance and oromyofunctional behavior. PATIENTS AND METHODS: A partial glossectomy was performed in 4 children with Beckwith- Wiedemann syndrome between the ages of 0.5 and 3.1 years. An ENT assessment, a phonetic inventory, a phonemic and phonological analysis and a consensus perceptual evaluation of speech intelligibility, resonance and oromyofunctional behavior were performed. RESULTS: It was not possible in this study to separate the effects of the surgery from the typical developmental progress of speech sound mastery. Improved speech intelligibility, a more complete phonetic inventory, an increase in phonological skills, normal resonance and increased motor-oriented oral behavior were found in the postsurgical condition. The presence of phonetic distortions, lip incompetence and interdental tongue position were still present in the postsurgical condition. CONCLUSION: Speech therapy should be focused on correct phonetic placement and a motor-oriented approach to increase lip competence, and on functional tongue exercises and tongue lifting during the production of alveolars. Detailed analyses in a larger number of subjects with and without Beckwith-Wiedemann syndrome may help further illustrate the long-term impact of partial glossectomy.

Lingual frenulum: changes after frenectomy.

PURPOSE: To describe the changes after frenectomy concerning mobility and functions of the tongue. METHODS: Participants were 53 subjects who had never undergone speech therapy or lingual frenulum surgery. A specific lingual frenulum protocol with scores was used by speech-language pathologists when there was evidence of frenulum alteration. Ten subjects had abnormal frenulum and were referred to an otolaryngologist for frenectomy. After surgery, the subjects were re-evaluated using the same protocol. Photos and videos were taken for comparison. RESULTS: Thirty days after surgery, the subjects had the shape of the tip of the tongue and its movements improved. Lip closure and speech were also improved. CONCLUSION: Frenectomy is efficient to improve tongue posture, tongue mobility, oral functions, and oral communication.

Frênulo lingual: modificações após frenectomia / Lingual frenulum: changes after frenectomy

OBJETIVO: Descrever as mudanças ocorridas após a frenectomia com relação à mobilidade e funções da língua. MÉTODOS: Foram avaliados 53 sujeitos, os quais nunca haviam se submetido a fonoterapia ou a cirurgia do frênulo. Um protocolo com escores específicos para avaliação do frênulo lingual foi utilizado para avaliar os sujeitos com evidências de alteração neste aspecto. Foi encontrada alteração em dez sujeitos, que foram encaminhados a um otorrinolaringologista para frenectomia. Após a cirurgia, esses sujeitos foram reavaliados pelo fonoaudiólogo utilizando-se o mesmo protocolo. Fotos e vídeos foram usados para comparação. RESULTADOS: Trinta dias após a cirurgia, os sujeitos apresentaram a forma da ponta da língua modificada, assim como os movimentos melhorados. O fechamento labial e a fala também melhoraram. CONCLUSÃO: A frenectomia é eficiente para melhorar a mobilidade e a postura da língua, assim como suas funções, incluindo a produção da fala.

PURPOSE: To describe the changes after frenectomy concerning mobility and functions of the tongue. METHODS: Participants were 53 subjects who had never undergone speech therapy or lingual frenulum surgery. A specific lingual frenulum protocol with scores was used by speech-language pathologists when there was evidence of frenulum alteration. Ten subjects had abnormal frenulum and were referred to an otolaryngologist for frenectomy. After surgery, the subjects were re-evaluated using the same protocol. Photos and videos were taken for comparison. RESULTS: Thirty days after surgery, the subjects had the shape of the tip of the tongue and its movements improved. Lip closure and speech were also improved. CONCLUSION: Frenectomy is efficient to improve tongue posture, tongue mobility, oral functions, and oral communication.

[Neonatal tongue-tie: myths and science].

Anatomical restraining of tongue movement (tongue-tie, ankyloglossia) has been known for centuries and the subject of dozens of articles. The heated debate persists on its clinical significance and indications for treatment. Most authorities in the field of infant feeding and Lactation agree that breastfeeding problems, such as nipple pain and latching difficulties, are common signs of clinicaLly significant tongue-tie and indications for performing a frenotomy, while the sole presence of a visible lingual frenulum is not. In contrast, the lack of a visible frenulum does not rule out the diagnosis of clinically significant tongue-tie since submucosal ties, also called "posterior tongue-tie", may interfere with efficient breastfeeding. Whether tongue-tie interferes with speech articulation to a significant extent is currently unknown. Theoretically, articulation of some consonants (e.g., /s/, /th/, /r/) would be affected by impeded tongue movement. These articulation problems are, however, Less common than tongue-tie itself, and children and adults characteristically use various compensatory techniques of mouth opening and tongue movements. When it is indicated, frenotomy is performed by lifting the tongue and snipping the frenulum with scissors. Complications of frenotomy are rare and consist mainly of self-limited minor bleeding. The significance of posterior tongue tie and the long-term effects of frenotomy performed during early infancy are unresolved issues.

Novel outpatient approach to lower lip reanimation using a palmaris longus tendon sling.

OBJECTIVE: To report a new approach to lower lip reanimation, which can be performed in the outpatient clinic setting. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary and quaternary care academic hospital, Toronto. SUBJECTS AND METHODS: An evaluation of nine patients with marginal mandibular nerve injury, who underwent harvest of the palmaris longus tendon and static suspension of the lower lip, was performed in the outpatient setting. Outcome measures included subjective self-evaluation of the functional and aesthetic results using the Lip Reanimation Outcomes Questionnaire and postoperative photographic grading of symmetry at rest and during three smile poses. Medical records were reviewed for demographics and complications. RESULTS: Seventy-eight percent of patients reported overall improvements in smiling, oral competence, and speech articulation following tendon transfer. Photographic grading by the judging panel found satisfactory smile symmetry postprocedure. CONCLUSIONS: The palmaris longus tendon sling procedure provides an effective, additional option for reanimation of the paralyzed lower lip.

[Pilot study on facial palsy correction with suture suspension]. / Estudio piloto sobre la corrección de la parálisis facial con hilos tensores.

We present a pilot study to evaluate the benefit of static facial suspension with Silhouette sutures. We operated on a female patient with complete facial palsy secondary to otic tuberculosis. The patient has currently achieved satisfactory facial symmetry, mastication and speech production. As a result, self-esteem and social interaction have also been recovered. Static facial suspension with Silhouette sutures is an alternative to dynamic techniques in patients who do not wish to or cannot undergo those more complex surgeries.

Facial animation in patients with Moebius and Moebius-like syndromes.

Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterised predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. Facial paralysis causes inability to smile and bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling. Other relevant clinical findings are incomplete eye closure and convergent strabismus. The authors report on 48 patients with Moebius and Moebius-like syndromes seen from 2003 to September 2007 (23 males and 25 females, mean age 13.9 years). In 20 cases a reinnervated gracilis transplant was performed to re-animate the impaired sides of the face. In this series, all free-muscle transplantations survived the transfer, and no flap was lost. In 19 patients complete reinnervation of the muscle was observed with an excellent or good facial symmetry at rest in all patients and whilst smiling in 87% of cases. In conclusion, according to the literature, the gracilis muscle free transfer can be considered a safe and reliable technique for facial reanimation with good aesthetic and functional results.

Pharyngoplasty after primary repair of clefts of the secondary palate.

Our aim was to identify factors associated with the incidence of pharyngoplasty in patients with clefts of the secondary palate (CP). We studied 351 children born between 1968 and 1999 with CP alone, who had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. During the study period 1968-2007, 68 children (19%) had a pharyngoplasty to improve their speech. Mean follow up time from the primary operation was 16 years (range 2-37). The estimated incidence of pharyngoplasty at 5, 7, 10, and 15 years after the primary operation was 9%, 12%, 14%, and 15%, respectively. Thirty-one (46%) of the pharyngoplasties were done more than seven years after the primary palatal repair. Children with total clefts of the secondary palate had a pharyngoplasty more often than children with clefts of the soft palate alone (7 years incidence: 11 (42%) compared with 22 (10%), p<0.001). Sex, age at time of primary operation, and surgeon's experience were not significantly associated with the necessity for pharyngoplasty. Our study suggested that the necessity for pharyngoplasty is related to the severity of clefts, and duration of observation.

Phonological development in children with obstructive sleep-disordered breathing.

Adeno-tonsillar hypertrophy with obstructive sleep disordered breathing (OSDB) is known to affect oral-motor function, behaviour, and academic performance. Adeno-tonsillectomy is the most frequently performed operation in children, with total tonsillectomy (TE) being more common than partial resection, 'tonsillotomy' (TT). In the present study 67 children, aged 50-65 months, with OSBD were randomized to TE or TT. The children's phonology was assessed pre-operatively and 6 months post-operatively. Two groups of children served as controls. Phonology was affected in 62.7% of OSBD children before surgery, compared to 34% in the control group (p < .001). Also, OSBD children had more severe phonological deficits than the controls (p < .001). Phonology improved 6 months equally after both surgeries. Despite improvement post-operatively, the gap to the controls increased. Other functional aspects, such as oral motor function, were normalized regardless of surgical method--TE or TT. The impact of OSBD should be considered as one contributing factor in phonological impairment.