Bonnie E. Smith

Relationship between rapid maxillary expansion and nasal cavity size and airway resistance: Short- and long-term effects

INTRODUCTION The availability of new, reliable, objective, and 3-dimensional techniques to assess the effects of rapid maxillary expansion on the morphology of the maxillary dental arch, nasal cavity dimensions, and nasal airway resistance led to the development of this research. METHODS Thirty-eight subjects participated in this study (mean age, 13 years). Data were collected before expansion, when the expander was stabilized, when the expander was removed, and 9 to 12 months after the expander was removed. Subjective assessment of improvement in nasal respiration was obtained when the expander was stabilized. Three-dimensional imaging and acoustic rhinometry were used to assess the virtual cast and the nasal cavity, respectively. RESULTS AND CONCLUSIONS The statistically significant short-term effects of RME were (1) mean increases in palatal area, volume, and intermolar distance; (2) a mean reduction of nasal airway resistance; and (3) mean increases in total nasal volume and nasal valve area. Our long-term findings were the following: (1) mean palatal area and intermolar distance were reduced, while palatal volume was stable, and (2) nasal airway resistance was stable, whereas mean nasal cavity volume and minimal cross-sectional area increased. Additionally, 61.3% of our subjects reported subjective improvement in nasal respiration. Weak correlations were found between all variables analyzed.

Changes in Speech following Maxillary Distraction Osteogenesis

OBJECTIVE The purpose of this study was to describe changes in articulation and velopharyngeal function following maxillary distraction osteogenesis. DESIGN This is a descriptive, post hoc clinical report comparing the performance of patients before and after maxillary distraction. The independent variable was maxillary distraction while the dependent variables were resonance, articulation errors, and velopharyngeal function. SETTING The data were collected at a tertiary health care center in Chicago. PATIENTS The data from pre- and postoperative evaluations of 18 maxillary distraction patients were used. OUTCOME MEASURES The outcome measures were severity of hypernasality and hyponasality, velopharyngeal orifice size as estimated using the pressure-flow technique, and number and type of articulation errors. RESULTS At the long-term follow-up, 16.7% exhibited a significant increase in hypernasality. Seventy-five percent of patients with preoperative hyponasality experienced improved nasal resonance. Articulation improved in 67% of patients by the 1-year follow-up. CONCLUSIONS In a predominately cleft palate population, the risk for velopharyngeal insufficiency following maxillary distraction is similar to the risk observed in Le Fort I maxillary advancement. Patients being considered for maxillary distraction surgery should receive pre- and postoperative speech evaluations and be counseled about risks for changes in their speech.

Long-term effects of orthodontic therapy on the maxillary dental arch and nasal cavity

INTRODUCTION Rapid maxillary expansion (RME) can enlarge the maxillary dental arch while increasing nasal cavity volume and nasal valve area, and decreasing upper airway resistance over time. However, the long-term effects of RME on arch morphology and nasal cavity geometry in patients treated with RME compared with the general population are unclear. METHODS Three-dimensional morphometic analysis and acoustic rhinometry were used to evaluate the maxillary dental arches and nasal cavities in a post-RME-treatment group (n = 25) and a control group (n = 25). RESULTS Palatal area and volume increased substantially after expansion and remained stable until posttreatment. Small increases in intermolar distance were not significant between the time points. Nasal airway resistance significantly decreased after RME and remained stable until posttreatment. Nasal cavity volume was stable during expansion and posttreatment. It increased significantly during expander stabilization and 9-12 months after expander removal. The minimal cross-sectional area significantly increased between the end of expansion and expander removal and remained stable until posttreatment. All measurements were comparable with those of the matched controls at posttreatment except for palatal area, which was smaller in the treatment group. CONCLUSIONS RME is a powerful tool to normalize most of the variables investigated. Edgewise orthodontic treatment and a retention regimen that consisted of maxillary circumferential or traditional Hawley retainers met satisfactory standards to stabilize the achieved outcomes. Future studies should include morphometric, functional, and skeletal analyses so that the effects of growth and remodeling are better elucidated.

Objective assessment of the breathe-right device during exercise in adult males.

In order to improve nasal breathing during competition, many athletes recently have been wearing a spring-loaded, external nasal dilator referred to as the Breathe-Right device (BRD). Although there are many subjective claims that this device improves breathing during exercise, there are currently no controlled studies documenting its efficacy. To determine objectively whether the device improves the nasal airway, 20 subjects (10 Caucasian and 10 African-American) were studied during rest and after 15 minutes of exercise using anterior rhinomanometry and acoustic rhinometry to measure changes in airway resistance and minimal cross-sectional area, respectively. We found that the BRD exerts its main effect in the region of the nasal valve improving the airway an overall 21% in our group of subjects. This anatomic improvement in nasal airway resulted in an overall 27% reduction in nasal resistance in the Caucasian group. However, in the African-American group, a wider range of resistance changes was observed with application of the BRD with significant improvement in nasal resistance in some subjects but paradoxical worsening in others. In the African-American group as a whole, no significant change in nasal resistance occured with application of the BRD. These measured differences are likely due to variations in nasal anatomy that exist not only between races but also between individuals within a given race. In addition, this study confirms the well known decongestant effects of exercise providing anatomic data with acoustic rhinometry not previously documented in the literature. Overall improvement in nasal airway seen with application of the BRD occured independent of these exercise-related decongestant effects.

Evaluation of cleft palate speech

Children born with palatal clefts are at risk for speech/language delay and speech problems related to palatal insufficiency. These individuals require regular speech evaluations, starting in the first year of life and often continuing into adulthood. The primary role of the speech pathologist on the cleft palate/craniofacial team is to evaluate whether deviations in oral cavity structures, such as the velopharynx, negatively impact speech production. This article focuses on the assessment of velopharyngeal function before and after palatal surgery.

Long-term follow-up of tracheoesophageal puncture results

Since its introduction by Blom and Singer in 1980, tracheoesophageal puncture with a voice prosthesis has become the most frequently recommended choice for speech rehabilitation of total laryngectomees. Many studies have reviewed the initial speech acquisition success rates following tracheoesophageal puncture; however, long-term follow-up in these initial successes has been lacking. In addition, factors predictive of long-term success with tracheoesophageal speech have not been defined. Over a 10-yearperiod, we retrospectively reviewed all total laryngectomy patients, including those who have undergone primary or secondary tracheoesophageal puncture, at the University of Illinois Hospital and Clinics and the Westside Veterans Administration Hospitals. Survival in the total laryngectomy cohort of 202 patients ranged from 35% to 50%. Forty of these patients underwent tracheoesophageal puncture, in whom survival was 75%. Short-term success with tracheoesophageal speech was approximately 70% for our patients, while long-term success was achieved in 66%. Despite low socioeconomic status and relatively high alcoholism rates, successful maintenance of tracheoesophageal speech was achieved in the majority of cases. Tracheoesophageal speech should therefore be considered as a primary method of vocal rehabilitation in all patients undergoing total laryngectomy.

Pressure-flow measurements for selected oral and nasal sound segments produced by normal adults.

Pressure-flow data are often used to provide information about the adequacy of velopharyngeal valving for speech. However, there is limited information available concerning simultaneous pressure-flow measurements for oral and nasal sound segments produced by normal speakers. This study provides normative pressure, flow, and velopharyngeal orifice area measurements for selected oral and nasal sound segments produced by 10 male and 10 female adult speakers. An aerodynamic categorization scheme of velopharyngeal function, including one typical category and three atypical categories (open, closed, and mixed) is proposed.

Aerodynamic assessment of the results of pharyngeal flap surgery: A preliminary investigation

Voice-quality (i.e., nasality) judgments are commonly used to evaluate the results of pharyngeal flap surgery. However, these are subjective judgments of questionable validity and reliability. This project was designed to systematically evaluate the outcome of pharyngeal flap surgery utilizing objective, quantifiable physiologic (pressure-flow) information. Thirty-one patients who had undergone pharyngeal flap surgery were selected. Pressure-flow measurements and perceptual judgments of speech were obtained following surgery. Results indicated that using pressure-flow criteria, only 52 percent of the outcomes were considered successful. Results also indicated that 35 percent of the cases were characterized by substantial nasopharyngeal airway obstruction. In the present study, these findings, along with the related perceptual phenomenon of denasality, were considered unsuccessful. Finally, results suggest that aerodynamic measurements can be used to assess other surgical techniques designed to correct velopharyngeal insufficiency.

Pressure-flow differences in performance during production of the CV syllables/pi/ and /pa/

Inconsistencies in velopharyngeal function were observed to have been reported in pressure-flow reports. This article introduces our findings from a sample of pressure-flow records and discusses possible implications for management. A retrospective review of the pressure-flow records for 51 patients was completed. All patients had been evaluated at the Craniofacial Center, University of Illinois at Chicago. Records were selected based on the following criteria: patients were referred for evaluation of velopharyngeal function and had no secondary surgeries on the velopharyngeal mechanism, no fistulae, no neurologic disorders, and no compensatory articulations. At the time of testing, patients ranged in age from 4 to 38 years with most being under 18 years of age. Velopharyngeal orifice areas were obtained using the pressure-flow technique during repeated CV syllables, including /pi/ and /pa/. Our results show that 8 of 51 patients exhibited a specific type of inconsistent velopharyngeal function (i.e., they exhibited velopharyngeal closing during /pa/ repetitions, but had openings during /pi/ repetitions). The reverse finding was not observed among any of the 51 patients. We concluded that the velopharyngeal incompetence observed during utterances involving /i/ may have been due to the downward pull on the palate of the palatoglossus muscle, which could not be counteracted by the already maximized levator activity in borderline patients.

Laryngeal airway resistance in cleft palate children with complete and incomplete velopharyngeal closure.

OBJECTIVE This study investigated the effect of velopharyngeal insufficiency on aerodynamic measures of laryngeal function in children with cleft palate. DESIGN Data were analyzed using analysis of covariance. The independent variable was velopharyngeal closure, and the dependent variables were laryngeal resistance, laryngeal airflow, and transglottal pressure. Age and gender were covariates. SETTING The data were collected at The Craniofacial Center, University of Illinois, a tertiary health care center located in Chicago. PATIENTS Thirty-six children with cleft palate were recruited from among the patients at The Craniofacial Center. Ten children with velopharyngeal areas >5 mm2 during oral speech were placed in the incomplete closure group, while 26 children with areas <1 mm2 were placed in the complete closure group. OUTCOME MEASURES The three dependent variables (transglottal pressure, transglottal airflow, and laryngeal resistance) were measured. RESULTS Laryngeal resistance and transglottal pressure were significantly higher, and transglottal airflow was significantly lower in the group with complete closure. CONCLUSIONS In summary, cleft palate patients with complete velopharyngeal closure exhibited higher laryngeal resistances than those with incomplete closure.