Pablo Antonio Ysunza

Current Controversies in Diagnosis and Management of Cleft Palate and Velopharyngeal Insufficiency

Background. One of the most controversial topics concerning cleft palate is the diagnosis and treatment of velopharyngeal insufficiency (VPI). Objective. This paper reviews current genetic aspects of cleft palate, imaging diagnosis of VPI, the planning of operations for restoring velopharyngeal function during speech, and strategies for speech pathology treatment of articulation disorders in patients with cleft palate. Materials and Methods. An updated review of the scientific literature concerning genetic aspects of cleft palate was carried out. Current strategies for assessing and treating articulation disorders associated with cleft palate were analyzed. Imaging procedures for assessing velopharyngeal closure during speech were reviewed, including a recent method for performing intraoperative videonasopharyngoscopy. Results. Conclusions from the analysis of genetic aspects of syndromic and nonsyndromic cleft palate and their use in its diagnosis and management are presented. Strategies for classifying and treating articulation disorders in patients with cleft palate are presented. Preliminary results of the use of multiplanar videofluoroscopy as an outpatient procedure and intraoperative endoscopy for the planning of operations which aimed to correct VPI are presented. Conclusion. This paper presents current aspects of the diagnosis and management of patients with cleft palate and VPI including 3 main aspects: genetics and genomics, speech pathology and imaging diagnosis, and surgical management.

Acoustic analysis of voice in children with cleft palate and velopharyngeal insufficiency

BACKGROUND Acoustic analysis of voice can provide instrumental data concerning vocal abnormalities. These findings can be used for monitoring clinical course in cases of voice disorders. Cleft palate severely affects the structure of the vocal tract. Hence, voice quality can also be also affected. OBJECTIVE To study whether the main acoustic parameters of voice, including fundamental frequency, shimmer and jitter are significantly different in patients with a repaired cleft palate, as compared with normal children without speech, language and voice disorders. MATERIALS AND METHODS Fourteen patients with repaired unilateral cleft lip and palate and persistent or residual velopharyngeal insufficiency (VPI) were studied. A control group was assembled with healthy volunteer subjects matched by age and gender. Hypernasality and nasal emission were perceptually assessed in patients with VPI. Size of the gap as assessed by videonasopharyngoscopy was classified in patients with VPI. Acoustic analysis of voice including Fundamental frequency (F0), shimmer and jitter were compared between patients with VPI and control subjects. RESULTS F0 was significantly higher in male patients as compared with male controls. Shimmer was significantly higher in patients with VPI regardless of gender. Moreover, patients with moderate VPI showed a significantly higher shimmer perturbation, regardless of gender. CONCLUSION Although future research regarding voice disorders in patients with VPI is needed, at the present time it seems reasonable to include strategies for voice therapy in the speech and language pathology intervention plan for patients with VPI.

Synchronous electrical stimulation of laryngeal muscles: an alternative for enhancing recovery of unilateral recurrent laryngeal nerve paralysis.

BACKGROUND Although electrical stimulation of the larynx has been widely studied for treating voice disorders, its effectiveness has not been assessed under safety and comfortable conditions. This article describes design, theoretical issues, and preliminary evaluation of an innovative system for transdermal electrical stimulation of the larynx. The proposed design includes synchronization of electrical stimuli with laryngeal neuromuscular activity. OBJECTIVE To study whether synchronous electrical stimulation of the larynx could be helpful for improving voice quality in patients with dysphonia due to unilateral recurrent laryngeal nerve paralysis (URLNP). MATERIALS AND METHODS A 3-year prospective study was carried out at the Instituto Nacional de Rehabilitacion in the Mexico City. Ten patients were subjected to transdermal current electrical stimulation synchronized with the fundamental frequency of the vibration of the vocal folds during phonation. The stimulation was triggered during the phase of maximum glottal occlusion. A complete acoustic voice analysis was performed before and after the period of electrical stimulation. RESULTS Acoustic analysis revealed significant improvements in all parameters after the stimulation period. CONCLUSION Transdermal synchronous electrical stimulation of vocal folds seems to be a safe and reliable procedure for enhancing voice quality in patients with (URLNP).

Acoustic Analysis and Electroglottography in Elite Vocal Performers

BACKGROUND Acoustic analysis of voice (AAV) and electroglottography (EGG) have been used for assessing vocal quality in patients with voice disorders. The effectiveness of these procedures for detecting mild disturbances in vocal quality in elite vocal performers has been controversial. OBJECTIVE To compare acoustic parameters obtained by AAV and EGG before and after vocal training to determine the effectiveness of these procedures for detecting vocal improvements in elite vocal performers. MATERIALS AND METHODS Thirty-three elite vocal performers were studied. The study group included 14 males and 19 females, ages 18-40 years, without a history of voice disorders. Acoustic parameters were obtained through AAV and EGG before and after vocal training using the Linklater method. RESULTS Nonsignificant differences (P > 0.05) were found between values of fundamental frequency (F0), shimmer, and jitter obtained by both procedures before vocal training. Mean F0 was similar after vocal training. Jitter percentage as measured by AAV showed nonsignificant differences (P > 0.05) before and after vocal training. Shimmer percentage as measured by AAV demonstrated a significant reduction (P < 0.05) after vocal training. As measured by EGG after vocal training, shimmer and jitter were significantly reduced (P < 0.05); open quotient was significantly increased (P < 0.05); and irregularity was significantly reduced (P < 0.05). CONCLUSIONS AAV and EGG were effective for detecting improvements in vocal function after vocal training in male and female elite vocal performers undergoing vocal training. EGG demonstrated better efficacy for detecting improvements and provided additional parameters as compared to AAV.

Diagnosis and Management of Velopharyngeal Insufficiency Associated with Chromosomal Syndromes

All congenital structural defects in the body are the result of an error in morphogenesis. Morphogenesis takes place around 25 to 29 days of intrauterine life. Chromosomal syndromes involve a phenotypically significant structural and/or numerical chromosomal abnormality. An insufficient function of the velopharyngeal sphincter induces excessive nasal resonance during speech. This abnormal resonance is called hypernasality. A deficient seal of the velopharyngeal sphincter creates an airflow leaking into the rhinopharynx, resulting in abnormal air turbulence through the nasal cavities which can be easily perceived and is called nasal emission. Hypernasality and nasal emission are the clinical signs of velopharyngeal insufficiency (VPI). In other words, VPI is the velopharyngeal inability to create an efficient seal during speech. Most chromosomal syndromes cause VPI as a consequence of a cleft palate. However, when patients with a chromosomal abnormality and VPI are being clinically assessed, it is essential to keep in mind that an apparently and morphologically intact uvula and velum do not rule out the possibility of a sub mucous cleft palate. Several chromosomal syndromes can be associated with VPI, including: 22q11.2 deletion syndrome (22q11.2DS) or velocardiofacial syndrome among other names, Opitz G/BBB syndrome (OS), Kabuki syndrome (KS) and Jacobsen syndrome (JS). Pierre – Robin sequence (PRS) can be associated with some chromosomal syndromes. In these ncases, PRS is referred as syndromic PRS. In this paper, the diagnosis and management of VPI in the most common chromosomal syndromes is discussed.

Palatal Protective Stents Prevent Oro-Nasal Fistulas after Surgery for Velopharyngeal Insufficiency: A Preliminary Report

Background: One of the potential complications of surgery for velopharyngeal insufficiency (VPI) is postoperative oral-nasal fistula (ONF). Reported rates vary from 0 to 60%. Several factors are on account of these disproportionate rates. Objective: The purpose of this study was to describe the use of a palatal protective stent (PPS) to preserve the VPI repair surgical site and to study its effectiveness for decreasing the incidence of postoperative ONF. Materials and Methods: A retrospective study was carried out. All patients undergoing surgery for VPI with complete preoperative and postoperative evaluations including at least one year follow up after surgery from 2012 to 2016 were studied. Some of the patients were operated on using a pre-molded palatal protective stent (PPS). Twenty-seven patients were included in the study group. Most of the patients underwent a customized pharyngeal flap according to findings of imaging procedures. The remaining cases underwent a Furlow palatoplasty. Twelve patients were operated on using PPS. Results: There were no surgical complications during the procedures. ONF was detected in four of the patients operated on without PPS. None of the patients undergoing surgery using PPS demonstrated ONF. All fistulas were located at the soft/hard palate junction. VPI was corrected in 92% of the cases. Conclusion: Although only a reduced number of cases were studied, these preliminary results suggest that using PPS during surgical procedures for correcting VPI is a safe and reliable tool for preventing ONF.

Acoustic Analysis of Voice and Electroglottography in Patients With Laryngopharyngeal Reflux

BACKGROUND Laryngopharyngeal reflux (LPR) refers to the flow of gastric acid content into the laryngopharynx. It has been reported that 10% of the patients consulting an otolaryngologist present with this condition. Signs of LPR can be identified during flexible or rigid laryngoscopy. The Voice Handicap Index (VHI) is a reliable tool for detecting the impact of voice disorders, and acoustic assessment of voice including acoustic analysis of voice (AAV) and electroglottography (EGG) provide objective data of voice production and voice disorders. OBJECTIVE This study aimed to describe changes in AAV, EGG, and VHI in patients who present with LPR compared with a matched control group of healthy subjects. MATERIALS AND METHODS Seventeen patients with LPR were studied. A group of healthy subjects matched by age and gender without any history of voice disorder, LPR, or gastroesophageal reflux disease was assembled. Both groups of patients were studied by VHI, flexible laryngoscopy, AAV, and EGG. RESULTS All patients with LPR demonstrated abnormal VHI values. Shimmer, jitter, open quotient, and irregularity were significantly increased in the patients with LPR. Nonsignificant correlations were found between VHI scores and abnormal acoustic parameters in patients with LPR. CONCLUSIONS Although abnormal acoustic parameters of patients with LPR were not predictive of the overall VHI score, the abnormal acoustic parameters of patients with LPR suggest a decrease in adequate laryngeal control during phonation.

Audiovisual materials are effective for enhancing the correction of articulation disorders in children with cleft palate

INTRODUCTION Children with cleft palate frequently show speech disorders known as compensatory articulation. Compensatory articulation requires a prolonged period of speech intervention that should include reinforcement at home. However, frequently relatives do not know how to work with their children at home. OBJECTIVE To study whether the use of audiovisual materials especially designed for complementing speech pathology treatment in children with compensatory articulation can be effective for stimulating articulation practice at home and consequently enhancing speech normalization in children with cleft palate. MATERIALS AND METHODS Eighty-two patients with compensatory articulation were studied. Patients were randomly divided into two groups. Both groups received speech pathology treatment aimed to correct articulation placement. In addition, patients from the active group received a set of audiovisual materials to be used at home. Parents were instructed about strategies and ideas about how to use the materials with their children. Severity of compensatory articulation was compared at the onset and at the end of the speech intervention. RESULTS After the speech therapy period, the group of patients using audiovisual materials at home demonstrated significantly greater improvement in articulation, as compared with the patients receiving speech pathology treatment on - site without audiovisual supporting materials. CONCLUSION The results of this study suggest that audiovisual materials especially designed for practicing adequate articulation placement at home can be effective for reinforcing and enhancing speech pathology treatment of patients with cleft palate and compensatory articulation.