Renata Paciello Yamashita

Proposta de classificação da função velofaríngea na avaliação perceptivo-auditiva da fala

TEMA: a avaliacao perceptivo-auditiva da funcao velofaringea apresenta limitacoes em funcao de sua subjetividade. OBJETIVO: propor um metodo de classificacao baseado nos escores atribuidos a hipernasalidade, emissao de ar nasal e disturbios articulatorios compensatorios. CONCLUSAO: o uso do metodo traz inumeras vantagens em termos de documentacao clinica e de pesquisa e para acompanhamento de resultados terapeutico-cirurgicos.

Effects of orthognathic surgery on speech and breathing of subjects with cleft lip and palate: acoustic and aerodynamic assessment.

OBJECTIVE To evaluate the impact of orthognathic surgery on acoustic nasalance of subjects with cleft and investigate the causes of possible changes by analyzing velopharyngeal function and nasal patency. DESIGN/PATIENTS Nasalance was measured in 29 subjects with operated cleft palate +/- lip before (PRE) and 45 days (POST1) and 9 months (POST2) after surgery, on average. In 19 of the patients, the minimum velopharyngeal (VP) and nasal cross-sectional (N) areas were also determined. INTERVENTIONS Le Fort I osteotomy with maxillary advancement in combination with procedures involving the nose, maxilla, mandible or all three. MAIN OUTCOME MEASURES Nasalance, VP area, N area. RESULTS We observed: (1) a significant (p < .05) increase in mean nasalance at POST1 and POST2, compared with PRE during the reading of oral sentences and nasal sentences; at POST2, high nasalance on the oral sentences was observed in 45% of the patients with normal nasalance at PRE, and 57% of patients with low nasalance on the nasal sentences at PRE no longer presented abnormal nasalance; (2) a significant increase in mean VP area at POST1; two borderline patients demonstrated deterioration of VP closure at POST2, compared with PRE; and (3) a significant increase in mean N area at POST2, with 73% of patients no longer presenting subnormal areas seen at PRE. CONCLUSIONS On a long-term basis, orthognathic surgery modifies speech nasalance of some subjects with cleft, perhaps because of an increase in internal nose size. This may also improve nasal patency for breathing.

Long-Term Effects of Pharyngeal Flaps on the Upper Airways of Subjects With Velopharyngeal Insufficiency

Objectives: To investigate the long-term effects of pharyngeal flap surgery (PFS) on nasal and nasopharyngeal dimensions of patients with velopharyngeal insufficiency (VPI) and to correlate the findings with the onset of respiratory complaints after surgery. Design/Participants: Prospective study in 58 nonsyndromic patients with repaired cleft palate and VPI, evaluated 2 days before and 5 months (POST1) and 1 year (POST2) after PFS, on average. Patients were divided into two groups: one consisting of patients with postoperative respiratory complaints (RC group) and the other without complaints (NRC group). Interventions: Superiorly based PFS. Main Outcome Measures: Respiratory complaints (self reports of mouth breathing, snoring, and other sleep obstructive events) assessed at POST1 and POST2, and minimum nasal (NCSA) and nasopharyngeal (NPA) cross-sectional areas assessed by rhinomanometry at POST2. Results: Respiratory complaints were reported by 55% and 36% of the patients evaluated at POST1 and POST2, respectively. Posterior rhinomanometry showed a significant postoperative reduction of mean NCSA in the RC and NRC groups (p < .05), to subnormal levels in some of them. The decrease was more pronounced in the RC group. No significant changes in NCSA were observed by anterior rhinomanometry. Similar results were obtained when NPA was assessed by modified anterior rhinomanometry. Conclusion: In the long-term, PFS yielded a significant reduction in upper airways dimensions beyond what should be expected and associated with persistent respiratory complaints in some cases.

Short- and long-term effect of surgically assisted maxillary expansion on nasal airway size.

Transverse maxillary deficiency (TMD) may reduce nasal dimensions and lead to oral breathing. The objective of the present study was to investigate the short- and long-term effects of surgically assisted maxillary expansion on nasal airway size of patients with TMD. Eleven subjects with TMD and skeletal maturity were submitted to posterior rhinomanometry to determine the minimum nasal cross-sectional area (CSA) before and 3, 6, and 12 months after surgery. Subjects were also investigated concerning their habitual diurnal and nocturnal breathing mode (oral, nasal, and oronasal). A statistically significant increase in mean CSA was observed in the early postoperative period (3 months), followed by a decrease to the preoperative levels in the subsequent periods (6 and 12 months). No variations were observed in the breathing mode for 63.6% of the subjects. The results showed that, in the short-term, maxillary expansion most frequently produced an increase in nasal patency. However, it was observed that the effect did not persist over time in most subjects.

Speech outcomes and velopharyngeal function after surgical treatment of velopharyngeal insufficiency in individuals with signs of velocardiofacial syndrome.

Objective: The objective of the study was to analyze if individuals with velocardiofacial syndrome (VCFS) present the same characteristics of speech and velopharyngeal function (VPF) compared with patients with nonsyndromic submucous cleft palate, as well as to compare the effectiveness of palate surgery on the speech function and VPF between groups. Methods: This was a prospective study performed at the Speech Therapy Sector and Physiology Laboratory, Hospital for Rehabilitation of Craniofacial Anomalies/University of São Paulo. The procedure performed was primary palatoplasty associated or not to superiorly based pharyngeal flap surgery. There were 50 patients with velopharyngeal insufficiency: 25 with signals of VCFS (VCFS group) and 25 without syndrome with submucous cleft palate (SMCP group). The hypernasality was scored by 3 examiners; nasalance was evaluated by nasometry, and VPF was assessed by the size of the velopharyngeal gap on the nasoendoscopy. The evaluations were conducted before and, in average, 18 months after surgery. Results: Before surgery, the VCFS and SMCP groups presented similar speech function and VPF characteristics in all parameters, with no statistically significant differences. After surgery, there was reduction in the hypernasality, nasalance, and VPF in, respectively, 20%, 31%, and 36% of patients in the VCFS group and in 24%, 30%, and 30% in the SMCP group. Elimination/normalization of variables was obtained in 28%, 19%, and 8% of patients in the VCFS group and 20%, 40%, and 25% in the SMCP group, respectively, for hypernasality, nasalance, and VPF. There was no statistically significant difference between groups. Conclusions: Patients with VCFS presented similar speech function and VPF characteristics as patients with nonsyndromic SMCP. The surgery for velopharyngeal insufficiency correction was equally effective for the improvement and resolution of speech symptoms and VPF in patients with VCFS compared with the SMCP group.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: Institutional outcomes assessment and the role of the Laboratory of Physiology

The Laboratory of Physiology provides support for the diagnosis of functional disorders associated with cleft lip and palate and also conducts studies to assess, objectively, the institutional outcomes, as recommended by the World Health Organization. The Laboratory is conceptually divided into three units, namely the Unit for Upper Airway Studies, Unit for Stomatognathic System Studies and the Unit for Sleep Studies, which aims at analyzing the impact of different surgical and dental procedures on the upper airways, stomatognathic system and the quality of sleep of individuals with cleft lip and palate. This paper describes the main goals of the Laboratory in the assessment of procedures which constitute the basis of the rehabilitation of cleft lip and palate, i.e., Plastic Surgery, Orthodontics and Maxillofacial Surgery and Speech Pathology.

Efeito da veloplastia intravelar sobre a nasalidade em indivíduos com insuficiência velofaríngea

OBJETIVO: verificar o efeito da palatoplastia secundaria realizada com veloplastia intravelar sobre a nasalidade e nasalância dos pacientes com fissura de palato reparada e insuficiencia velofaringea (IVF) e comparar os resultados entre estes pacientes, de acordo com o grau de fechamento velofaringeo aferido na nasofaringoscopia. METODO: estudo prospectivo com 40 pacientes de ambos os sexos, com idades entre 4 e 48 anos, com fissura de palato reparada e IVF residual, avaliado 3 dias antes e 8 meses apos a palatoplastia, em media, divididos em dois grupos: um com 25 pacientes com falhas pequenas (grupo I) e outro com 15 pacientes com falhas medias a grandes (grupo II) no fechamento velofaringeo. A hipernasalidade foi avaliada perceptivamente e nasalância foi avaliada por meio da nasometria. Diferencas entre grupos e etapas foram consideradas significativas ao nivel de 5%. O estudo foi aprovado pelo Comite de Etica para Pesquisa com Seres Humanos da Instituicao. RESULTADOS: apos a cirurgia, verificou-se reducao da hipernasalidade em 84% dos pacientes do grupo I e em 73% dos pacientes do grupo II. Reducao da nasalância foi observada em 52% dos casos do grupo I e em 43% dos pacientes do grupo II. CONCLUSAO: a palatoplastia secundaria com veloplastia intravelar levou a melhora da nasalidade na maioria dos pacientes analisados. Os resultados tambem demonstraram que a cirurgia foi mais efetiva nos pacientes que apresentavam falhas pequenas no fechamento velofaringeo.

Surgical outcome of pharyngeal flap surgery and intravelar veloplasty on the velopharyngeal function

PURPOSE To investigate the postoperative outcomes of pharyngeal flap surgery (PF) and secondary palatoplasty with intravelar veloplasty (IV) in the velopharyngeal insufficiency management regarding nasalance scores and velopharyngeal area. METHODS Seventy-eight patients with cleft palate±lips submitted to surgical treatment for velopharyngeal insufficiency, for 14 months on an average, were evaluated: 40 with PF and 38 with IV, of both genders, aged between 6 and 52 years old. Hypernasality was estimated by means of nasalance scores obtained by nasometry with a cutoff score of 27%. The measurement of velopharyngeal orifice area was provided by the pressure-flow technique and velopharyngeal closure was classified as: adequate (0.000-0.049 cm²), adequate/borderline (0.050-0.099 cm²), borderline/inadequate (0.100-0.199 cm²), and inadequate (≥0.200 cm²). RESULTS Absence of hypernasality was observed in 70% of the cases and adequate velopharyngeal closure was observed in 80% of the cases, in the PF group. In the IV group, absence of hypernasality was observed in 34% and adequate velopharyngeal closure was observed in 50% of the patients. Statistically significant differences were obtained between the two techniques for both evaluations. CONCLUSION PF was more efficient than the secondary palatoplasty with IV to reduce hypernasality and get adequate velopharyngeal closure.

Correlação entre fechamento velofaríngeo e dimensões nasofaríngeas após cirurgia de retalho faríngeo avaliados por meio da técnica fluxo-pressão

PURPOSE: To investigate whether postoperative velopharyngeal orifice area during nasal breathing at rest (VPAb) can predict velopharyngeal closure during speech (VPAs). METHODS: The subjects were 62 patients with cleft palate, associated or not with cleft lip, of both genders, with ages between six and 32 years, who underwent pharyngeal flap surgery (PFS) at least 12 months before the evaluation performed for this study. VPAb and VPAs were assessed using the pressure-flow technique. VPAb values below 0.500cm2 were considered subnormal. VPAs was categorized as adequate (0-0.049cm2), borderline (0.050-0.199cm2) or inadequate (>0.200cm2). A logistic regression model analyzed the association between VPAb and VPAs. RESULTS: After PFS, 92% of the patients with subnormal VPAb values ( 0.500cm2) who also presented adequate closure was smaller, but still significant (55%). The association between VPAb and VPAs values was not statistically significant. CONCLUSION: Most patients with large flaps presented adequate velopharyngeal closure during speech. However, the findings show that the velopharyngeal orifice area during breathing is not a good predictor of the effectiveness of the pharyngeal flap for speech.

Obstructive Sleep Apnea Following Pharyngeal Flap Surgery for Velopharyngeal Insufficiency: A Prospective Polysomnographic and Aerodynamic Study in Middle-Aged Adults

Objective To compare the frequency and severity of obstructive sleep apnea (OSA) in middle-aged adults who underwent pharyngeal flap surgery for velopharyngeal insufficiency (VPI) with matched subjects who did not undergo pharyngeal flap surgery and to verify the relationship between OSA severity and internal pharyngeal dimensions. Setting National referral care center for cleft lip and palate. Method Prospective study on 42 nonsyndromic subjects with repaired cleft palate with flap (F group, n = 22) and without flap (NF group, n = 20), aged 40 to 58 years. The main outcome measure was the apnea-hypopnea index (AHI), measured by in-lab nocturnal polysomnography (PSG). The OSA-related symptoms were investigated by Pittsburgh, Epworth, and Berlin questionnaires. The nasopharyngeal or velopharyngeal (NP/VP) cross-sectional area was measured by modified anterior rhinomanometry in subgroups of the F (n = 14) and NF (n = 10) groups at rest and during speech. Differences were considered significant at P < .05. Results Questionnaire scores and frequency of self-reported symptoms of snoring, nasal obstruction, and breathing interruptions during sleep did not differ between groups. OSA was diagnosed by PSG in 60% and 77% of the NF and F subjects, respectively. The difference was not significant. No cases of severe OSA were observed. There was no correlation between AHI and NP/VP area. Conclusion A significant number of middle-aged adults with repaired cleft palate had OSA and related symptoms, regardless of the presence of a pharyngeal flap. Results suggest that VPI treatment with a flap may not cause sleep-disordered breathing in the cleft population. Besides advancing age, congenital upper airway abnormalities may be involved.