A new nasal acoustic reflection technique to estimate pharyngeal cross-sectional area during sleep.

The conventional acoustic reflection technique in which acoustic waves are launched through the mouth cannot be applied during sleep, nor can it be applied to the nasopharynx, which is the major site of occlusion in patients with obstructive sleep apnea syndrome. We propose a new technique of nasal acoustic reflection to measure pharyngeal cross-sectional areas including the nasopharynx. The acoustic waves are introduced simultaneously to both nostrils during spontaneous nasal breathing. A new algorithm takes into account the nasal septum with asymmetric nasal cavities on both sides and assumes prior knowledge of the cross-sectional area of the nasal cavities and the position of the nasal septum. This method was tested on an airway model with a septum and on healthy human subjects. The conventional technique gave inaccurate measurements for pharyngeal cross-sectional areas for an airway model with asymmetric branching, whereas the new technique measured them almost perfectly. The oro- and hypopharyngeal cross-sectional area measurements acquired by the new method were not different from those obtained by the conventional method in normal subjects. This new method can be used as a monitor of upper airway dimensions in nocturnal polysomnography.     

Effects of velopharyngeal openings on flow characteristics of nasal emission

Biomechanics and Modeling in Mechanobiology - Nasal emission is a speech disorder where undesired airflow enters the nasal cavity during speech due to inadequate closure of the velopharyngeal...     

Voice low tone to high tone ratio--a new index for nasal airway assessment

There are several methodology based on voice analysis to evaluate nasal airway. Here we introduce a new quantitative index based on voice spectrum analysis to evaluate nasal obstruction. Ten subjects of nasal blockage were instructed to produced the sustained consonant-vowel syllable /m partial partial differential/ at comfortable levels of speech for at least 5 seconds. After nasal decongestant treatment, the second voice sample was collected. Sound spectrum was obtained by the algorithm of fast Fourier transform and the fundamental frequency (F0) was calculated by the method of autocorrelation. Voice low tone to high tone ratio (VLHR) was defined as the division of low frequency power (LFP) into high frequency power (HFP) of the sound power spectrum and was finally expressed in decibels. The cut-off frequency was the product of F0 and square root of (4 x 5). The VLHR after nasal decongestant treatment increased significantly as compared with that before treatment (P < 0.01). VLHR is a new index derived from sound spectral analysis and that may detect the changes in frequency characteristics of voice during treatment for nasal obstruction. The index is quantitative, non-invasive, and potentially useful for basic researches and clinical applications.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

Side-selective, unobtrusive monitoring of nasal airflow and conductance.

Whether nasal obstruction disturbs sleep and nocturnal breathing is controversial because convenient techniques for measuring nasal resistance during sleep are lacking. Therefore, we developed a technique for unobtrusive, side-selective nasal conductance monitoring. The technique measures left and right nasal airflow and transnasal pressure using nasal cannulas, thin catheters inserted through the cannulas into the nasopharynx, and three pressure transducers. Their processed signals provide conductance as airflow-to-resistive pressure ratio for the left and right side and the sum, total nasal conductance. For validation, total nasal conductance was also determined by a flowmeter attached to a nasal mask and nasopharyngeal pressure that served as reference standard. Methods were compared in five normal subjects during pharmacological interventions and in 12 snorers during sleep. The novel technique accurately tracked total nasal conductance by the reference method at baseline, after nasal application of histamine and xylomethazoline in normal subjects; mean difference (bias) was 1%, and limits of agreement (+/-2 SD of bias) were +/- 22% (75 comparisons). Corresponding values during overnight sleep studies in snorers were 0 +/- 19% (192 comparisons); bias and limits of agreement of changes in nasal conductance were 1 +/- 19% (180 comparisons). Conductance measured once at the beginning of sleep studies differed from subsequent measurements during the night by a mean +/- SD of 26 +/- 20%, P < 0.0001. The novel technique accurately measures side-selective conductance. It is suitable to investigate interactions among nasal obstruction, sleep and nocturnal breathing, and drug effects. One-time measurements at the beginning of sleep studies do not appropriately reflect the highly variable nasal conductance during an entire night.     

Cleft palate repair at 3 to 7 months of age

We report the speech outcome in 90 children with complete unilateral cleft lip and palate who underwent soft palate repair either between 3 and 7 months of age (n = 40) or later than 7 months of age (n = 50). In all patients, palatoplasty was performed by one of two experienced surgeons using a modification of the Furlow technique, and speech evaluations were conducted using the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence by two speech pathologists with high inter-rater reliability. There were no differences between the groups with respect to resonance, nasal air emission, and articulation. Velopharyngeal function, as measured by the total speech score, was similar between the two groups of patients, as were the rates of secondary pharyngoplasty. These results suggest that very early closure of the soft palate may not offer significant benefit over repair later in infancy with respect to speech outcome.     

Positive narrowing pharyngoplasty with forearm flap for functional restoration after extensive soft palate resection

The restoration of velopharyngeal function after extensive soft palate resection to treat malignant oropharyngeal tumors is a major challenge to reconstructive surgeons. The authors had previously reconstructed soft palatal defects routinely with the folded forearm flap. A patient who had more than half of the soft palate excised experienced postoperative velopharyngeal dysfunction. To restore efficient velopharyngeal function, pharyngoplasty was additively applied where the folded ridge of the forearm flap was sutured to the posterior pharyngeal wall in an inverse manner of the pharyngeal flap technique. The essence of the procedure was positive narrowing of the nasopharyngeal space. Five patients who underwent this pharyngoplasty and another five who did not were evaluated for postoperative functions of speech intelligibility and of nasal regurgitation during oral feeding. The velopharyngeal movements of all patients were examined under a nasopharyngeal endoscope. The evaluations demonstrated that this surgical procedure afforded satisfactory results. This positive narrowing pharyngoplasty technique is simple, easy, and minimally invasive to the remaining healthy tissue, and it is the method of choice for the reconstruction of the soft palate after malignant tumor resection.     

Use of the pharyngeal flap in the treatment of congenital velopharyngeal incompetence

Seventy-four patients were referred to the senior author because of presumed velopharyngeal incompetence without cleft palate. As a result of an extensive preoperative evaluation that included assessment of articulation patterns, nasal emission, oronasal resonance, and general speech intelligibility, 57 of the 74 patients were selected for a pharyngeal flap procedure. In 54 of the 57 patients (95 percent), the operation corrected inappropriate nasal emission and hypernasality and improved intraoral air pressure to allow normal speech production.     

Modified mattress suture technique to correct anterior septal deviation

The purpose of this study was to evaluate the efficacy of a modified mattress suture technique in septal anterior deviation correction and to compare it with the Hinderer technique. This was a randomized, controlled, single-blind clinical trial. Fifty patients with anterior septal deviation were assigned to one of two surgery treatment groups: in group A, 25 patients underwent anterior septoplasty with modified mattress suture technique; and in group B, 25 patients underwent anterior septoplasty with the Hinderer technique. Subjective (oral respiration, epistaxis, rhinorrhea, and nasal obstruction) and objective (anterior rhinomanometry) parameters were analyzed and compared between groups. Better results in obstructive deflections were achieved with the modified mattress suture technique. Unilateral and total nasal resistances improved during the 6-month follow-up in patients who underwent anterior septoplasty with the modified mattress suture technique, and there was a significant difference in the values when compared with patients who underwent anterior septoplasty with rhinoplasty using the Hinderer technique (p = 0.003). The modified mattress suture technique had better subjective and objective results than rhinoplasty with the Hinderer technique and therefore could be considered as an alternative technique in anterior septal surgery.     

Velopharyngeal incompetence: a guide for clinical evaluation

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.     

Detecting Nasal Vowels in Speech Interfaces Based on Surface Electromyography

Nasality is a very important characteristic of several languages, European Portuguese being one of them. This paper addresses the challenge of nasality detection in surface electromyography (EMG) based speech interfaces. We explore the existence of useful information about the velum movement and also assess if muscles deeper down in the face and neck region can be measured using surface electrodes, and the best electrode location to do so. The procedure we adopted uses Real-Time Magnetic Resonance Imaging (RT-MRI), collected from a set of speakers, providing a method to interpret EMG data. By ensuring compatible data recording conditions, and proper time alignment between the EMG and the RT-MRI data, we are able to accurately estimate the time when the velum moves and the type of movement when a nasal vowel occurs. The combination of these two sources revealed interesting and distinct characteristics in the EMG signal when a nasal vowel is uttered, which motivated a classification experiment. Overall results of this experiment provide evidence that it is possible to detect velum movement using sensors positioned below the ear, between mastoid process and the mandible, in the upper neck region. In a frame-based classification scenario, error rates as low as 32.5% for all speakers and 23.4% for the best speaker have been achieved, for nasal vowel detection. This outcome stands as an encouraging result, fostering the grounds for deeper exploration of the proposed approach as a promising route to the development of an EMG-based speech interface for languages with strong nasal characteristics.     

Evaluation of speech after correction of rhinophonia with pushback palatoplasty combined with pharyngeal flap.

A comparison is made of the preoperative and postoperative speech evaluations of 15 selected subjects who had pharyngeal flap operations combined with palatal pushback. Postoperatively, 13 of the 15 patients (86 percent) showed no abnormal nasal emission and no evidence of significant hypernasality during word production. Gross substitution errors were also corrected by the surgical repair. While the number of patients is small, this study indicates equal effectiveness of the surgical technique described--regardless of the sex, the medical diagnosis, whether the procedure was primary or secondary, or the amount of postoperative time--providing there is good function of the muscles of the soft palate.     

The Dynamic Dento-palatography System: a new approach for evaluating speech

The assessment of speech in patients with craniofacial anomalies is important to develop appropriate treatment strategies to optimize this aspect of oropharyngeal function. The Dynamic Dento-palatography System which uses multi-electrode array sensors to detect tongue position during articulation is described. Three levels of the speech chain, articulatory, auditory and acoustic, may be analysed in an integrated fashion using this instrument; preliminary results are described. These studies suggest that the quality of speech sounds such as ‘s’ and ‘t’ improve post-operatively.     

Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.     

Augmentation of the failed pharyngeal flap.

Pharyngeal flaps are frequently used with good results to eliminate hypernasality and/or nasal escape. In a small percentage of patients, however, cicatricial contracture of the flap occurs to such a degree that velopharyngeal incompetence returns. The authors have devised a method of augmenting the scarred flap with small, superiorly based flaps lateral and adjacent to the original flap. Four cases are presented in which speech analysis was conducted prior to the procedure and then for 9 to 24 months postoperatively. The postoperative speech results are all within normal limits.     

Controlled trial of speech therapy versus oxprenolol for stammering.

In a controlled trial of treatment for stammering under stress oxprenolol (40 mg) compared with placebo was assessed in a double-blind manner over two days, six weeks apart, in 31 stammerers before and after speech therapy. The trial design also allowed six weeks of intensive speech therapy, using a slowed-speech and relaxation technique, to be compared with not treatment and assessed single-blind. Oxprenolol produced a significant fall in pulse rate and systolic blood pressure but no overall change in performance either before or after speech therapy. Intensive speech therapy produced a highly significant improvement in the global performance of untrained subjects (p less than 0.001) and a significant reduction in the number (p less than 0.001) and duration (p less than 0.001) of blocks. Maintenance speech therapy tended to produce further improvement in trained subjects. Speech therapy is apparently an effective treatment for stammering, whereas oxprenolol appears to be of no value when given routinely; oxprenolol may be of value, however, in very stressful conditions.     

Cleft palate repair by double opposing Z-plasty

In an attempt to improve speech results following palate repair while allowing adequate maxillary growth, a palatoplasty using two opposing Z-plasties of the soft palate, one of the oral and one of the nasal layers, has been used in 22 infants. Eight patients had unilateral cleft lip and palate, eight had bilateral cleft lip and palate, and six had cleft palate. The Z-plasties facilitate effective dissection and redirection of the palatal muscles to produce an overlapping muscle sling and lengthen the velum without using tissue from the hard palate, which permits hard palate closure without pushback or lateral relaxing incisions. Of the 20 children old enough for speech evaluation, 18 have no velopharyngeal insufficiency. Two have very mild velopharyngeal insufficiency. None has required a pharyngeal flap.     

Cleft-palate repair by modified Furlow double-opposing Z-plasty: the Children's Hospital of Philadelphia experience

Although the optimal technique of cleft-palate repair remains controversial, several small series have suggested that superior speech results may be obtained with the Furlow double-opposing Z-plasty. To examine speech outcome in a large series of Furlow palatoplasties performed at a single center, we retrospectively reviewed the records of 390 cleft-palate patients who underwent Furlow palatoplasty at The Children's Hospital of Philadelphia from 1979 to 1992. Speech outcome at 5 years of age or greater was available for 181 nonsyndromic patients and was scored using the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence. No or mild hypernasality was noted in 93.4 percent of patients, with 88.4 percent demonstrating no or inaudible nasal escape and 97.2 percent demonstrating no errors in articulation associated with velopharyngeal incompetence. Secondary pharyngeal flap surgery was required in just 7.2 percent of patients. Age at palatoplasty, cleft type, and experience of the operating surgeon had no significant effect on speech results, although there was a trend toward better outcome in those undergoing palatal repair before 6 months of age and toward poorer outcome in those with Veau class I and II clefts. Overall, Furlow palatoplasty yielded outstanding speech results, with rates of velopharyngeal dysfunction that seem to improve upon those reported for other techniques.     

Long term transtracheal oxygen delivery through microcatheter in patients with hypoxaemia due to chronic obstructive airways disease.

Transtracheal administration of oxygen is a new technique for long term treatment. Twenty patients with hypoxaemia due to chronic obstructive airways disease were studied while receiving oxygen through a microcatheter inserted percutaneously into the trachea. By bypassing most of the dead space and avoiding oxygen wastage at the face this method of delivery reduced oxygen requirements by roughly half compared with delivery through nasal cannulas, thus reducing costs and facilitating portable treatment. Twelve of these patients continued to use the system for up to 13 months in preference to using nasal cannulas. Two important complications were a staphylococcal infection and a fractured catheter. Transtracheal oxygen reduced breathlessness and helped patients with routine daily activities. Transtracheal administration of oxygen is a practical method of treatment which may have an important role in rehabilitating patients with chronic lung disease.     

Chin augmentation with nasal osteocartilaginous graft

The use of the nasal hump removed during rhinoplasty was described by Aufricht in 1934 and 1958. In the past 10 years, the author has been using a similar technique but with significant variations. Before beginning the rhinoplasty surgery, the author dissects, through a submental incision, a subperiosteal mental pocket. Then, the osteocartilaginous nasal hump is removed; once the mucoperiosteum/mucoperichondrium is meticulously dissected, the nasal hump is tailored to achieve a mental form and the removed alar cartilage, nasal spine, or septal cartilage is used to fill or supplement the concavities of the hump. This report includes a total of 36 cases, 10 of which were controlled after 3 to 8 years of implantation by tridimensional computed tomography, from which the author observed an osteointegration with the mandibular bone and no reabsorption of the grafts or alteration of the structure of this bone. The patients revealed a high degree of satisfaction, and during the clinical examination, the author could not observe or palpate any distortion of the shape or projection of the chin. None of the grafts needed review or removal. This simple, fast procedure is a very good alternative for patients with some form of microgenia or when patients and surgeons are not likely to use alloplastic implants.