Hypernasality Research Articles

Speech and language development in toddlers with and without cleft palate

The effect of early palate closure on speech and language development in children with cleft palate. Comparative study. University Medical Center Groningen, Cleft Palate Team (The Netherlands). Forty-three toddlers with cleft palate and thirty-two toddlers without cleft palate were analyzed with standardized tests for language comprehension and language production. Moreover articulation and hyper nasality were examined by trained speech therapists. For language comprehension, language production and articulation there were no significant differences between the children with and without cleft lip and/or palate. This is despite the high percentage of conductive hearing loss (55%) in children with clefts. Significant difference was found for hyper nasality (mean: 35% vs. 0%, p=0.001). In both groups articulation problems raise to a higher percentage than language production problems (63-20%; 24-4%). Early surgical treatment is effective for a part of the communicative development, i.e. language development and articulation. Besides conductive hearing loss hyper nasality remains a serious problem in 30-50% of the children with cleft palate. Therefore, speech therapy and pharyngoplasty also are part of the treatment procedure. Because of the high amount articulation problems in all children, standards for articulation development are perhaps too strict. Future research should be carried out after normal variations in articulation development.

Non-Allergic Rhinitis with Eosinophils and Mast Cells Constitutes a New Severe Nasal Disorder

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). A new particular type has been characterized with current infiltration by eosinophils and mast cells (NARESMA). The aim of this study is to evaluate the clinical and functional characteristics in patients with NARES, NARMA, NARNE, and NARESMA and to define the latter. One hundred and seventy-six NAR patients were prospectively and consecutively evaluated: 52 patients with NARES, 38 with NARMA, 36 with NARNE, and 50 with NARESMA. Clinical features, Quality of Life (QoL), and rhinomanometry were evaluated in all of them. QoL was significantly different in the 4 groups. NARESMA patients had the worst QoL. Nasal function and QoL in NARESMA patients were significantly correlated. Significant associations were shown with both nasal polyps and asthma in NARESMA patients. This study provides the first evidence that NARESMA constitutes a new type of NAR and is a particularly severe disorder.

Effect of Cochlear Implantation on Nasality in Children

Hypernasality is a commonly perceived characteristic of speech in deaf adults and children, but the mechanism of this abnormal nasal resonance is poorly understood. The impact of cochlear implantation on nasalance measures in children with severe auditory deprivation has not been previously reported. We conducted a study of nasality in 6 deaf children who had undergone cochlear implantation. Voice recordings were obtained before surgery and 6 months after activation of the implants. The MacKay-Kummer SNAP Test--which consists of a syllable-repetition subtest and a picture-cued subtest--was used to obtain nasalance scores for oral (bilabial, alveolar, velar, and sibilant) and nasal phonemes. Before cochlear implantation, mean nasalance scores were significantly higher than normal during the production of oral phonemes for both subtests (p < or = 0.05). Six months after activation, the nasalance measures for all components of the syllable-repetition subtest had been restored to within 1 standard deviation of normal. For all oral phonemes of the picture-cued subtest, the elevated nasalance scores were consistently lower after cochlear implant activation, although the difference was statistically significant only for velar tasks. Nasalance scores for nasal phonemes were within 1 standard deviation of normal both before and after implant activation. Our study showed that cochlear implantation partially corrects elevated nasalance measures. Disturbances in nasal resonance may be caused in part by the inability of deaf speakers to monitor velopharyngeal valving with auditory feedback. The trend toward improved nasalance scores after implantation highlights the role of auditory feedback in monitoring velopharyngeal function. Visual biofeedback may be required to further normalize hypernasal speech in profoundly deaf children.

Nasal speaking valve: a device for managing velopharyngeal incompetence1

Velopharyngeal incompetence is a contributing factor for speech disorders, and other frequently accompanying disorders, such as cleft palate, congenital paralysis of the soft palate and cerebrovascular disease. A palatal lift prosthesis (PLP) has been fabricated for managing velopharyngeal incompetence to improve speech. Because of discomfort, such as difficulty in swallowing or vomiting reflex, while wearing the PLP, rigorous adjustment is required. Patients may have difficulty becoming accustomed to using the prosthesis. This article reports on a newly developed device, the nasal speaking valve, for improving hypernasal speech caused by velopharyngeal incompetence.

Reconstruction of the Soft Palate In Oral Cancer to Repair an Operative Defect with Speech Aid Prosthesis: A Case Report

A soft palate defect may result from surgical resection, and its consequences could include hypernasal speech and nasal regurgitation of food and liquids. A speech aid prosthesis fabricated for patients can improve nasal emission during speech, and assist in preventing nasal regurgitation of food. This article presents a case of the reconstruction of a soft palate defect by prosthetic obturation.

Nasal congestion after visual sexual stimulation with and without sildenafil (Viagra®): a randomized placebo-controlled study

Sildenafil (Viagra) is a selective phosphodiesterase type 5 inhibitor (PDE5-I) approved for treatment of erectile dysfunction. Although relatively well-tolerated, sildenafil is associated with undesired effects including headache, flushing, dyspepsia, nasal congestion, and visual disturbances. In the present study we explored the impact of sildenafil on nasal airway parameters in young potent men. Eleven men (age 26.0 +/- 1.8 years) with normal BMI (25.7 +/- 0.5) and without nasal respiratory disorders were enrolled in a double-blind, crossover study. All men underwent evaluation of systolic (SBP) and diastolic blood pressure (DBP), heart rate (HR), SpO2%, acoustic rhinometry, and nasal endoscopy before and after placebo or sildenafil (50 mg) plus visual sexual stimulation (VSS). Nasal examination was performed using 0 degrees rigid telescopes, 4 mm in diameter. A Student's t test was used for direct comparisons, while the Kruskal-Wallis test (K-W) was utilized for multiple comparisons. After administration of sildenafil plus VSS, the minimum cross sectional area (MCA) was significantly lower that observed with either placebo (P = 0.03) or sildenafil alone (P = 0.003). However, the post-stimulation values did not demonstrate any significant differences among the different treatment arms (P = 0.48; DF = 2; K-W test). In contrast, endonasal volume (VOL) was significantly lower after sildenafil + VSS (P = 0.01), but not after placebo + VSS (P = 0.18). None of the other parameters monitored showed any significant variations. Rhinoscopy showed a characteristic increase of the volume of the inferior turbinates, with subjective differences between placebo and sildenafil. These preliminary results suggest that sildenafil reduces nasal volume, and that sexual stimulation may decrease nasal airflow by itself.

Ethmomaxillary sinus

Ethmomaxillary sinus is a variation of the posterior ethmoid cells. It is formed by the extension of the posterior ethmoid cells into the maxillary sinus and drains into superior nasal meatus. It is incidentally seen on paranasal sinus computerized tomography (CT) scans. Its prevalence has been reported as 0.7 and 2% in two studies. In this study, paranasal CT scans of 466 patients were investigated for the presence of ethmomaxillary sinus. The patients had paranasal CT with the preliminary diagnoses of septal deviation, chronic inflammatory paranasal sinus disease and nasal turbinate disorders. The ethmomaxillary sinus was present in nine of those patients (1.93%). It was septated in one of them. The CTs were further investigated for other anatomical variations and co-existent mucosal disease of the paranasal sinuses.

Hypertonic saline solution stimulated CLC-3 production in primary cultured human nasal epithelial cells

Objective To determine the molecular mechanisms of hypertonic saline on nasal disorders. Methods Primary human nasal epithelial cells (HNECs) were treated with 0.9 and 3% saline for 12 h. CLC-3 was detected in HNECs by immunohistochemistry, reverse transcriptase-polymerase chain reaction (RT-PCR) and western blotting. Results Positive expression of CLC-3 was detected in HNECs in all subjects by immunohistochemistry. The relative density of CLC-3 mRNA was 0.22 ± 0.09 and 0.12 ± 0.05 in HNECs treated with 3 and 0.9% saline, respectively. The effect of 3% saline on the expression of CLC-3 in HNECs was observed in a time-dependent manner. Conclusions Hypertonic saline decreases the nasal edema and influences the mucocilliary function through the fluid secretion in vitro and may be associated with the upregulation of CLC-3.

Die diagnostische Wertigkeit der Nasometrie – eine repräsentative Studie für Patienten mit Lippen-Kiefer-Gaumensegel-Spalten und Gesunde

In the rehabilitation of cleft palate patients the quality of spoken language represents one of the most important aspects of successful social integration. It is therefore necessary to direct special attention to phoniatric care and speech therapy following operative reconstruction. One of the main problems is the comparison of subjective and objective measures of the degree and type of nasal disorder. In an interdisciplinary project at the University of Jena nasometry was assessed. Due to a lack of norm values for German a representative sample for the calibration of cleft palate patients and normal subjects was collected. Speech was elicited using standardized and phonetically validated reading materials. Nasalance measurements were compared with judgements made by a group of trained listeners who were asked to assess voice quality (RBH) and nasality. A database containing nasalance values and acoustic signals from 120 subjects was built up. The results generally exhibited highly significant correlations between instrumental measurements and auditory judgements. Profiles of norm values for a phonetically and statistically reliable standard for German were obtained, which in turn can be used as a comparative basis for further studies.

An inherited atypical 1 Mb 22q11.2 deletion within the DGS/VCFS 3 Mb region in a child with obesity and aggressive behavior

The DiGeorge, Velocardiofacial, and Conotruncal Anomaly Face syndromes (DGS/VCFS/CTAF) are knowncollectively as the 22q11.2 deletion syndrome (22q11 DS) [Shaikh et al., 2000; Swillen et al., 2000]. Although most individuals have the same large 3 Mb 22q11.2 de novo deletion, a recurrent 1.5–2 Mb proximally nested deletion is more common in familial cases of 22q11.2 DS [Iascone et al., 2002; Adeyinka et al., 2004; Fernandez et al., 2005]. Atypical smaller or uniquely placed deletions have been described in only a few patients [Kurahashi et al., 1996, 1997; Amati et al., 1999; Shaikh et al., 2000; Garcia-Minaur et al., 2002; Rauch et al., 2005]. We report on a rare 1 Mb 22q11.2 deletion in a female patient with obesity, hyperphagia, and aggressive behavior, and in her mother who had a major depressive disorder. The deletion was identified serendipitously in the proband during a microdeletion screening for syndromic obesity and was limited to the most telomeric region of the 3 Mb typically deleted region. The patient (Fig. 1) was the first child of nonconsanguinous parents with an unremarkable family history. Decreased fetal movement was reported. She was delivered at term by caesarean. Apgar scores were 8 and 9 at 1 and 5 min, respectively. The birth weight was 2.9 kg ( 25th centile), length 48 cm ( 10th centile), and the OFC 34 cm ( 25th centile). Neonatal jaundice was treated with phototherapy. The sucking reflex was present, but she fed with difficulty until 1 year of age when gastroesophageal reflux was diagnosed. Delayed closure of anterior fontanel was reported. She walked independently at 1 year and 4 months. On examination at 4 years of age, the OFC was 52 cm (50–98th centile), height was 101 cm (25–50th centile), and weight was 27 kg (>97th centile). She had a narrow forehead, synophrys, upslanted palpebral fissures, deep-set eyes, divergent strabismus of the right eye, small mouth and thin lips, high-arched palate, short philtrum, retrognathia, small hands, and pes planus. Her problems included speech articulation, sleep difficulties, hyperphagia, decreased sensitivity to pain, hyperactivity, and aggressive behavior, such as beating strangers, and self-injurious behaviors including head banging, biting, hair pulling, and skin picking. When re-evaluated at age 8 years, there were no significant changes. Compulsive food eating and behavioral problems had worsened. She weighed 67 kg (>97th centile) with truncal obesity, and height was 130 cm (50–75th centile). She took antipsychotic medication to control aggressiveness and attended a special education school. The patient’s mother has had a major depressive disorder and anxiety for 10 years, for which she has taken several psychiatric medications. She had similar facial features to her daughter including divergent strabismus on the right eye, and a hypernasal speech. She weighed 71 kg and was 160 cm tall (BMI 27.7, overweight). She was otherwise

Effects of adenotonsillectomy on speech spectrum in children

The vocal tract, which starts from the glottis and extends to the lips is considered to be a resonator for speech production. Enlarged palatine tonsils may cause hypernasal speech, oral breathing or muffled voice. Changes in the structure of this resonator are assumed to modify the speech characteristics. The aim of this study was to evaluate changes in acoustic feature of speech after adenotonsillectomy in children and to establish concepts of management and rational therapeutic approach. Before and after surgery, an acoustic analysis was made to 40 children, aged between 5 and 14 years old, with enlarged palatine tonsils and hypetrophic adenoids. Phonetically balanced sentences were carried out and digitalized with Multi Dimensional Voice Program (MDVP, Kay Elemetrics). As a control group, 40 healthy children were identified. These parameters were estimated: average of fundamental frequency (Fo), Jitt, Shim, noise to harmonics ratio (NHR), voice turbulence index (VTI), soft phonation index (SPI), degree of voiceless (DUV) and degree of voice breaks (DVB). After adenotonsillectomy, our data showed an improvement in all the parameters: the analysis of Fo, Jitt, Shim, NHR, VTI, SPI, DUV and DVB showed a postoperative decrease; comparison with healthy children highlighted a postoperative normalization of NHR, VTI and DVB. The postoperative improvement of the parameters suggests a reduction of the nasal resonance and the improvement of voice quality. MDVP method may be useful for analyzing speech characteristics, evaluating the effects of surgical excision and therapeutic approach: in selected cases of patients with enlarged tonsils, the decision to perform tonsillectomy depends on its potential positive effect on speech too.

Nasal Obstruction, Sleep Disorder, and Fatigue: Cause and Effect Remain Elusive

Nasal Obstruction, Sleep Disorder, and Fatigue: Cause and Effect Remain Elusive

Acoustic Analysis and Detection of Hypernasality Using a Group Delay Function

In this paper, we describe a group delay-based signal processing technique for the analysis and detection of hypernasal speech. Our preliminary acoustic analysis on nasalized vowels shows that, even though additional resonances are introduced at various frequency locations, the introduction of a new resonance in the low-frequency region (around 250 Hz) is found to be consistent. This observation is further confirmed by a perceptual analysis carried out on vowel sounds that are modified by introducing different nasal resonances, and an acoustic analysis on hypernasal speech. Based on this, for subsequent experiments the focus is given only to the low-frequency region. The additive property of the group delay function can be exploited to resolve two closely spaced formants. However, when the formants are very close with considerably wider bandwidths as in hypernasal speech, the group delay function also fails to resolve. To overcome this, we suggest a band-limited approach to estimate the locations of the formants. Using the band-limited group delay spectrum, we define a new acoustic measure for the detection of hypernasality. Experiments are carried out on the phonemes /a/, /i/, and /u/ uttered by 33 hypernasal speakers and 30 normal speakers. Using the group delay-based acoustic measure, the performance on a hypernasality detection task is found to be 100% for /a/, 88.78% for /i/ and 86.66% for /u/. The effectiveness of this acoustic measure is further cross-verified on a speech data collected in an entirely different recording environment.

Cigarette Smoke Extract Induces Cytotoxicity on Human Nasal Epithelial Cells

The nasal mucosa is the first area to be exposed to a variety of inhaled toxins. Among various inhaled toxins, cigarette smoke is the most common one and is associated with several nasal and sinus disorders. To evaluate the cytotoxic effects of cigarette smoke, primary human nasal epithelial cells were cultured in various concentrations of cigarette smoke extract (CSE) for various times. Cell viability was evaluated by WST-1 (4-[3-(4-iodophenyl)-2-(4-nitrophenyl)-2H-5-tetrazolio]-1,3-benzene disulfonate) assay. Morphological findings were observed under the light microscope and the electron microscope. Annexin-V stain was used for the detection of apoptosis. Using the WST-1 assay, CSE reduced cell viability in a time- and concentration-dependant manner. CSE-treated cells showed initial membrane blebbing followed by vesicle formation without apoptotic body formation or cell membrane rupture. Cells were stained with annexin-V but without propidium iodide under a fluorescence microscope. TUNEL (terminal deoxynucleotidyltransferase-mediated dUPT nick end labeling) stain was positive in CSE-treated cells. CSE induces cytotoxicity on primary human nasal epithelial cells and the morphological findings closely mimic partition apoptosis.

水疱性鼓膜炎症例の検討―水疱性鼓膜炎は急性中耳炎なのだろうか？―

Bullous myringitis (BM) is an acutely painful condition of the ear characterized by bulla formation on the tympanic membrane. The etiology is unknown despite its recognition over a hundred years ago by Lowenberg (1892). BM was described in early articles as occurring in association with acute otitis media; however, BM has different features from AOM: usually unilateral, more often in school age children and frequently in adults, and almost always with a self-limited clinical course.We studied 74 patients with BM aged 0 to 83 years (average age: 8.53), of which 65 patients had allergic rhinitis and others nasal disorders. Most patients had a sudden onset of very severe otalgia, but rarely had a high temperature. In all cases, bulla formations on the tympanic membrane were unilateral, and 54 of 69 patients had significant bulging of the pars tensa, whereas only 44 of 69 patients had significant middle ear fluid. As other findings of the tympanic membrane, including a patient who strongly blew the nose, 24 of 72 patients had bleeding and 32 of 36 patients with analysis of recorded photography had significant bulging of the pars flaccida.Merifield (1966) considered that BM is a mechanical injury, which follows upper-respiratory infection of any sort (eg, Eustachian tube insufficiency, fever etc). We thought that BM might be a middle ear barotrauma: abnormal nasopharynx pressure due to allergic rhinitis and others nasal disorders caused a sudden reflux of secretions and air from the nasopharynx into the middle ear such that a vibration and positive pressure suddenly struck the tympanic membrane.

Endonasal endoscopy and computerized tomography in diagnosis of the middle nasal meatus pathology

Diagnostic nasal endoscopy enables clear visualization of all structures of the middle nasal meatus and of the ostiomeatal complex. It is a primary means for diagnosis of all anatomic variations and other pathogenic factors of the lateral nasal wall, which cannot be diagnosed by using anterior/posterior rhinoscopy. Furthermore, the effects of therapy can be endoscopically controlled and, if necessary, a surgical procedure may be performed. Computed tomography has become the imaging study of choice in the diagnosis and management of sinonasal diseases. It provides detailed information and an unparalleled view of the sinuses, especially the bony anatomy. The following methods were used in the study: endoscopic examination and CT of the nose and paranasal cavities. Data processing and comparison of diagnostic methods tomography was done using a biostatistical apporach--kappa. The correlation between computerized tomography and endoscopy of the nose and sixty nasal cavities of examined patients is significantly high. with mean kappa coefficient of k = 0.89, kappa > 0.8. The diagnosis of rhinosinusitis is generally based on clinical grounds. In 1997, the Task Force of Rhinosinusitis developed the major and minor criteria for diagnosing rhinosinusitis. The presence of two major or one major and two minor symptoms is generally sufficient to make a clinical diagnosis of rhinosinusitis. In order to make a specific diagnosis and provide specific treatment, ednonasal endoscopy is the method of choice. In cases with refractory rhinosinusitis, acute rhinosinusitis with complications, or atypical cases requiring confirmation of sinusitis, use of coronal and axial CT is necessary. This article confirms that diagnostic endoscopy of the nose and paranasal cavities with computer tomography of paranasal cavities represent an ideal combination and a widely recognized standard for diagnosis and treatment of nasal and paranasal cavity disorders in many countries.

Speech evaluation with and without palatal obturator in patients submitted to maxillectomy

Most patients who have undergone resection of the maxillae due to benign or malignant tumors in the palatomaxillary region present with speech and swallowing disorders. Coupling of the oral and nasal cavities increases nasal resonance, resulting in hypernasality and unintelligible speech. Prosthodontic rehabilitation of maxillary resections with effective separation of the oral and nasal cavities can improve speech and esthetics, and assist the psychosocial adjustment of the patient as well. The objective of this study was to evaluate the efficacy of the palatal obturator prosthesis on speech intelligibility and resonance of 23 patients with age ranging from 18 to 83 years (Mean = 49.5 years), who had undergone inframedial-structural maxillectomy. The patients were requested to count from 1 to 20, to repeat 21 words and to spontaneously speak for 15 seconds, once with and again without the prosthesis, for tape recording purposes. The resonance and speech intelligibility were judged by 5 speech language pathologists from the tape recordings samples. The results have shown that the majority of patients (82.6%) significantly improved their speech intelligibility, and 16 patients (69.9%) exhibited a significant hypernasality reduction with the obturator in place. The results of this study indicated that maxillary obturator prosthesis was efficient to improve the speech intelligibility and resonance in patients who had undergone maxillectomy.

The Nasality Severity Index: An Objective Measure of Hypernasality Based on a Multiparameter Approach

There is a need for an objective measure that describes normal resonance and resonance disorders. The current standard of practice has not led to mismanagement but a refined objective assessment protocol will benefit a more precise objective assessment of velopharyngeal disorders. The purpose of the present study is to construct a nasality severity index (NSI) that reflects the multidimensional nature of resonance. Objective and subjective assessment techniques were used to determine the nasalance, the nasality and aerodynamic capacities in 21 children with cleft palate and a control group of 25 children without cleft palate. Stepwise logistic regression was used to determine the optimal index. The NSI consists of a linear combination of 4 variables, where each variable has a different weight. The equation is: NSI = –60.69 – (3.24 × percent oral text) – (13.39 × Glätzel value /a/) + [0.244 × maximum duration time (seconds)] – (0.558 × % /a/) + (3.38 × percent oronasal text). NSI sensitivity is 88% and specificity is 95%. Daily clinical use of the NSI has shown it to be an efficient and practical tool to describe the presence of hypernasality. Three distinct follow-up cases are presented to illustrate the impact of a surgical technique, the use of a speech bulb and velopharyngeal biofeedback training on NSI. The implementation of the NSI may help clinicians to quantitatively assess the severity of nasality disorders beside the perceptual judgments.

Pediatric meningoencephaloceles and nasal obstruction: A case for endoscopic repair

Congenital anterior skull base defects with meningoencephaloceles causing nasal obstruction are rare clinical entities. Nasal obstruction in children may also be a symptom of multiple benign nasal and allergic disorders, making the initial diagnosis of meningoencephalocele difficult. Traditionally, skull base defects have been repaired via a bifrontal craniotomy approach. With the advent of pediatric endoscopic instrumentation, more of these lesions are accessible via an intranasal endoscopic approach, even in the infant population. However, owing to the rarity of these lesions, there is a paucity of data demonstrating successful adaptation of endoscopic skull base techniques to the pediatric population. Retrospective review of two cases of endoscopic repair of anterior skull base defects with meningoencephaloceles at a tertiary care medical center. Two children, ages 15 months and 6 years, underwent successful endoscopic closure of their anterior skull base defects and resection of their intranasal meningoencephalocele with resolution of their nasal obstruction and cerebrospinal fluid rhinorrhea. Pediatric nasal meningoencephaloceles with anterior skull base defects can be successfully repaired via a transnasal endoscopic technique, thus minimizing the complications associated with craniotomy and frontal lobe retraction. Triplanar computed tomographic and magnetic resonance imaging is paramount to evaluate the caliber of the skull base defect, consistency of the herniated intracranial contents, as well as the presence of cerebral vasculature.

Bilateral spontaneous hemotympanum: Case report

BackgroundThe most common causes of hemotympanum are therapeutic nasal packing, epistaxis, blood disorders and blunt trauma to the head. Hemotympanum is characterized as idiopathic, when it is detected in the presence of chronic otitis media. A rare case of spontaneous bilateral hemotympanum in a patient treated with anticoagulants is presented herein.Case presentationA 72-year-old male presented with acute deterioration of hearing. In the patient's medical history aortic valve replacement 1 year before presentation was reported. Since then he had been administered regularly coumarinic anticoagulants, with INR levels maintained between 3.4 and 4.0. Otoscopy revealed the presence of bilateral hemotympanum. The audiogram showed symmetrical moderately severe mixed hearing loss bilaterally, with the conductive component predominating.Tympanograms were flat bilaterally with absent acoustic reflexes. A computerized tomography scan showed the presence of fluid in the mastoid and middle ear bilaterally. Treatment was conservative and consisted of a 10-day course of antibiotics, anticongestants and temporary interruption of the anticoagulant therapy. After 3 weeks, normal tympanic membranes were found and hearing had returned to previous levels.ConclusionAnticoagulant intake should be included in the differential diagnosis of hemotympanum, because its detection and appropriate treatment may lead to resolution of the disorder.