Normal Nasal Resonance Research Articles

Quantitative and Qualitative Assessment of Medial Osteotomy of the Greater Palatine Foramen in Wide Cleft Palate Repair

Background:Repairing of a wide cleft palate faces with several problems, e.g. medialization of palatal flaps, lack of tissue for repair, and fistula formation. We aimed at quantitative and qualitative evaluation of medial osteotomy of the greater palatine foramen for patients with wide cleft palate and its postoperative outcomes. Methods:Eight patients 4 males, 4 females with wide cleft palate and the median age of 1.5 year were operated using medial osteotomy of the greater palatine foramen from 2018-2020. In this technique, the osteotomy was carried in the outlet of vascular pedicle medially and posteriorly. This led to more degrees of freedom for the vascular pedicle and a palatoplasty without tension through mucoperiosteal flap movement toward the medial direction. Results:After osteotomy and repairing for 8 patients (16 flaps), the mean (SD) length of mucoperiosteal flap pedicle was significantly increased from 2.78 mm to 6.09 mm (P<0.001). All patients were successfully repaired with no major complications, and none of them required any secondary repair. Three weeks postoperatively, all patients showed normal feeding, normal nasal resonance of speech with normal palatal mobility.Conclusion:Osteotomy of the greater palatine foramen for the closure of wide palatal clefts showed a good efficiency, quantitatively and qualitatively. The mean length of mucoperiosteal pedicle increased by 3.22 mm (6.44 mm for bilateral) after repairing, which helps to more freely medial movement of the palatal flap and lesser tension across its closure. All patients were successfully improved without any major complications.

Predictors of Success in Furlow Palatoplasty for Submucous Clefts: An Experience with 91 Consecutive Patients.

The aim of this study was to evaluate, through multivariate ordinal logistic regression, variables contributing to good postoperative speech outcomes following Furlow palatoplasty. A series of 91 consecutive patients was evaluated. Variables analyzed included demographics; speech perceptual assessment; and measures on videonasopharyngoscopy and videofluoroscopy such as preoperative closure pattern, velopharyngeal gap, and lateral pharyngeal wall motion. Univariate and multivariate analysis of predictors of high scores of articulation, nasal resonance, and resolution of velopharyngeal insufficiency were performed using simple and multinomial logistic regression. A summative perceptual assessment score was generated and analyzed for correlation with postoperative speech outcomes. There were 39 patients (42.9 percent) with a good outcome as defined by adequate articulation and lack of velopharyngeal insufficiency with normal nasal resonance. There was improvement of articulation in 53 patients (58.2 percent), of nasal resonance in 75 patients (82.4 percent), and of velopharyngeal insufficiency in 80 patients (87.9 percent). Predictors of good postoperative speech outcomes (p < 0.05) were preoperative articulation, nasal resonance, and lateral pharyngeal wall movement greater than 37.5 percent on one side. Preoperative severity of velopharyngeal insufficiency, velopharyngeal gap, pattern of closure, age, and sex were not predictive of a good outcome. Logistic regression demonstrated that the preoperative perceptual assessment score was predictive of postoperative outcome, with a significant difference (p < 0.05) between mild and severe groups. A scoring system based on summated perceptual assessment parameters is predictive of good postoperative speech outcomes. Risk, III.

Oral Pressure and Nasal Flow on /m/ and /p/ in 3- to 5-Year-Old Children without Cleft Palate

Objectives : (1) To compare oral pressure and nasal airflow in 3- to 5-year-olds versus older children and adults; (2) to describe stability of these measures in 3- to 5-year-olds at two recording times; and (3) to report participation rates of 3- to 5-year-olds for the aerodynamic protocol. Design : Prospective, nonrandomized, convenience samples in four age groups. Setting : University clinic. Participants : A total of 105 individuals without cleft palate and with normal speech for their age who were 3 to 5 (n = 45), 7 to 9 (n = 20), 11 to 13 (n = 20), or 20 to 30years old (n = 20). All had normal nasal resonance and absence of nasally obstructive conditions on the testing day. Main Outcome Measures : Oral pressure and nasal airflow on /p/ and /m/ in syllable series and the word "hamper." Results : Oral pressure was significantly higher on /p/ for 3- to 5-year-olds versus the two oldest groups. Nasal airflow on /p/ occurred infrequently across groups. Oral pressure on /m/ was significantly higher for 3- to 5-year-olds versus adults. Nasal airflow on /m/ increased significantly with age. Oral pressure and nasal flow did not differ at two measurement times for the 3- to 5-year-olds. Of the 3- to 5-year-olds, 88% completed the protocol. Conclusions : Oral pressure decreased on /p/ and nasal airflow increased on /m/ from early childhood into adulthood. Nasal air escape on /p/ occurred rarely for speakers of any age; when it did occur, the magnitude was limited. Most preschool-aged children should be able to complete a velopharyngeal aerodynamic protocol, and measures are stable even for these young speakers.

Islandized mucoperiosteal flaps: A versatile technique for closure of a wide palatal cleft

A variety of surgical methods have been described to repair wide cleft palate; they are all challenging to perform and yield consistently good results. The islandized mucoperiosteal flap, the technique described in the present article, is very versatile because it can close palatal defects of any size without undue tension. Moreover, it provides adequate length and mobility of the soft palate with improved speech and feeding functions without fistula formation. Between 2005 and 2011, 36 patients with wide cleft palate were operated on using islandized mucoperiosteal flaps. This technique involves dissection of the neurovascular bundle from the mucoperiosteal flaps for approximately 1 cm and dissecting the muscle from the posterior edge of the hard palate with intravelar veloplasty. The flaps subsequently become freely mobile in all directions. It can move medially to close palatal defects of any size without tension. In addition, posterior or backward mobilization lengthens the soft palate and renders it freely mobile. All repairs were successful, with no complications and no patients requiring secondary procedures. All patients regained normal feeding function three weeks postoperatively. All patients showed normal nasal resonance of speech except for two (three and five years of age) who experienced abnormal resonance in the form of open nasality that required regular speech therapy for six months. There was significant improvement and no secondary procedures were required for either. A technical modification for closure of wide palatal clefts is introduced. The islandized mucoperiosteal flap, which is a very versatile technique, can close cleft palates of any width without tension, lengthens the soft palate and renders it freely mobile for proper speech functions. Using this technique, good speech and feeding function with no complications were achieved.

Speech outcomes in 10-year-old children with complete unilateral cleft lip and palate after one-stage lip and palate repair in the first year of life

An evaluation of the results of one-stage repair of unilateral cleft lip and palate (UCLP) performed at the Institute of Mother and Child, Warsaw, Poland, has shown that the dentofacial outcomes are comparable with those of the best cleft centres. The aim of this study was to assess speech development after one-stage closure of UCLP. Twenty boys and eight girls at the mean age 9.6 years consecutively treated with one-stage closure of the cleft at the mean age of 8.8 (range, 6-13) months were included. The same surgeon performed palatal repair using a vomerplasty. The evaluated outcomes included (1) perceptual speech evaluations with assessment of hypernasality, audible nasal emissions (ANEs) and compensatory articulations, (2) evaluation of compensatory facial grimacing, (3) clinical intraoral evaluation and (4) videonasendoscopy when indicated. Our results demonstrated that 25 patients (89.3%) had normal nasal resonance. Severe hypernasality and compensatory articulation disorders caused by velopharyngeal insufficiency were assessed in one patient. In 13 patients (46.4%), oronasal fistulas were found. Two children (7%) with larger fistulas presented with mild hypernasality. In 11 cases (39.2%), fistula friction was heard at pronunciation of some anterior sounds. Ten children (35.7%) demonstrated compensatory facial grimacing, mostly inconsistent and mild, in the form of nasal valving. In conclusion, articulation development, velopharyngeal sphincter competence and incidence of compensatory articulations in our sample are satisfactory. However, only 54% of the present groups were rated as having entirely normal speech because of high incidences of anterior palatal fistulas, and mild but frequent fistula-related speech disturbances.

Nasal Resonance in Middle-Aged Women: A Multiparameter Approach

Aging influences several speech characteristics in middle-aged women. However, the effect of aging on nasal resonance has not been widely investigated, and findings are contradictory. The purpose of this study was to investigate the effect of aging on nasal resonance by comparing young women (between 20 and 28 years of age) with middle-aged women (between 45 and 55 years of age). Thirty-one middle-aged women with a mean age of 48 years participated in the subject group. The control group consisted of 22 young women with a mean age of 23 years. To investigate nasal resonance, we used a multiparameter approach by means of the Nasal Severity Index (NSI). Objective acoustic (nasal resonance scores of sounds and connected speech measured with the Nasometer) and aerodynamic measurements (maximum duration time of /s/, vital capacity, and mirror fogging test), as well as perceptual evaluations (Gutzmann /a/-i/test), were performed. The results of this study showed no differences in aerodynamic measurements and nasal resonance scores of connected speech and the sounds /i/, /u/, and /m/. Only the mean nasal resonance score of /a/ and the Gutzmann /a/ test were significantly different between the young and middle-aged women. The mean (+/- SD) NSI scores of the young women (12.93 +/- 17.9) and the middle-aged women (-1.49 +/- 14.4) both corresponded to normal nasal resonance. The results of this study indicate that both young and middle-aged women show a normal nasal resonance. Differences in objective and subjective measurements of nasal resonance were only found in isolated vowels, and not in connected speech.

A Comparative Study of Two Acoustic Measures of Hypernasality

This study aimed to compare 2 quantitative acoustic measures of nasality in children with cleft lip and palate (CLP) and healthy controls using formalized perceptual assessment as a guide. Fifty participants (23 children with CLP and 27 age- and gender-matched healthy controls) aged between 4 and 12 years produced a variety of high and low vowels that allowed perceptual ratings of nasal resonance severity as well as acoustic analysis of spectral changes. Two objective measures of nasality were used: 1/3 octave spectra analysis and the voice low tone high tone ratio. Each respective technique has been evaluated in previous research, and their potential as an effective means of detecting changes in nasal resonance has been demonstrated. Only 1/3 octave spectra analysis differentiated between participants with hypernasal speech and those perceived to have normal nasal resonance. Significant differences were also observed between varying levels of perceived severity on vowels within nonnasalized phonemic environments (/pIt/, /tIp/). Perceptual judgment remains the primary means of evaluating levels of nasality in children with CLP. However, the development and validation of easy-to-use objective techniques remains an important goal for effective clinical and empirical practice.

Surgical planning for restoring velopharyngeal function in velocardiofacial syndrome

Background Velocardiofacial syndrome (VCFS) is one of the most common multiple anomaly syndromes in humans. Around 70% of the cases show velopharyngeal insufficiency (VPI), as a consequence of cleft palate. VPI is much more frequent due to special abnormal conditions inherent to VCFS including: platybasia, hypotrophy of adenoid, enlarged tonsils, hypotonia and abnormal pharyngeal muscles. Objective To evaluate the surgical treatment of VPI in VCFS patients. Materials and methods In the Hospital Gea Gonzalez at Mexico City, all cases of VCFS from January 2000 to July December 2007 were studied. All patients subjected to velopharyngeal surgery for correcting VPI were selected. Twenty-nine patients underwent velopharyngeal surgery. All operations were planned according to findings of videonasopharyngoscopy (VNP) and multiview video fluoroscopy (MVF). Results Twenty patients underwent pharyngeal flap operations, and 9 patients were operated on with a sphincter pharyngoplasty. After a pharyngeal flap, 17 cases (85%) improved to normal nasal resonance or mild hypernasality. Three flaps showed moderate hypernasality postoperatively. From the 9 sphincter pharyngoplasties, 6 cases (66%) improved to moderate hypernasality. Four patients (33%) persisted with severe hypernasality postoperatively. There were no complications. Conclusions Tailor-made pharyngeal flaps seem to be the best option for restoring velopharyngeal function in cases of VPI in VCFS patients. The use of VNP and MVF is useful for planning the operations for VPI, and they are also useful for indicating the removal of tonsils in cases with high risk of obstruction. Moreover, VNP is also useful for preventing damage to the internal carotids which are usually displaced in VCFS patients.

Nasometric Values for Normal Nasal Resonance in the Speech of Young Flemish Adults

Abstract Objective: The purpose of this study was to obtain normative nasalance scores for adult subjects speaking the Flemish language. Additional objectives of the study were to determine if speaker sex played a role in differences in nasalance scores and if significantly different nasalance scores existed for Flemish compared with other languages or dialects. Design: Nasalance scores were obtained while young Flemish adults read three standard nasalance passages. These passages were an oronasal passage (a text that contained the same approximate percentage of nasal consonants as found in the standard Dutch speech), an oral passage (a text that excluded nasal consonants), and a nasal passage (a reading text loaded with nasal consonants). Participants: Subjects included 58 healthy young Flemish adults with normal oral and velopharyngeal structure and function, normal hearing levels, normal voice characteristics, and normal resonance and articulation skills. Methods: The Nasometer (model 6200) was used to...

The orthodontist and complex craniofacial anomalies

The orthodontist and complex craniofacial anomalies

Nasalance distance and ratio: two new measures.

Mean nasalance in speakers with perceptually normal nasal resonance can differ in magnitude considerably. In addition, categorizations of speech based on nasalance scores may not agree with perceptual judgments. To overcome this limitation, we evaluated two new simple measures derived from mean nasalance data: the nasalance distance (range between maximum and minimum nasalance) and the nasalance ratio (minimum nasalance divided by maximum nasalance). Department of Oral and Maxillofacial Surgery, University of Technology, Munich, Germany. The sample consisted of 133 cleft lip and palate patients with normal nasal resonance or varying degrees of hypernasality. Oral and nasal acoustic measurements were made using the NasalView system. Nasalance distance and nasalance ratio were calculated for five non-nasal and three nasal sentences from the modified Heidelberg Rhinophonia Assessment Form. Optimum cutoffs were derived from receiver-operating characteristics. Results for the sentence stimuli ranged from 64.4% to 89.6% sensitivity and from 91.2% to 94.1% specificity. When the analysis was limited to only one nonnasal and one nasal sentence, results ranged from 79.7% to 87.5% sensitivity and from 88.2% to 97.1% specificity. We conclude that the two new measurements are valuable in routine clinical examinations. Nasalance distance and ratio derived from sentence stimuli are two useful and easily applicable measures that can be used to supplement the nasalance mean value.

Nasalance Distance and Ratio: Two New Measures

Abstract Objectives: Mean nasalance in speakers with perceptually normal nasal resonance can differ in magnitude considerably. In addition, categorizations of speech based on nasalance scores may not agree with perceptual judgments. To overcome this limitation, we evaluated two new simple measures derived from mean nasalance data: the nasalance distance (range between maximum and minimum nasalance) and the nasalance ratio (minimum nasalance divided by maximum nasalance). Setting: Department of Oral and Maxillofacial Surgery, University of Technology, Munich, Germany. Subjects: The sample consisted of 133 cleft lip and palate patients with normal nasal resonance or varying degrees of hypernasality. Procedures: Oral and nasal acoustic measurements were made using the NasalView system. Nasalance distance and nasalance ratio were calculated for five nonnasal and three nasal sentences from the modified Heidelberg Rhinophonia Assessment Form. Results: Optimum cutoffs were derived from Receiver-Operating Charact...

Quantitative diagnosis of hypernasality in cleft lip and palate patients by computerized nasal quality assessment

In patients with cleft lip and palate (CLP), the assessment of velopharyngeal morphology and function and the quantitative analysis of perceptual consequences of velopharyngeal insufficiency are of major importance regarding the effective planning of velopharyngoplasties for speech improvement. The NasalView, a new instrument for the objective assessment of rhinophonia, is presented. The NasalView measures nasalance, the relative sound pressure level of the nasal signal in speech, expressed as a percentage. In order to evaluate the effectiveness of the computerised measurement of nasalance, 156 patients with surgically treated CLP were examined. The NasalView differentiated with high sensitivity and specificity between patients with normal nasal resonance and patients with varying degrees of hypernasality. To illustrate the importance of the NasalView for making the decision for a velopharyngoplasty, a single case is presented.

Examination of the standard deviation of mean nasalance scores in subjects with cleft palate: implications for clinical use.

To evaluate the standard deviation of the nasalance scores in patients having normal and abnormal nasal resonance and to determine its potential value for clinical use. Additionally, the mean nasalance scores were examined across varying degrees of hypernasality. Prospective study design. Pediatric tertiary care hospital. One hundred and forty-eight subjects, ranging in age from 4;0 to 37;0 years, having repaired cleft lip and/or palate and normal resonance, inconsistent, mild, or moderate/severe hypernasality. Oral-nasal acoustic measurements were made using the Nasometer. The standard deviation and mean nasalance scores were calculated for subjects reading three standard passages (Zoo Passage. Rainbow Passage, Nasal Sentences). The major finding in this study showed that the standard deviation score cannot distinguish speakers beyond a gross normal and abnormal resonance diagnostic category. The values obtained could not be used to distinguish among the varying degrees of hypernasality. A secondary finding was that a mean nasalance score in the high 20 s could be used to differentiate speakers with borderline velopharyngeal function from those who were non-nasal. In general, the standard deviation value serves little overall clinical utility; however, it may be of benefit in some specific clinical situations. In support of previous research, the mean nasalance score continues to be the best measure of nasalance. It should serve as a supplement to but not a substitute for clinical judgments.

Videonasopharyngoscopy as an instrument for visual biofeedback during speech in cleft palate patients

Videonasopharyngoscopy was used as an instrument for visual biofeedback during speech in cleft palate patients. Seventeen cleft palate patients were randomly selected for the study. All patients showed velopharyngeal insufficiency (VPI), compensatory articulation (CA) and negative movement of lateral pharyngeal walls (NMLPW) during speech. Nine patients received speech therapy for correcting CA. Eight patients received speech therapy and underwent videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter. After 12 weeks, NMLPW was modified in the patients receiving speech therapy and visual biofeedback. In contrast, NMLPW was still present in eight out of nine patients receiving only speech therapy. These patients received visual biofeedback and NMLPW was corrected in all cases. After six months, all 17 patients had corrected CA during isolated speech. All patients received a tailor-made pharyngeal flap. VPI was completely corrected in 15 cases. In the two cases in which VPI was still present postoperatively, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used postoperatively for increasing lateral pharyngeal walls (LPW) motion towards the borders of the flap. After 18 months since the onset of speech therapy all the patients had normal nasal resonance and normal articulation during connected speech.

Disorders of nasality in subjects with upper motor neuron type dysarthria following cerebrovascular accident

The nasality of 19 subjects with upper motor neuron (UMN) damage following cerebrovascular accident (CVA), and 19 control subjects matched for age and sex, was investigated using both perceptual judgements of nasality and a modified version of the nasal accelerometric procedure described by Horii (1980). Nasality indices were calculated for each subject during the production of a series of nasal and non-nasal sounds, words, and sentences. Statistical comparison of the two groups revealed that the CVA subjects had significantly higher nasality indices on the production of non-nasal speech tasks than the controls. No significant difference was noted between the two groups on nasal tasks. Individual case by case examination of the accelerometer data confirmed the presence of hypernasality in 7 of the 19 CVA subjects. In contrast to the instrumental findings, the results of the perceptual judgements of nasality identified the presence of hypernasality, hyponasality, and normal nasal resonance within the CVA group.

Hypernasality in the Presence of “Adequate” Velopharyngeal Closure

In some instances, hypernasality occurs despite an instrumental assessment of "adequate" velopharyngeal closure. The pressure-flow technique was used to assess the timing characteristics associated with velopharyngeal closure in 11 such subjects. The group's performance was compared to the aerodynamic characteristics of two other subject groups. One was comprised of 13 cleft palate subjects with adequate closure and normal nasal resonance, while the second group consisted of 16 noncleft subjects who also manifested normal speech. The data indicate that there are several unique timing features that differentiate the hypernasal but "adequate" group from the two control groups. These include a delay of about 50 ms in achieving closure, a longer interval of nasal emission, and a shorter duration of actual closure. Hypernasality seems to be associated with the actual time the velopharyngeal mechanism is open, rather than the volume of air escaping from the nasal chamber.

Hypernasality in the presence of "adequate" velopharyngeal closure.

In some instances, hypernasality occurs despite an instrumental assessment of "adequate" velopharyngeal closure. The pressure-flow technique was used to assess the timing characteristics associated with velopharyngeal closure in 11 such subjects. The group's performance was compared to the aerodynamic characteristics of two other subject groups. One was comprised of 13 cleft palate subjects with adequate closure and normal nasal resonance, while the second group consisted of 16 noncleft subjects who also manifested normal speech. The data indicate that there are several unique timing features that differentiate the hypernasal but "adequate" group from the two control groups. These include a delay of about 50 ms in achieving closure, a longer interval of nasal emission, and a shorter duration of actual closure. Hypernasality seems to be associated with the actual time the velopharyngeal mechanism is open, rather than the volume of air escaping from the nasal chamber.

Velopharyngeal Sphincter Physiology in Deaf Individuals

Fifty-three deaf subjects with a history of prelingual profound bilateral sensorineural hearing loss, similar language habilitation with hearing aids, and normal velopharyngeal structures underwent a study protocol including speech evaluation, behavioral pure-tone audiometry, videonasopharyngoscopy, multiview videofluoroscopy, and electromyography of the velopharyngeal muscles. Subjects were divided into two groups: the first group included 13 subjects with normal nasal resonance or mild hypernasality (four normals and nine with mild hypernasality); the second group had subjects with severe hypernasality and severe articulation deficits. Pure-tone thresholds, velopharyngeal closure patterns, and electromyographic activity of velopharyngeal muscles were similar for both groups of subjects. However, in subjects with severe hypernasality, despite normal muscle activity as observed by electromyography, velopharyngeal valving activity lacked rhythm and strength during speech. It is concluded that deaf subjects may present a functional disorder of the velopharyngeal sphincter related to absence of auditory regulation during phonation. Visual biofeedback using videonasopharyngoscopy may be useful for treating this disorder.

Velopharyngeal Sphincter Physiology in Deaf Individuals

Fifty-three deaf subjects with a history of prelingual profound bilateral sensorineural hearing loss, similar language habilitation with hearing aids, and normal velopharyngeal structures underwent a study protocol including speech evaluation, behavioral pure-tone audiometry, videonasopharyngoscopy, multiview videofluoroscopy, and electromyography of the velopharyngeal muscles. Subjects were divided into two groups: the first group included 13 subjects with normal nasal resonance or mild hypernasality (four normals and nine with mild hypernasality); the second group had subjects with severe hypernasality and severe articulation deficits. Pure-tone thresholds, velopharyngeal closure patterns, and electromyographic activity of velopharyngeal muscles were similar for both groups of subjects. However, in subjects with severe hypernasality, despite normal muscle activity as observed by electromyography, velopharyngeal valving activity lacked rhythm and strength during speech. It is concluded that deaf subjects may present a functional disorder of the velopharyngeal sphincter related to absence of auditory regulation during phonation. Visual biofeedback using videonasopharyngoscopy may be useful for treating this disorder.