Short-term effect of short, intensive speech therapy on articulation and resonance in Ugandan patients with cleft (lip and) palate

OBJECTIVES

The purpose of the current study was to assess the short-term effectiveness of short and intensive speech therapy provided to patients with cleft (lip and) palate (C(L)P) in terms of articulation and resonance.

METHODS

Five Ugandan patients (age: 7.3-19.6 years) with non-syndromic C(L)P received six hours of individualized speech therapy in three to four days. Speech therapy focused on correct phonetic placement and contrasts between oral and nasal airflow and resonance. Speech evaluations performed before and immediately after speech therapy, including perceptual and instrumental assessment techniques, were compared.

RESULTS

Post-therapy, improvement of speech was noted for most of the patients, although to varying degrees. Clinically relevant progress of objective nasalance values and/or articulation was obtained in four patients. Overall, two patients showed normal speech intelligibility, while three patients required additional speech therapy.

CONCLUSION

These preliminary short-term results demonstrate that short and intensive speech therapy can be effective for patients with C(L)P in countries with limited access to speech-language therapy. However, further research is needed on the long-term effectiveness and the advantages of applying this treatment protocol in countries with good access to speech therapy.

LEARNING OUTCOMES

The reader will be able to (1) list the challenges in resource poor-countries to achieve access to speech-language therapy services, (2) describe when the application of speech therapy is appropriate in patients with C(L)P, (3) describe the speech therapy that can be applied to reduce compensatory articulation and resonance disorders in patients with C(L)P, and (4) list the (possible) advantages of short, intensive speech therapy for both resource-poor and developed countries.

Longitudinal progress of overall intelligibility, voice, resonance, articulation and oromyofunctional behavior during the first 21 months after Belgian facial transplantation

PURPOSE

The purpose of this study is to document the longitudinal progress of speech intelligibility, speech acceptability, voice, resonance, articulation and oromyofunctional behavior in a male facial transplant patient 8 days, 15 days, 5 months, 12 months and, finally, 21 months after surgery.

METHOD

Identical objective (Dysphonia Severity Index, nasometry, acoustic analysis) and subjective (consensus perceptual evaluation, Dutch speech intelligibility test; flexible videolaryngostroboscopy/naso-endoscopy) assessment techniques and questionnaires (speech and voice handicap index, oral health impact profile, facial disability index) were used during each of the five postsurgical assessments.

RESULTS

The pattern of results shows a longitudinal progress of speech intelligibility and acceptability and of the interactive processes underpinning overall speech intelligibility. Vocal quality is normal and resonance is characterized by hypernasality. The phonetic inventory is complete but four phonetic disorders remain. Outcomes pertaining to articulation (formant analysis) show evident progress over time. Lip functions are improving but still decreased.

CONCLUSIONS

Transplantation of the face in this patient has largely restored speech. To what extent resonance, articulation, and lip functions can be enhanced by the permanent use of a palatal obturator, by specialized facial and lip movement exercises in combination with motor-oriented speech therapy, is subject for further research. Learning outcomes Facial transplantation: Readers will be able to (1) describe the relationship between facial transplantation and the impact on speech and oromyofunctional behavior, (2) identify variables that influence the outcome after facial transplantation, (3) define an assessment protocol after facial transplantation, (4) define facial transplantation.

Oral strength in subjects with a unilateral cleft lip and palate

PURPOSE

Facial appearance and speech outcome may affect psychosocial functioning in girls and boys. Several studies reported dissatisfaction with facial appearance and more specifically the lip and mouth profile in children with cleft lip and palate (CLP). The purpose of this controlled study was to measure the tongue and lip strength and endurance in boys and girls with CLP.

METHODS

Twenty-five subjects (mean age: 10.6 years) with a unilateral CLP and a gender- and age- matched control group were selected. All subjects with an unilateral CLP consulted the same craniofacial team and had undergone an identical surgical procedure. Surgical procedure of the lip was performed using a modified Millard technique without primary nose correction at an average age of 5.5 months. The Iowa Oral Performance instrument was used to measure lip and tongue strength and tongue endurance.

RESULTS

The results of the Iowa Oral Performance measurement showed no significant differences between the subjects with an unilateral cleft lip and palate and the age and gender matched control group without a cleft lip and palate.

CONCLUSION

There is no significant differences regarding oral strength more specifically the lip and tongue strength and endurance between subjects with and without an unilateral cleft lip and palate. ENT specialists and speech pathologists must be aware of this aspect of the normal lip and tongue functions.

Harlequin syndrome after thyroidectomy for compressive retrosternal goiter. Case report and review of the literature

A 74-year-old woman with known euthyroid multinodular retrosternal goiter necessitated an urgent intubation at home, due to acute respiratory distress evoked by tracheal compression. Extubation after a few days failed, and she underwent an urgent total thyroidectomy. During postoperative extubation the patient developed suddenly unilateral facial flushing and sweating at the left side, without ptosis of the left levator palpebrae superioris. These symptoms persisted during the next 24 hours. The skin at the right side of the face remained uninvolved. In the early postoperative period this appearance recurred at moments of emotions, exercise or heat. Beside this, the patient had a normal recovery. Six weeks later this reaction couldn't be provoked anymore. 'Harlequin' syndrome (unilateral facial flushing and sweating) is caused by a lesion of the controlateral sympathetic chain at the levels T2 and T3. It is unknown if the sweating and vasodilation at the "healthy" side is normal or if it is a reaction of hyperactivity.

Parental satisfaction in Ugandan children with cleft lip and palate following synchronous lip and palatal repair

The purpose of the present case control study was to assess parental satisfaction with speech and facial appearance in Ugandan children with complete unilateral or bilateral cleft lip and palate (CLP), who underwent a synchronous lip and palatal closure. The results are compared with an age- and gender-matched control group. The experimental group consisted of the parents or guardians of 44 Ugandan patients (21 males, 23 females) with complete unilateral or bilateral CLP (mean age: 3;1 years). The control group included the foster mothers of 44 orphan children matched by age and gender (mean age: 3;7 years). A survey based on the Cleft Evaluation Profile was used to assess the perceived satisfaction for individual features related to cleft care. Overall high levels of satisfaction were observed in the experimental group for all features (range: 56-100%). No significant differences could be established regarding age, gender, age of lip and palatal closure, cleft type or maternal vs. paternal judgments. In participants who were dissatisfied with the appearance of the lip, the time period between the cleft closure and the survey was significantly larger compared with satisfied participants. Furthermore, significantly lower levels of satisfaction were observed in the cleft group for speech and the appearance of the teeth and the nose compared with the control group. Satisfaction with speech and facial appearance in Ugandan children with cleft lip and/or palate is important since normal esthetics and speech predominantly determine the children's social acceptance in the Ugandan society.

LEARNING OUTCOMES

As a result of reading this manuscript, the reader will be able to explain the attitudes of parents toward the surgical repair of their children's cleft lip and palate. As a result of reading this manuscript, the reader will be able to identify differences in parental attitudes toward synchronous lip and palate repair.

Phototoxic reaction after parathyroid surgery: case report and review of the literature

BACKGROUND

A woman of 41 years old underwent surgery for primary hyperparathyroidism. She developed a long-lasting sharply demarcated erythematous skin reaction, appearing one hour after parathyroid surgery. This erythematous reaction felt like sunburn and was limited to the light exposed skin of the operation field, leading to the diagnosis of a phototoxic reaction. Since this phototoxic reaction occurred just after changing the operation lamp from a halogen type to a Light-Emitting Diode (LED) type, we suspected that the type of operation lamp could be a part of the cause of this phototoxic reaction. This is because our department has never before diagnosed phototoxic reactions (with a halogen type of operation lamp) during methylene blue (MB) assisted parathyroid surgery.

METHODS

To investigate the cause of this phototoxic reaction, we performed an analysis of the adverse effects of all administered peroperative drugs and an evaluation of altered operation conditions.

RESULTS

MB, used as a peroperative surgical marker of the parathyroid glands, was the most likely causal agent of this phototoxic reaction. Emission spectrum analysis of the operation light shows that the new LED operation lamp gives a high intensity of blue light. This may have resulted in activation of MB leading to a phototoxic reaction.

CONCLUSIONS

To our knowledge, this is the first described phototoxic reaction in adults due to MB used as peroperative marker. Although rare, this potential side effect should be considered when using high doses of MB in combination with high intensity of blue light.

Expression and prognostic value of glucose transporters and hexokinases in tonsil and mobile tongue squamous cell carcinoma

The aim of this study was to assess the expression pattern and prognostic value of the high affinity glucose transporters GLUT-1, 3, 4, 8 and 9, SGLT-1 and of hexokinases (HK) I, II and III in squamous cell carcinoma of the tonsil and mobile tongue (TTSCC) by means of immunohistochemistry. Seventy-one consecutive patients suffering from TTSCC were included. The intensity and amount of positive tumour cells in the immunoreaction (histology score (H-score)) for GLUT-1, 3, 4, 8 and 9 as well as for HK-I, II and III were assessed independently by two experienced observers, blinded to the clinical results. H-scores as well as clinical variables were related to patient outcome. Median follow-up time was 49 months (range 1-123 months). Mean H-scores for GLUT expression in decreasing order of magnitude were respectively 10.99 for GLUT-1 (sd 3.9), 5.7 for GLUT-8 (sd 4.0), 5.4 for GLUT-3 (sd 3.7), 1.0 for GLUT-4 (sd 2.0), 1.1 (sd 1.3) for SGLT-1, and 0.4 for GLUT-9 (sd 0.6); GLUT-1 > GLUT-8 = GLUT-3 > GLUT-4 = GLUT-9 = SGLT-1 (with > meaning significantly (p<0.05 on ANOVA + posthoc Bonferroni correction) higher than and =, meaning not significantly different from). Mean H-scores for hexokinase expression were respectively 5.8 for HK-I (sd 3.5), 4.6 for HK-II (sd 3.0) and 2.0 for HK-III (sd 2.0); HK-I > HK-II > HK-III. Finally high H-scores for GLUT-4 were favourably related to disease-free and overall survival on multivariate analysis. To conclude, TTSCC expresses a wide variety of glucose transporter systems and hexokinase enzymes with the "housekeeping" GLUT-1 and HK-I being the most intensely expressed. GLUT-4 over-expression appears to confer a favourable prognosis in squamous cell carcinoma of the tonsil and mobile tongue. Additional studies confirming this finding in larger cohorts of patients are mandatory.

Impact of tongue reduction on overall speech intelligibility, articulation and oromyofunctional behavior in 4 children with Beckwith-Wiedemann syndrome

OBJECTIVE

The purpose of this study was to determine the impact of partial glossectomy (using the keyhole technique) on speech intelligibility, articulation, resonance and oromyofunctional behavior.

PATIENTS AND METHODS

A partial glossectomy was performed in 4 children with Beckwith- Wiedemann syndrome between the ages of 0.5 and 3.1 years. An ENT assessment, a phonetic inventory, a phonemic and phonological analysis and a consensus perceptual evaluation of speech intelligibility, resonance and oromyofunctional behavior were performed.

RESULTS

It was not possible in this study to separate the effects of the surgery from the typical developmental progress of speech sound mastery. Improved speech intelligibility, a more complete phonetic inventory, an increase in phonological skills, normal resonance and increased motor-oriented oral behavior were found in the postsurgical condition. The presence of phonetic distortions, lip incompetence and interdental tongue position were still present in the postsurgical condition.

CONCLUSION

Speech therapy should be focused on correct phonetic placement and a motor-oriented approach to increase lip competence, and on functional tongue exercises and tongue lifting during the production of alveolars. Detailed analyses in a larger number of subjects with and without Beckwith-Wiedemann syndrome may help further illustrate the long-term impact of partial glossectomy.

Metabolic tumour volume. Prognostic value in locally advanced squamous cell carcinoma of the head and neck

PURPOSE

Evaluate the predictive and prognostic value of semi-quantitative FDG-PET variables derived from pretreatment FDG-PET images in patients suffering from locally advanced squamous cell carcinoma of the head and neck (SCCHN), treated by means of concomitant radiochemotherapy.

PATIENTS, METHODS

40 patients with newly diagnosed SCCHN that were treated with concomitant radiochemotherapy underwent FDG-PET/CT for treatment planning; 18 patients had neck dissection prior to their baseline scan and to receiving radiochemotherapy. FDG-PET images were used to calculate metabolic tumour volumes using region growing and a threshold of 50% (MTV50) of primary lesions and involved lymph nodes as well as the mean and maximum standard uptake value (SUVmean and SUVmax) of the primary tumours.

RESULTS

Neither SUVmean nor SUVmax values of the primary tumour were significantly different between responders and non-responders whereas MTV50 values of the primary tumour proved significantly higher in non-responders. SUVmean, SUVmax and MTV50 of the primary tumour were not predictive for overall or disease free survival. Contrariwise, dichotomized summed MTV50 values (cut-off≥31 cm3) of the primary tumour and involved lymph nodes in patients that didn't have neck dissection prior to radiochemotherapy were predictive for disease free and overall survival in both univariate and multivariate analysis (p≤0.05).

CONCLUSION

Summed MTV50 values of both the primary tumour and involved lymph nodes provided independent prognostic information on disease free and overall survival.

Overall intelligibility, articulation, resonance, voice and language in a child with Nager syndrome

OBJECTIVE

The purpose of this study was to provide a description of the language and speech (intelligibility, voice, resonance, articulation) in a 7-year-old Dutch speaking boy with Nager syndrome. To reveal these features comparison was made with an age and gender related child with a similar palatal or hearing problem.

METHODS

Language was tested with an age appropriate language test namely the Dutch version of the Clinical Evaluation of Language Fundamentals. Regarding articulation a phonetic inventory, phonetic analysis and phonological process analysis was performed. A nominal scale with four categories was used to judge the overall speech intelligibility. A voice and resonance assessment included a videolaryngostroboscopy, a perceptual evaluation, acoustic analysis and nasometry.

RESULTS

The most striking communication problems in this child were expressive and receptive language delay, moderately impaired speech intelligibility, the presence of phonetic and phonological disorders, resonance disorders and a high-pitched voice. The explanation for this pattern of communication is not completely straightforward. The language and the phonological impairment, only present in the child with the Nager syndrome, are not part of a more general developmental delay. The resonance disorders can be related to the cleft palate, but were not present in the child with the isolated cleft palate. One might assume that the cul-de-sac resonance and the much decreased mandibular movement and the restricted tongue lifting are caused by the restricted jaw mobility and micrognathia. To what extent the suggested mandibular distraction osteogenesis in early childhood allows increased mandibular movement and better speech outcome with increased oral resonance is subject for further research.

CONCLUSION

According to the results of this study the speech and language management must be focused on receptive and expressive language skills and linguistic conceptualization, correct phonetic placement and the modification of hypernasality and nasal emission.

FDG uptake in primary squamous cell carcinoma of the head and neck. The relationship between overexpression of glucose transporters and hexokinases, tumour proliferation and apoptosis

AIM

This study aimed at assessing the relationship between over-expression of glucose transporters and hexokinases, tumour proliferation and apoptosis corrected for cellularity and partial volume corrected (pvc) FDG SUV values in primary squamous cell carcinoma of the head and neck (pSCCHN).

PATIENTS, METHODS

In 27 consecutive patients suffering from pSCCHN, FDG SUVmax and mean pvc values of the primary tumour were derived from a pre-surgical routine staging FDG PET/CT examination. GLUT-1, GLUT-3, HK-1, HK-3 expression, tumour proliferation (Ki-67 staining) and the number of apoptotic cells (cleaved caspase-3 staining), corrected for tumour cellularity, were subsequently assessed on the corresponding post-surgically obtained biopsies and tumour specimens. FDG SUVmax and mean pvc values of pSCCHN were correlated with the corresponding histological findings.

RESULTS

FDG SUV max and mean pvc values correlated significantly: with GLUT-1 scores r = 0.408 (p = 0.04) and r = 0.439 (p = 0.03) as well as with the number of apoptotic cells r = 0.529 (p = 0.008) and r = 0.484 (p = 0.017). The number of apoptotic cells also correlated to GLUT-3 scores: r = 0.62 (p = 0.001) and GLUT-1 scores r = 0.528 (p = 0.008).

CONCLUSION

FDG SUV pvc proved significantly related to GLUT-1 expression by tumour cells and to the absolute number of apoptotic cells. The latter finding warrants further exploration and confirmation by additional studies.

Long-term impact of tongue reduction on speech intelligibility, articulation and oromyofunctional behaviour in a child with Beckwith-Wiedemann syndrome

The purpose of the present case study was to determine the long-term impact of partial glossectomy (using the keyhole technique) on overall speech intelligibility and articulation in a Dutch-speaking child with Beckwith-Wiedemann syndrome (BWS). Furthermore the present study is meant as a contribution to the further delineation of the phonation, resonance, articulation and language characteristics and oral behaviour in a child with BWS. Detailed information on the speech and language characteristics of children with BWS may lead to better guidance of pediatric management programs. The child's speech was assessed 9 years after partial glossectomy with regard to ENT characteristics, overall intelligibility (perceptual consensus evaluation), articulation (phonetic and phonological errors), voice (videostroboscopy, vocal quality), resonance (perceptual, nasometric assessment), language (expressive and receptive) and oral behaviour. A class III malocclusion, an anterior open bite, diastema, overangulation of lower incisors and an enlarged but normal symmetric shaped tongue were present. The overall speech intelligibility improved from severely impaired (presurgical) to slightly impaired (5 months post-glossectomy) to normal (9 years postoperative). Comparative phonetic inventory showed a remarkable improvement of articulation. Nine years post-glossectomy three types of distortions seemed to predominate: a rhotacism and sigmatism and the substitution of the alveolar /z/. Oral behaviour, vocal characteristics and resonance were normal, but problems with expressive syntactic abilities were present. The long-term impact of partial glossectomy, using the keyhole technique (preserving the vascularity and the nervous input of the remaining intrinsic tongue muscles), on speech intelligibility, articulation, and oral behaviour in this Dutch-speaking child with congenital macroglossia can be regarded as successful. It is not clear how these expressive syntactical problems demonstrated in this child can be explained. Certainly they are not part of a more general developmental delay, hearing problems or cognitive malfunctioning. To what extent the presence of expressive syntactical problems is a possible aspect of the phenotypic spectrum of children with BWS is subject for further research. Multiple variables, both known and unknown can affect the long-term outcome after partial glossectomy in a child with BWS. The timing and type of the surgical technique, hearing and cognitive functioning are known variables in this study. But variables such as children's motivation, the contribution of the motor-oriented speech therapy, the parental articulation input and stimulation and other family, school and community factors are unknown and are all factors which can influence speech outcome after partial glossectomy. Detailed analyses in a greater number of subjects with BWS may help further illustrate the long-term impact of partial glossectomy.

Why do we prefer the external approach?

Open structure rhinoplasty (OSR) is an old technique that has gained in popularity amongst plastic surgeons and otolaryngologists over the past twenty years. Opponents of the external approach cite potential problems such as unnecessary scaring, reduction of tip support, extended operative time and excessive post-operative tip swelling. However, even relatively inexperienced rhinoplastic surgeons embrace this approach, especially in cases with more complex tip deformities and skeletal abnormalities. Concerns about scarring and post-operative tissue reaction due to the more "aggressive" external approach make it necessary to consider the indications for the open approach carefully. Various incisions have been described for open rhinoplasty to reduce scarring, such as the Z, V, reverse V, and W incisions. There should be a strong emphasis on post-operative care in open approach rhinoplasty since open structure rhinoplasty is generally considered to be a more traumatic technique than the endonasal approach. Careful incision and dissection of the skin flap in the right surgical plane and proper suturing are essential to avoid short- and long-term complications. In conclusion, the external approach is preferable in selected cases where extended exposure (asymmetry cases, for example), per-operative assessment (revision cases), grafting and suturing are required. It allows the surgeon to work bimanually during reconstruction and the better per-operative evaluation reduces the revision rate.

Prognostic value of FDG uptake by the bone marrow in squamous cell carcinoma of the head and neck

BACKGROUND

The appearance of natural suppressor cells and circulating endothelial progenitor cells in tumour tissue has been associated with myelopoetic stimulation by growth factors that may increase fluorodeoxyglucose (FDG) uptake by the bone marrow and high FDG uptake by bone marrow in patients suffering from human malignancies is a not uncommon finding.

METHODS

This study looked at the relationship between bone marrow FDG uptake, biochemical (Hb level, RBC count, WBC count and platelet count), clinical and radiological findings and outcome in a series of 35 patients suffering from squamous cell carcinoma of the head and neck (SCCHN), consecutively referred for FDG PET as part of their routine staging procedure.

RESULTS AND CONCLUSION

In SCCHN, mean FDG standardized uptake values (SUVs) of the primary tumour correlate significantly with blood WBC count (r=0.44; P=0.011, Bonferroni corrected P=0.04) and mean FDG SUVs of bone marrow are significantly correlated to the maximum FDG SUVs of the primary tumour (r=0.523; P=0.002). Finally, FDG uptake by the bone marrow is related to disease-free and overall survival. These findings warrant confirmation in a larger patient series.