To understand the mechanism of occurrence of these anomalies, one should study the process of formation of the lip and palate.

The formation of the lip and palate begins at 5-10 weeks of intrauterine life; The primary oral cavity is divided into two sections:

oral cavity and nasal cavity.

This is due to the formation of lamellar projections of the palatine processes on the internal surfaces of the maxillary processes. At the beginning eighth week the edges of the palatine processes are directed obliquely downwards and lie along the floor of the oral cavity, on the sides of the tongue. The lower jaw is enlarged. The tongue descends into this space, allowing the palatine processes to move from a vertical to a horizontal position.

At the end second month During the life of the embryo, the edges of the palatine processes begin to connect with each other, begins in the anterior sections and gradually spreads posteriorly. The septum of the oral bay represents the rudiment of the hard and soft palate. It separates the final oral cavity from the nasal cavity. At the same time, the nasal septum grows, which fuses with the palate and divides the nasal cavity into the right and left nasal chambers.

by the 11th week the lip and hard palate are formed,

and by the end of the 12th week, fragments of the soft palate grow together. The condition of the lip and palate in the embryo at certain stages of development is the same as in case of nonunions observed in the clinic: from a through bilateral cleft defect of the lip, alveolar process and palate to nonunion of only the soft palate and even only the uvula or hidden nonunion of the lip. Conventionally, this condition of the lip or palate can be called a physiological cleft. Under the influence of one or more of the listed etiological factors, the fusion of the edges of the “physiological clefts” is delayed, which leads to congenital nonunion of the lip, palate, or a combination of them.

One of the pathogenetic factors of non-union of the halves of the palate, obviously, is the pressure of the tongue, the size of which, as a result of discorrelation of growth, turned out to be larger than usual. Such a discrepancy may arise due to hormonal metabolic disorders in the mother’s body.

Topic 3. Causes and mechanisms of disorders in rhinolalia

.Causes of rhinolalia.

Types and forms of congenital clefts.

Classification of rhinolalia.

The mechanism of occurrence of speech disorders in rhinolalia.

Mechanisms of disturbances in speech breathing, voice formation and sound pronunciation.

Etiology

Etiological factors of abnormalities in the human body, including the maxillofacial region, are divided into exogenous and endogenous.

TO exogenous factors include:

1) physical (mechanical and thermal effects; external and internal ionizing radiation);

2) chemical (hypoxia, malnutrition of the mother in critical periods embryo development, lack of vitamins (retinol, tocopherol acetate, thiamine, riboflavin, pyridoxine, cyanocobalamin), as well as essential amino acids and iodine in the mother’s food; hormonal imbalances. Exposure to teratogenic poisons that cause fetal hypoxia and deformities, the influence of chemical compounds that imitate the effect of ionizing radiation, such as mustard gas;

H) biological (measles rubella viruses, mumps, herpes zoster, bacteria and their toxins);

4) mental (cause hyperadrenalineemia).

TO endogenous factors belong to:

1) predisposition to pathological heredity (there is no gene carrying a hereditary predisposition to nonunion)

2) biological inferiority of cells;

H) influence of age and gender.

In the anamnesis of patients and their parents, it is often possible to establish the following factors with which the occurrence of birth defects has to be associated: infectious diseases suffered by the mother during pregnancy; toxicosis, spontaneous and induced abortions; severe physical trauma in the 8th–12th week of pregnancy; diseases of the genital area; severe mental trauma of the mother; late birth; maternal nutritional disorder.

Types and forms of congenital clefts

Congenital palate defects include:

1) congenital cleft palate and lip

2) submucosal clefts;

3) congenital underdevelopment of the palate;

4) congenital asymmetry of the face due to deformation of the palate.

The most common clefts in practice are cleft lip and palate. The forms of palatal clefts are extremely diverse, but they all lead to speech impairment.

Cleft lips. There are partial and complete cleft lips. The anatomical structure and size of the lips in children and adults vary significantly.

A normally developed upper lip has the following anatomical components:

1) filter 2) two columns; H) red border; 4) median tubercle; 5) line, or arc, of Cupid. This is the name of the line separating the red border and the skin of the upper lip.

When treating a child with a congenital lip defect, the surgeon must recreate all of the listed elements.

Classification. In accordance with clinical and anatomical characteristics, congenital defects of the upper lip are divided into several groups.

1. Nonunion of the upper lip is divided into lateral – unilateral(accounting for about 82%), bilateral.

2. on partial(when nonunion has spread only to the red border or, simultaneously with the red border, there is nonunion of the lower part of the skin of the lip

And full– within the entire height of the lip, as a result of which the wing of the nose is usually deployed due to non-union of the base of the nostril

Cleft palate. The normal palate is a formation that separates the cavities of the mouth, nose and pharynx. It consists of the hard and soft palate. Solid has a bone base. It is framed in front and on the sides by the alveolar process of the upper jaw with teeth, and behind by the soft palate. The hard palate is covered with a mucous membrane, the surface of which behind the alveoli has increased tactile sensitivity. The height and configuration of the hard palate affect resonance.

The soft palate is the posterior part of the septum between the cavities of the nose and mouth. The soft palate is a muscular formation. The front third of it is practically motionless, the middle third is most actively involved in speech, and the back third is in tension and swallowing. As you ascend, the soft palate lengthens. In this case, thinning of its anterior third and thickening of the posterior third are observed.

The soft palate is anatomically and functionally connected to the pharynx; the velopharyngeal mechanism is involved in breathing, swallowing and speech.

When breathing, the soft palate is lowered and partially covers the opening between the pharynx and the oral cavity. When swallowing, the soft palate stretches, rises and approaches the posterior wall of the pharynx, which accordingly moves towards and comes into contact with the palate. At the same time, other muscles contract: the tongue, the side walls of the pharynx, and its superior constrictor.

When blowing, swallowing, or whistling, the soft palate rises even higher than during phonation and closes the nasopharynx, while the pharynx narrows.

Velopharyngeal insufficiency refers to a disruption of the normal physiological interaction of the structures of the velopharyngeal ring. In children with congenital cleft palates after palatoplasty, velopharyngeal insufficiency is a consequence of insufficient closure of the soft palate with the posterior wall of the pharynx and manifests itself in the form speech disorder- rhinolalia. Slurred speech, nasal sounds, nasal emissions (audible leakage of air from the mouth into the nasal cavity), and compensatory articulation mechanisms (including compensatory facial grimaces) are typical signs of velopharyngeal insufficiency.

The main cause of velopharyngeal insufficiency is the insufficient participation of the soft palate in the mechanism of velopharyngeal closure: in some cases the soft palate is too short, in others it is not mobile enough.

The main reasons for the formation of velopharyngeal insufficiency:

the use of surgical techniques leading to the formation of a shortened soft palate;

performing primary palate surgery after the first year of life;

disruption of normal healing processes in the postoperative period.

Methods for diagnosing velopharyngeal insufficiency

The simplest and most accessible method for diagnosing velopharyngeal insufficiency is speech therapy examination and testing. It is carried out by a highly qualified speech therapist and is based on identifying nasal sounds and nasal emissions when pronouncing special words that require complete closure of the velopharyngeal ring (read).

The most objective method for studying the function of the velopharyngeal ring is fiberoptic nasopharyngoscopy. When conducting this examination, the doctor can not only visualize all the structures of the velopharyngeal ring and assess the degree of their participation in the process of closure, but also determine the size of the residual opening between the soft palate and the posterior wall of the pharynx directly at the moment of closure.

Based on the results of speech therapy testing and nasopharyngoscopy, during a joint consultation, the operating surgeon and speech therapist choose the most optimal way to eliminate velopharyngeal insufficiency.

Nasopharyngoscopy is a standard procedure used in the diagnosis of velopharyngeal insufficiency

Treatment methods

The treatment program for children with velopharyngeal insufficiency developed at the center includes the following stages:

1. Speech therapy courses in a hospital or in a center clinic.

2. Speech therapy examination and nasopharyngoscopy.

3. Depending on the results of the examination, continuation of speech therapy training or surgical treatment (reconstruction of the soft palate or use of pharyngeal tissue to achieve velopharyngeal closure).

Pay attention!
Rhinolalia is a speech pathology that is observed in almost 100% of cases in children with congenital cleft palates after late palate surgery.

The optimal prevention of its occurrence is to perform palate surgery before the age of 1 year. However, rhinolalia is a reversible pathology, its manifestations can be eliminated by conducting speech therapy courses.

Diagnosis palatopharyngeal - means that after repeated courses of speech therapy training, clinical signs of rhinolalia remain, and with nasopharynoscopy, there is a significant area of ​​non-closure of the soft palate with the posterior wall of the pharynx. As a rule, this implies the need for surgical treatment.

Assistant, Department of Pediatric Dentistry and Orthodontics, First Moscow State Medical University named after I.M. Sechenov

Treatment of children with CGN is one of complex tasks reconstructive surgery of the maxillofacial area. The problem lies not only in correcting the anatomical defect, but also in fully restoring the function of the organ. The integrity of the anatomical structures of organs can be restored using various plastic surgeries. However, despite the variety of methods, in some cases, surgical intervention does not lead to restoration of the integrity of the NGC, which causes insufficiency of its function (A. E. Gutsan, 1982; E. I. Samar, 1986; L. N. Gerasimov, 1991; A . A. Mamedov, 1997-2012; R. O'Neal, 1971; S. Cohen et al., 1992; ., 1993; A. E. Rintala, 1980;

Classification of velopharyngeal ring insufficiency

In a number of proposed classifications of insufficiency of the OG function, in our opinion, the degree of insufficiency of the function of the structures is not taken into account; there is no exhaustive list of the causes of speech impairment in their relationship with dysfunction of the OG.

Why does it seem to us that the need for a detailed listing and analysis of the causes of speech impairment is so important?

Firstly, only by determining the causes - according to the degree of impairment of the mobility of the structures of the OGN - can one accurately determine the tactics of surgical rehabilitation of patients with NGN.

Secondly, it is necessary to constantly take into account the reasons of a central nature (in particular, a delay in psychosis speech development), and consequently, speech development, emotional-volitional sphere. Speech impairment to varying degrees (depending on the nature of speech disorders) negatively affect the mental development of the child and affect his conscious activity. Can cause inappropriate behavior, affect mental development, especially the formation higher levels cognitive activity.

Thirdly, in our opinion, the cause of speech impairment is the missed time for primary uranoplasty, i.e., when the operation was performed later than the patient’s 5th birthday: by this time he has already developed pathological speech stereotypes. That is why the diagnosis of speech disorders should be carried out by a surgeon together with a speech therapist, neurologist, psychologist, and orthodontist.

The cause of speech impairment is the missed time for primary uranoplasty, when the operation was performed later than the patient’s 5th birthday

The desire for an objective diagnosis of the above reasons, 37 years of clinical experience, including the use of complex diagnostics and complex rehabilitation of a large group of patients with NPC, naturally led to the creation of a classification based on a quantitative assessment of the anatomical and functional characteristics of the function of the structures of the GPC, determined on the basis endoscopic examination.

Anatomical and functional endoscopic classification of insufficiency of the velopharyngeal ring (NPR) (A. A. Mamedov, 1996)

• Type I: insufficiency of the NGC, resulting from poor mobility of the entire velum palatine (PV).
• Type II: insufficiency of the NGC, resulting from poor mobility of one BSG.
• Type III: insufficiency of the NGC, resulting from poor mobility of both BSGs.
• Type IV: insufficiency of the NGC, resulting from poor mobility of all structures of the NGC.
• Type V: insufficiency of the NGC that occurred after velopharyngoplasty, pharyngoplasty.

The classification we propose (a grouping of the causes of insufficiency of the function of the structures of the genital tract) allows in practice to choose a tactic of surgical treatment in which the least mobile tissues of the structures of the cervical tract are identified and used in the process of surgical intervention. Determining the degree of mobility of each of the structures in fragments and all together allows us to recommend a specific surgical method aimed at correcting the least mobile tissues and eliminating their negative impact on the mechanism of closure of the NC.

We determine the degree of mobility of the LSG structures during endoscopic examination of patients: good mobility, satisfactory mobility, poor mobility (we did not take into account the quantitative assessment of the degree of mobility of the LSG, since it is not significantly involved in the closure mechanism).

Material and methods

Based on clinical experience and objective methods of comprehensive examination of patients with IFN, in our work we found that most patients, unfortunately, primary uranoplasty was performed too late, at the age of over 5 years (80 children), and only 6 children underwent primary uranoplasty at the optimal time - from 2 to 4 years - in the form of a two-stage uranoplasty (stage I - plastic surgery of the soft palate - veloplasty; stage two - plastic surgery within the hard palate).

In 9 patients, after NGN was once surgically eliminated using the Schoenborn method or its modifications, it persisted. All patients had complaints of speech disorders in the form of nasality associated with the inferior function of the cervical tract as a whole or of its individual structures. In addition, the majority of those examined were diagnosed with chronic diseases of the ENT organs.

The noted high positive result of the operation to eliminate NGN may create the illusion of simplicity of this surgical technique

We emphasize our general experience (classification of the causes of CGN) is due to modern specialized practice, many years of clinical experience in the surgical treatment of patients with CGN (1975-2012), and the use of a complex of fundamentally new modern diagnostic technologies in the treatment of patients in this complex field of reconstructive surgery. In this case, the choice of surgical tactics and the determination of the relationship of anatomical and functional disorders with speech disorders and types of insufficiency of the function of the structures of the genital tract largely depend on the operator.

I would like to emphasize that researchers analyzing the function of the NGC and its relationship with the NPC did not use a quantitative assessment of the mobility of the NGC structures. It seems to us that the proposed classification allows us to obtain a reliable picture of a quantitative assessment of the degree of mobility of the structures of the OG and its relationship with speech impairment, thus making it possible to choose the tactics of surgical treatment of patients, which largely ensures a positive treatment result, and therefore restoration of speech.

Methods for eliminating velopharyngeal insufficiency without using pharyngeal flaps

Surgical methods for eliminating NGN are very diverse and interesting, and the results are contradictory. When eliminating NGN, we (A. A. Mamedov, 1986) proposed a method in which an artificial defect was created in the area of ​​the soft palate and one small mucoperiosteal flap (SNL) was sutured into it, the wound surface of which was covered with a second large SNL (Fig. 1) . In the same way, narrowing of the pharyngeal ring is achieved, approaching the posterior wall of the pharynx when using double Z-plasty (Fig. 2).

Rice. 1. Elimination of NGN using inverted and detached mucoperiosteal flaps moved along the plane (A. Mamedov, 1986). Rice. 2. Elimination of NGN using double Z-plasty in the oral and nasal mucous-muscular layer of the soft palate, tissues of the lateral wall of the pharynx on both sides (A. Mamedov, 1995).

In this case (Fig. 2), an increase in the length of the soft palate is achieved by midline, the narrowing of the pharyngeal ring is achieved due to the simultaneous participation of the tissues of the lateral walls of the pharynx and the soft palate, and this leads to the approximation of all structures and to the narrowing of the OGK and the approximation of all structures to the posterior wall of the pharynx. This method reduces the size of the nasal cavity and eliminates air leakage through the nose during spontaneous speech.

Although most described techniques are named after one or more of the surgeons involved in their development, often numerous modifications build on the basis of the original description. In this sense, “understanding other people’s ways gives birth to our own” (A. Mamedov, 1998). One center or surgeon may perform the technique as originally described, while use elsewhere results in numerous modifications. It is impossible to formally compare not only methods, but also the execution of methods, since in practice a lot depends on the operator. Palate plastic surgery in the hands of one surgeon can lead to completely different results in the hands of another surgeon (A. Mamedov, 1998, J. Bardach, K. Salyer, 1991).

In conclusion, it should be emphasized that synchronization plays an important role in the interpretation of results. The procedure performed by the surgeon on patients of different age groups makes possible different results also due to the complex interaction between the form of pathology, the degree, the method of operation and the age of the patient (M. Lewis, 1992). In this part of the article, we have not yet described all the methods for eliminating NGN without pharyngeal flaps. They are still in development.

Methods for eliminating velopharyngeal insufficiency using pharyngeal flaps

Velopharyngoplasty- the formation of a permanent flap of the mucous membrane, submucosa and muscle between the structures of the soft palate and the posterior pharyngeal wall (PPW) to eliminate IFN - is approved today by most surgeons.

The high positive result of surgery to eliminate NGN, noted by many researchers, can create the illusion that this surgical technique is uncomplicated. But only with extensive experience these operations undoubtedly have best results restoration of the anatomy and function of the OGN, especially for patients whose primary uranoplasty ended with NGN.

Operations to eliminate NGN should be carried out in specialized medical institutions

However, the variety of pharyngeal flaps (on the upper, lower pedicle, from the middle third, lateral (lateral) third of the GSG), as well as various ways their hemming requires high professionalism. Treatment of such patients should be carried out in specialized centers where there are highly qualified staff and all the necessary equipment for comprehensive diagnosis of the defect and treatment at all stages of rehabilitation.

As for the illusions of simplicity, we again emphasize that operations to eliminate NGN are a highly professional surgical intervention and should be carried out in specialized medical institutions. This can serve as a certain kind of recommendation for novice surgeons and surgeons with extensive work experience, but who do not have experience in performing interventions to eliminate IFN.

NGN is a kind of “social marker” of the patient, a limiter of communication, an anti-professional “load”, a “speech inhibitor” in many areas of the formation of the psycho-emotional sphere and social adaptation of the individual. That is why we are so persistently looking for ways to overcome NGN and restore speech, as the most striking communicative ability of a person.

Discussion

In 1876, D. Schoenborn proposed an operation, the idea of ​​which is attributed to Trendelenburg: on the back wall of the pharynx, a pharyngeal flap is formed on the lower pedicle 4-5 cm long and 2 cm wide. After peeling off, the flap is turned downwards, its apex is given a triangular shape and sewn into the refreshed edges of the soft palate. A similar technique was used by J. Shede (1889), Bardenheuer (1892).

In 1924, the operation to eliminate NGN was described by W. Rosenthal and named after him. The technique of W. Rosenthal differs little from the technique of D. Schoenborn: he included the mucomuscular layer into the flap up to the prevertebral fascia.

Great contributions to the development of the technique of using a pharyngeal flap for velopharyngoplasty were made by Fruend (1927), E. Padgett (1930), Sanvenero-Rosseli (1935), H. Marino, R. Segre (1950), R. Moran (1951), H. Conway (1951), F. Dunn (1951, 1952), R. Trauner (1952, 1953), M. Ruch (1953), M. Petit, Papillon-Leage, M. Psaume (1955), R. Stark, C . DeHaan (1960), J. Owsleytal. (1966), K. Ousterhout, R. Jobe, R. Chase (1971).

V. I. Zausaev (1956) and E. U. Fomicheva (1958) described the use of a pharyngeal flap for plastic surgery of a soft palate defect. However, the obtained functional and speech results did not satisfy the authors, as a result of which the use of FLs proposed by these authors was not widely used. V.S. Dmitrieva and R.L. Lando (1968) examined 28 patients to compare the results of palate plastic surgery using the Rauer and Schoenbor-Rosenthal methods. There were no noticeable changes in sound pronunciation in patients compared to preoperative results.

A. A. Vodotyka (1970), used a pharyngeal flap on the upper leg, suturing it into a previously prepared bed of the middle third of the soft palate. Only 3 patients out of 48 had complete discrepancy; in the rest, velopharyngoplasty gave positive results.

In the clinic of surgical dentistry in Dnepropetrovsk medical institute E. S. Malevich et al. (1970) 35 operations were performed using a pharyngeal flap on the upper and lower legs for primary uranoplasty and for NGN. No complications were observed, and improvement in speech was noted.

Vodotyka used a pharyngeal flap on the upper pedicle, suturing it in the bed of the middle third of the soft palate. Only 3 patients out of 48 had complete discrepancy

We believe that with modern “gentle” methods of primary uranoplasty, performed at the age of 1.5 to 3 years of life, given its satisfactory functional results in most cases, the need for surgery to eliminate IFN will decrease in the future. Research results and our practice have shown that when eliminating NGN, it is also necessary to use BSG tissue. So, since 1982, in the clinic led by prof. L. E. Frolova (Moscow), a method for eliminating NGN using a FL cut in the middle third of the SSG was used.

As a result of these studies, the “Method of velopharyngoplasty” was developed (L. E. Frolova, F. M. Khitrov, A. A. Mamedov, 1986), which consists of cutting out a FL on the upper leg from the middle third of the GSG and suturing it to the tissues of the soft palate , lateral walls of the pharynx. The difference between this method and that proposed by D. Schoenborn in 1876 is that the FL on the upper feeding leg is sutured not only to the NZ tissues, but also to the BSG tissues. This ensures the participation of all structures of the NGC in the closure mechanism, the process of speech restoration (Fig. 3).

Functional and speech results obtained by auditory speech therapy assessment and endoscopy were assessed as positive.

Elimination of velopharyngeal insufficiency caused by disruption of one side wall of the pharynx
In case of insufficiency of the GSG, which has arisen due to poor mobility of one of the lateral walls of the pharynx (determined endoscopically), we propose a surgical method using FL with one of the lateral thirds of the GSG. The choice of location for cutting out the pharyngeal flap depends on the side of the least mobility of one of the lateral walls of the pharynx (Fig. 4).

Rice. 4a. Pharyngoplasty. Elimination of NGN using a pharyngeal flap cut in the lateral third of the posterior wall (A. Mamedov, 1989). Rice. 4b. Photo of a patient with NGN before surgery.
Rice. 4c. Photo of the patient 1 week after surgery. Rice. 4g. Photo of the patient 1 year after surgery.

We used this method in patients with left-sided or right-sided poor mobility of the BSG tissues, who underwent surgery to eliminate NGN.

In the postoperative period, elimination of air leakage through the nose was observed almost immediately, and restoration of good mobility of the BSG, determined endoscopically, was noted no earlier than 4-6 months later. At a control study after 6-8 months. elimination of NGN and good mobility of tissues of the NGK structures were stated.

Elimination of velopharyngeal insufficiency caused by violation of both lateral walls of the pharynx

In case of insufficiency of the NGC, when the cause of the closure disorder is both lateral walls of the pharynx, we use methods aimed at involving the least mobile structures in the closure mechanism, in this case these are both lateral walls of the pharynx (Fig. 5-6). Rice. 6. Photo of the patient 1 year after surgery.

Conclusion

We have presented a set of surgical methods for eliminating the IFN after primary uranoplasty, velopharyngoplasty, pharyngoplasty, aimed at restoring the anatomical integrity and function of the IFN structures and eliminating the pathological mechanism of closure.

Based on the available data, it can be concluded that systematic approach to the problem of speech restoration allows:

• solve the problem of rehabilitation based on the use of endoscopic diagnostic data, which makes it possible to determine which of the structures of the lower limb is the least mobile and to what extent it takes part in the closure mechanism, which is the main component of speech restoration;
• determine the indications for the use of one or another method depending on the degree of participation in the closure mechanism of each of the structures and the entire NGC as a whole.

The use of surgical methods is based on methods for examining the function of the MG (spectral analysis of speech, electrodiagnostics of the muscular structures of the MG, etc.), which make it possible to most accurately select a method for eliminating the MG, taking into account the localization of the pathological process (in the NZ, one BSG, both BSG, all structures of the MG) , which ultimately makes it possible to solve the problem of rehabilitation and achieve the restoration of normal speech.

Our proposed anatomical and functional classification of NGN allows:

• differentiated selection of optimal treatment methods using new technological techniques;
• differentiated use of the surgical method, taking into account the quantitative assessment of the degree of impairment of the mobility of the structures of the urinary tract, determined endoscopically, in combination with all types of examination.

In the proposed set of measures, methods for eliminating IFN were used based on the use of pharyngeal flaps cut in the middle third of the FSG, lateral thirds (right or left), depending on the side of the impaired mobility of the FSG. All proposed methods are based on the creation of a single fully functioning anatomical formation - the velopharyngeal ring, including all its elements (NZ, BSG, SSG). We will present other elimination methods in subsequent publications.

Literature

1. Vodotyka A. A. Plastic surgery of congenital cleft palate using a flap from the posterior pharyngeal wall. dis. ...cand. honey. Sci. - Dnepropetrovsk, 1970.
2. Gerasimova L. P. Comparative analysis efficiency various methods complex therapy of children with congenital cleft lip and palate: Author's abstract. dis. …. Ph.D. honey. Sci. - Perm, 1991. - 21 p.
3. Gutsan A. E. Uranoplasty with mutually reversible flaps. - Chisinau: Shtintsa, 1982. - 94 p.
4. Dmitrieva V. S., Lando R. L. Surgical treatment of congenital and postoperative palate defects. - M., 1968.
5. Zausaev V.I. Plastic surgery of the soft palate with a mucomuscular flap from the posterior pharyngeal wall. Dentistry, 1956; 3:22-25.
6. Malevich E. S., Malevich O. E., Vodotyka A. A. Pharyngeal-palatal flap for plastic surgery of congenital cleft palates// Proceedings of the V All-Union Congress of Dentists. - M., 1970. - P. 188-191.
7. Mamedov A. A., Vasiliev A. G., Volkhina N. N., Ionova Zh. V. Endoscopic method for assessing the function of the velopharyngeal ring: a methodological letter for doctors. - Ekaterinburg, 1996. - P. 48.
8. Mamedov A. A. Velopharyngeal insufficiency and ways to eliminate it. / Sat. scientific tr., volume XXXII, Tbilisi State medical university. - Tbilisi, 1996. - pp. 449-450.
9. Mamedov A. A. Pharyngoplasty for velopharyngeal ring insufficiency// New technologies in dentistry and maxillofacial surgery. Abstracts of reports of the V International Symposium, Khabarovsk, July 8-12. - Publishing house of Khabarovsk State Medical Institute, 1996. - P. 51.

A complete list of references is in the editorial office

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The velopharyngeal complex includes the structures that separate the nasopharynx from the oropharynx. Velum (lat.) is an anatomical term denoting soft tissue structures - the velum or soft palate and uvula. Together with the adjacent structures of the pharynx, they form a valve that opens during nasal breathing and closes during speaking and swallowing. Normal velopharyngeal function varies depending on the type of activity or speech produced. It has been established that the velopharyngeal valve behaves differently during speech, blowing, whistling, swallowing and vomiting. Compared to blowing and producing sounds, swallowing appears to be accompanied by more active velopharyngeal movements.

Physiologically, the velopharyngeal movements during swallowing appear to be different from those during blowing and speech. Physiological differences in movement between speech and nonspeech activities are supported by the following clinical observation: Patients who can achieve complete velopharyngeal closure during swallowing (ie, do not have nasal regurgitation of food) may have insufficient or inconsistent closure during speech.

In speech production, the velopharyngeal complex acts as an articulator, as do the jaw, tongue, oral cavity, lips, pharynx, and larynx, which work together to produce the various sounds of speech. Normally, velopharyngeal functions vary according to the characteristics of the speech produced. The opening and closing of the velopharyngeal valve is influenced by factors such as the pitch of the vowel sound, the type of consonant sound, the proximity of nasal sounds to oral sounds, the duration of the sound, the speed of speech, and the height of the tongue.

When pronouncing high vowel sounds, the height of the velum is greater than when pronouncing low vowel sounds. For example, the height of the velum is usually higher when pronouncing the high vowel sounds and /i/ than when pronouncing the low vowel sound /ah/. However, no consistent differences were found in the production of front/back and tense/lax vowel sounds. It was found that the amount of velum elevation is usually greater when pronouncing the sound /v/ than when pronouncing low vowel sounds.

When pronouncing oral consonants and vowels, the velopharyngeal valve usually closes, separating the oral cavity from the nasal cavity. This directs acoustic energy and airflow from the mouth. When pronouncing vowel sounds, incomplete closure may occur, especially if the production of the vowel sound is close to the nasal consonant sound. IN English There are three nasal sounds: /p/, /t/ and /ng/. When producing these nasal sounds, there is low activity of the palatal valve, usually somewhere between a relaxed and completely closed position. Therefore, the velopharyngeal opening changes its relatively open and closed states depending on the ratio of oral and nasal consonants that arise when exposed to speech stimuli (Fig. 1).

Rice. 1. When pronouncing “tense” speech sounds, the air flow should be directed towards the structures of the mouth. This is achieved by lifting the palate and separating the nose from the mouth. A velopharyngeal incompetence occurs when the velopharyngeal opening is not sealed and air leaks into the nasal cavity, as shown in Figure A. Figure B shows the velopharyngeal valve closing.

Normally, the speed of movement and displacement of the velum palatine varies significantly depending on the specific speech situation. The displacement of the velum decreases with increasing speech rate. However, speech volume does not have a significant effect on the degree of velum elevation. U different people The closure of the velopharyngeal opening does not occur in the same way, due to different types of interactions between the muscles of the soft palate and the pharynx. The muscles involved in the functioning of the velopharyngeal sphincter include five muscles of the soft palate: the tensor palatine muscle, the levator velum palatine muscle, the uvula muscle, the palatoglossus muscle and the velopharyngeal muscle. A sixth muscle, the superior pharyngeal constrictor, is also involved in closing the velopharyngeal valve.

During speech, the velopharyngeal foramen closes as the velum palatine moves in a posterosuperior direction toward the posterior pharyngeal wall and the lateral walls of the pharynx move medially. In some people, the back of the throat may move anteriorly. Normally, a variety of movements can occur when the velopharyngeal valve closes.

The movement of the velum palatine posteriorly and upward occurs due to the action of the levator velum palatine (PV) muscle, which makes up the bulk of the soft palate and is the main muscle involved in lifting the velum palatine. There are individual differences in the angle of attachment of the PNZ to the velum relative to the base of the skull. Contraction of the palatoglossus and velopharyngeal muscles probably serves to displace the velum inferiorly, thereby counteracting the upward tension exerted by the PVD. The velopharyngeal muscle also helps to stretch the velum laterally, which increases velar mobility and contact surface. Minor changes the height of the velum, when it is in a raised position, occurs due to contractions of the velopharyngeal muscle. The thickening on the dorsal side of the velum palatine corresponds to the uvula muscle.

Although the involvement of the lateral pharyngeal wall in the closure of the velopharyngeal valve varies in different people, it has been found that it usually occurs during conversation and is determined by the characteristics of speech. According to the literature, maximum movements of the pharynx occur at the level of the full length of the velum palatine and hard palate, well below the prominence of the levator velum palatine muscle. It has been proposed that the lateral movement results from selective contraction of the most superior fibers of the superior constrictor muscle. Laterally, the superior constrictor connects to the fibers of the velopharyngeal muscle, so that this muscle is also actively involved in the movement of the lateral wall of the pharynx.

The Passavanti crest is a transverse elevation of the posterior pharyngeal wall found in some people during speaking and swallowing, which is associated with active movement of the lateral pharyngeal wall. Apparently, its presence is due to contraction of the uppermost fibers of the superior constrictor, with connecting fibers of the velopharyngeal muscle. In some people, this is the main pharyngeal structure, located on the back of the throat at the level of the velum. However, the position of the Passavanti crest relative to the velum palatine is different. The data obtained suggest that in approximately one third of the patients examined, the Passavanti ridge is one of the main pharyngeal structures at the level of the velopharyngeal closure. The presence of a Passavanti ridge may or may not promote velopharyngeal closure in some individuals.

Thus, six muscles of the soft palate and pharynx are involved in velopharyngeal closure. Normally, closure occurs differently in different people, which is expressed in different participation of the velum palatine and the lateral and posterior walls of the pharynx. The types of velopharyngeal closure vary among individuals. The opening and closing of the velopharyngeal opening corresponds to the needs of speech.

Marshall E. Smith, Steven D. Gray and Judy Pinborough-Zimmerman

Velopharyngeal insufficiency

Rhinolalia - violation of voice timbre and sound pronunciation, caused by anatomical and physiological defects of the speech apparatus.

Atrhinolalia the mechanism of articulation, phonation and voice formation has significant deviations from the norm and is caused by a violation of the participation of the nasal and oropharyngeal resonators. With normal phonation in a person, during the pronunciation of all speech sounds, except nasal sounds, the nasopharyngeal and nasal cavities are separated from the pharyngeal and oral cavities.

Forms of rhinolalia

Depending on the nature of the dysfunction of the velopharyngeal closure, various forms of rhinolalia are distinguished.

Closed rhinolalia characterized by decreased physiological nasal resonance during the production of speech sounds.

Characteristic:

Violation of pronunciation of nasal consonants (m, m, n, n "sound like oral b, b", d, d");

Violation of vowel pronunciation (it takes on an unnatural, dead tone);

Causes of closed rhinolalia most often there are organic changes in the nasal space or functional disorders of the velopharyngeal closure. Organic changes are caused by painful phenomena, as a result of which the nasal passage decreases and nasal breathing becomes difficult.

Anterior closed rhinolalia occurs with chronic hypertrophy of the nasal mucosa, mainly posterior sections inferior turbinates, with polyps in the nasal cavity, with a deviated nasal septum and with tumors of the nasal cavity.

Posterior closed rhinolalia in children it is most often a consequence of large adenoid growths, occasionally nasopharyngeal polyps, fibromas or other nasopharyngeal tumors.

Functional closed rhinolalia It occurs frequently in children, but is not always correctly recognized. It is characterized by the fact that it occurs with good conductivity of the nasal cavity and undisturbed nasal breathing. With functional closed rhinolalia, the timbre of nasal and vowel sounds may be more disturbed than with organic rhinolalia. The reason is that the soft palate rises above normal during phonation and pronunciation of nasal sounds and blocks sound waves from accessing the nasopharynx. Similar phenomena are more often observed in neurotic disorders in children.

Open rhinolalia .

Characteristic:

Violation of the timbre of vowel sounds;

Violation of the timbre of some consonants. When pronouncing hissing sounds and fricatives f, v, x, a hoarse sound is added that occurs in the nasal cavity. Plosive sounds p, b, d, t, k and g, as well as sonorant l and r sound unclear, since the air pressure necessary for their accurate pronunciation cannot be generated in the oral cavity.

Open rhinolalia can be organic and functional.

Organic open rhinolalia can be congenital or acquired.

Most commoncause of congenital form is a splitting of the soft and hard palate.

Acquired open rhinolalia formed due to trauma to the oral and nasal cavities or as a result of acquired paralysis of the soft palate.

Causes of functional open rhinolalia may be different. For example, it occurs during phonation in children with sluggish articulation of the soft palate. The functional open form manifests itself in hysteria, sometimes as an independent defect, sometimes as an imitative one.

One of the functional forms is habitual open rhinolalia, observed, for example, after removal of large adenoid growths, and occurs as a result of long-term restriction of the mobility of the soft palate.

A functional examination of open rhinolalia does not reveal organic changes in the hard or soft palate. A sign of functional open rhinolalia is also the fact that usually the pronunciation of only vowel sounds is impaired, while when pronouncing consonants, the velopharyngeal closure is good and nasalization does not occur.

The prognosis for functional open rhinolalia is more favorable than for organic one. The nasal timbre disappears after phoniatric exercises, and pronunciation disorders are eliminated by the usual methods used for dyslalia.

Rhinolalia caused by congenital nonunion of the lip and palate , represents serious problem for speech therapy and a number of sciences medical cycle(surgical dentistry, orthodontics, otolaryngology, medical genetics, etc.). Cleft lip and palate are the most common and severe congenital malformations.

The following are foundtypes of clefts :

1) cleft lip and alveolar process

2) clefts of the hard and soft palate;

3) clefts of the upper lip, alveolar process and palate - one-sided and two-sided;

4) submucosal (submucosal) cleft palate. With cleft lips and palates, all sounds acquire a nasal or nasal tone, which grossly interferes with the intelligibility of speech.

Impact on the physical development of the child

As a result of this defect in children during their physical development serious functional disorders occur.

In children with congenital nonunion of the lip and palate, the act of sucking is very difficult. It presents particular difficulties in children with a through cleft lip and palate, and with bilateral through clefts this act is generally impossible.

Difficulty feeding leads to a weakening of vitality, and the child becomes susceptible to various diseases. Children with clefts are most susceptible to upper respiratory tract catarrh, bronchitis, pneumonia, rickets, and anemia.

Often, such children experience pathological changes in the ENT organs: curvature of the nasal septum, deformation of the wings of the nose, adenoids, hypertrophy (enlargement) of the tonsils. They often experience inflammatory processes in the nasal area. The inflammatory process can move from the mucous membrane of the nose and pharynx to the Eustachian tubes and cause inflammation of the middle ear. Frequent otitis media, often taking a chronic course, cause hearing loss. Approximately 60-70% of children with cleft palates have varying degrees of hearing loss (usually in one ear) - from a slight decrease that does not interfere with speech perception to significant hearing loss.

Deviations in the anatomical structure of the lip and palate are closely related to underdevelopment of the upper jaw and malocclusion with defective arrangement of teeth.

Numerous functional disorders caused by defects in the structure of the lip and palate require constant medical supervision.

In our country, conditions have been created for complex treatment in specialized centers at the Research Institute of Traumatology, at the departments of surgical dentistry, as well as in other institutions where a lot of medical and preventive work is carried out.

Doctors from various specialties observe children and jointly decide on a comprehensive treatment plan.

During the first years of a child’s life, the leading role belongs to the pediatrician, who manages the feeding and daily routine of the baby, carries out prevention and treatment, and, if necessary, recommends outpatient or inpatient treatment.

Surgery to restore the upper lip (cheiloplasty) is recommended in the first year of a child’s life; it is often performed in maternity hospitals in the first days after birth.

In cases of cleft palate, the orthodontist uses various devices, including an obturator, which facilitate nutrition and create conditions for speech development in the preoperative period. The otolaryngologist identifies and treats all painful changes in the ear, nasal cavities, nasopharynx and larynx and prepares children for surgery.

In case of deviations in mental development and the presence of pronounced neurotic reactions, the child is consulted by a neurologist.

Palate restoration surgery (uranoplasty) is performed in most cases in preschool age.

According to condition mental development Children with cleft palates are divided into three categories:

1) children with normal mental development;

2) children with mental retardation;

3) children with olegophrenia (of varying degrees). During a neurological examination, signs of significant focal brain damage are usually not observed. Some children have individual neurological microsigns. Functional impairments are much more common in children nervous system, sometimes significantly pronounced psychogenic reactions, increased excitability.

Congenital cleft palates have a negative impact on the development of a child’s speech.

Cleft lip and palate play different roles in the formation of speech underdevelopment. This depends on the size and shape of the anatomical defect.

It is typical to superimpose additional noises on nasal sounds, such as aspiration, snoring, larynx, etc. It occurs specific disorder voice timbre and sound pronunciation.

To prevent food from passing through the nose, the child from the very early age acquire the habit of raising the back of the tongue to block the passage into the nasal cavity. This tongue position becomes habitual and also changes the articulation of sounds.

When speaking, children usually open their mouths little and raise the back of their tongue higher than required. Due to this, the tip of the tongue does not move fully. Such a habit worsens the quality of speech, since when high position jaw and tongue, the oral cavity takes on a shape that allows air to enter the nose, which enhances nasality.

When trying to pronounce the sounds p, b, f, c, a child with rhinolalia uses “his own” methods. The sounds are replaced by a pharyngeal click, which very uniquely characterizes the speech of a child with a severe form of rhinolalia. A specific click, reminiscent of the sound of a valve, is formed when the epiglottis touches the back of the tongue.

A direct correspondence between the size of the palatal defect and the degree of speech distortion has not been established. This is explained by large individual differences in the configuration of the nasal and oral cavity in children, the ratio of resonating cavities and compensatory techniques that each child uses to increase the intelligibility of his speech. In addition, speech intelligibility depends on the age and individual psychological characteristics of children.

Speech therapy sessions with the child must begin in the preoperative period in order to prevent the occurrence of serious changes in the functioning of the speech organs. At this stage, the activity of the soft palate is prepared, the position of the root of the tongue is normalized, the muscular activity of the lips is enhanced, and directed oral exhalation is produced. All this taken together creates favorable conditions to increase the efficiency of the operation and subsequent correction. 15-20 days after surgery, special exercises are repeated; but now the main goal of the classes is to develop the mobility of the soft palate.

The study of the speech activity of children suffering from rhinolalia shows that defective anatomical and physiological conditions of speech formation, limited motor component of speech lead not only to the abnormal development of its sound side, but in some cases to a deeper systemic disorder of all its components.

As the child ages, the indicators of speech development worsen (compared to the indicators of normally speaking children), the structure of the defect is complicated due to the violation various forms written speech.

Early correction of deviations in speech development in children with rhinolalia has an extremely important social, psychological and pedagogical significance for normalizing speech, preventing difficulties in learning and choosing a profession.