Treatment of children with ERHN is one of the most difficult tasks of the reconstructive surgery of the MAP. The problem lies not only in correcting the anatomical defect, but also in the full restoration of organ function. The integrity of the anatomical structures of organs can be restored with the help of various plastic surgeries. However, despite the variety of methods, in a number of cases, surgical intervention does not lead to the restoration of the integrity of the NGC, which causes a failure of its function (A.E. Gutsan, 1982; E.I. Samar, 1986; L.N. Gerasimov, 1991; A A. Mamedov, 1997-2012; R. Musgrave et al., 1960; R. O'Neal, 1971; C. Dufresne 1985; S. Cohen et al., 1991; C. Hung-Сhietal., 1992; J. Karling et al. ., 1993; AE Rintala, 1980; JD Smith, 1995).

Classification of insufficiency of the palatopharyngeal ring

In a number of proposed classifications of the insufficiency of the function of the NGC, 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 the impairment of the function of the NGC.

Why does it seem so important to us to list and analyze in detail the causes of speech impairment?

At first, only with the determination of the reasons - according to the degree of impairment of the mobility of the structures of the IHC - it is possible to accurately determine the tactics of surgical rehabilitation of patients with IHN.

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

Thirdly, in our opinion, the cause of speech impairment is the missed time for primary uranoplasty, that is, when the operation was performed later than the 5-year-old patient's age: by this time, pathological stereotypes of speech are already developing. That is why the diagnosis of speech disorders should be carried out by a surgeon in conjunction with a speech therapist, neuropathologist, psychologist, orthodontist.

The cause of speech impairment is the missed time for primary uranoplasty, when the operation was performed later than 5 years of age of the patient.

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 IHN, 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 IHC, determined on the basis of endoscopic examination.

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

• Type I: insufficiency of NGK, which arose due to poor mobility of the entire palatine curtain (NZ).
• Type II: insufficiency of NGK, which arose due to poor mobility of one BSG.
• Type III: insufficiency of NGK, which arose due to poor mobility of both BSGs.
• Type IV: insufficiency of NGK, which arose due to poor mobility of all structures of NGK.
• V type: insufficiency of NGK, which arose after velopharyngoplasty, pharyngoplasty.

Our proposed classification (grouping of causes of insufficiency of the function of the structures of the NGC) allows in practice to choose such a tactic of surgical treatment in which the least mobile tissues of the structures of the NGC are identified and used in the process of surgical intervention. Determination of the degree of mobility of each of the structures fragmentarily and all together allows us to recommend a specific surgical method aimed at correcting the least mobile tissues and eliminating their negative effect on the mechanism of closure of the NGC.

The degree of mobility of the structures of the NGC is determined by us 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 SGI, since it does not significantly participate in the closure mechanism).

Material and methods

Based on clinical experience and objective methods of comprehensive examination of patients with IHN in our work, we found that, unfortunately, the majority of patients underwent primary uranoplasty 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 two-stage uranoplasty (stage I - plastic surgery of the soft palate - bicycle plastic; the second stage - plastic surgery within the hard palate).

In 9 patients, after once surgically eliminated NGN using the Schoenborn method or its modifications, it remained. All patients had complaints of speech impairment in the form of nasality associated with the defective function of the NGC as a whole or its individual structures. In addition, most of the examined patients had chronic diseases of ENT organs.

Noted high positive result surgery to eliminate DUH can create the illusion of simplicity of this surgical technique

Let us emphasize our generalizing experience (classification of causes of IHN) is due to modern specialized practice, many years of clinical experience in the surgical treatment of patients with ERHN (1975-2012), the use of a complex of fundamentally new modern diagnostic technologies in the treatment of patients in this complex area of ​​reconstructive surgery. In this case, the choice of surgical tactics and determination of the relationship between anatomical and functional disorders with speech impairments and types of insufficiency of the function of the structures of the NGC largely depend on the operator.

I would like to emphasize that researchers analyzing the function of NGC and its relationship with NGN did not use a quantitative assessment of the mobility of 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 NGC and its relationship with speech impairment, thus, it makes it possible to choose the tactics of surgical treatment of patients, which largely ensures a positive treatment result, and therefore, the restoration of speech.

Methods for eliminating palatopharyngeal insufficiency without the use of pharyngeal flaps

Operational methods for eliminating GBV are very diverse and interesting, and the results are contradictory. When eliminating UHN, we (A.A.Mamedov, 1986) proposed a method in which an artificial defect was created in the soft palate and one small muco-periosteal flap (SNL) was sewn into it, the wound surface of which was closed with a second large SNL (Fig. 1) . In the same way, narrowing of the pharyngeal ring is achieved, approaching the posterior pharyngeal wall using double Z-plasty (Fig. 2).

Rice. 1. Elimination of NGN using overturned and detached and displaced along the plane of mucoperiosteal flaps (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 pharyngeal wall on both sides (A. Mamedov, 1995).

In this case (Fig. 2), the increase in the length of the soft palate is achieved along the 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 approach of all structures and to narrowing of the NHC and the approach of all structures to the posterior the wall of the pharynx. This method reduces the size of the NGK and eliminates air leakage through the nose during spontaneous speech.

Although most of the methods described are named after one or more of the surgeons who participated in the development, often numerous modifications are based on the original description. In this sense, “the understanding of other people's methods gives rise to their own” (A. Mamedov, 1998). One center or surgeon may perform the technique as originally described, while use elsewhere gives rise to 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. Plastic surgery of the palate 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 important role in the interpretation of the 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 the pathology, the degree, the method of the operation and the patient's age (M. Lewis, 1992). In this part of the article, we have described not all the methods for eliminating IHN without pharyngeal flaps. They are still in development.

Methods for eliminating palatopharyngeal insufficiency using pharyngeal flaps

Cyclopharyngoplasty- 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 (PSG) to eliminate IHN - is approved today by most surgeons.

The high positive result of the operation to eliminate IHN, noted by many researchers, can create the illusion of the simplicity of this surgical technique. But only with extensive experience these operations undoubtedly have top scores restoration of the anatomy and function of NHC, especially for patients in whom primary uranoplasty ended with NHN.

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

However, a variety of pharyngeal flaps (on the upper, lower leg, from the middle third, lateral (lateral) third of the SGI), as well as different ways their sewing requires high professionalism. Treatment of such patients should be carried out in specialized centers with highly qualified staff, all necessary equipment for a 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 IUH are highly professional surgical interventions and should be carried out in specialized medical institutions. This can serve as a kind of recommendation for novice surgeons and surgeons with solid work experience, but no experience in performing interventions to eliminate IHN.

NGN is a kind of "social marker" of the patient, a restrictor of communication, anti-professional "load", "speech brake" in many areas of the formation of the psychoemotional sphere and social adaptation of the individual. Therefore, we are so persistently looking for ways to overcome GBV and restore speech, as the most vivid communicative ability of a person.

Discussion

In 1876, D. Schoenborn proposed an operation, the idea of ​​which is attributed to Trendelenburg: on the posterior wall of the pharynx, a pharyngeal flap is formed on the lower leg 4-5 cm long and 2 cm wide.After peeling, the flap is turned downwards, its top 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 W. Rosenthal described the operation to eliminate NGN and named it by his own name. The technique of W. Rosenthal differs little from the technique of D. Schoenborn: he included the mucous-muscular layer in the flap up to the prevertebral fascia.

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. Owsley et al. (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 defect of the soft palate. However, the obtained functional and speech results did not satisfy the authors, as a result of which the use of PLs proposed by these authors did not find wide application. V.S.Dmitrieva and R.L. Lando (1968) examined 28 patients to compare the results of plastic surgery of the palate by the methods of Rauer and Schoenbor - Rosenthal. There was no noticeable change in sound pronunciation in patients compared to preoperative results.

AA 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 out of 48 patients had a complete discrepancy, in the rest velopharyngoplasty gave positive results.

In the clinic of surgical dentistry of the Dnepropetrovsk Medical Institute, E.S. Malevich et al. (1970), 35 operations were performed using a pharyngeal flap on the upper and lower legs in primary uranoplasty and in IHN. There were no complications, and there was an improvement in speech.

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

We believe that with modern "sparing" methods of primary uranoplasty performed at the age of 1.5 to 3 years of age, given its satisfactory functional results in most cases, the need for an operation to eliminate UHN will decrease in the future. Research results, our practice have shown that when eliminating NGN, it is also necessary to use BSG tissues. So, since 1982 in a clinic run by prof. L.E. Frolova (Moscow), a method for eliminating NGN using PL cut out in the middle third of the SGI was applied.

As a result of these studies, the "Method of velopharyngoplasty" was developed (L.E. Frolova, F.M. , the lateral walls of the pharynx. The difference between this method and the one proposed by D. Schoenborn in 1876 is that the FL on the upper feeding leg is sutured not only to the tissues of the NZ, but also to the tissues of the BSG. Thus, the participation of all structures of the NGC in the closure mechanism, the process of speech restoration is achieved (Fig. 3).

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

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

Rice. 4a. Pharyngoplasty. Elimination of IHN using a pharyngeal flap cut out 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. 4d. Photo of the patient 1 year after surgery.

This method was used by us in patients with left-sided or right-sided poor mobility of BSH tissues, who underwent surgery to eliminate IHN.

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

Elimination of opharyngeal insufficiency resulting from a violation of both lateral walls of the pharynx

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

Conclusion

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

Based on the available data, it can be concluded that systems 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 NGC is the least mobile and to what extent it participates in the closure mechanism, which is the main component of speech restoration;
• to determine indications for the use of one or another method, depending on the degree of participation in the mechanism of closure of each of the structures and the entire oil and gas complex as a whole.

The use of surgical methods is based on the methods of examining the function of the NGC (spectral analysis of speech, electrodiagnostics of muscle structures of the NGC, etc.), which make it possible with the greatest accuracy to choose a method for eliminating NGN, taking into account the localization of the pathological process (in the NZ, one BSG, both BSG, all structures of the NGC) , which, ultimately, allows you to solve the problem of rehabilitation and achieve the restoration of normal speech.

The anatomical and functional classification of NGN proposed by us allows:

• to differentiate the optimal methods of treatment using new technological methods;
• 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 NGC, determined endoscopically, in combination with all types of examination.

In the proposed set of measures, methods of eliminating NGN were used based on the use of pharyngeal flaps cut out in the middle third of the SGI, lateral thirds (right or left), depending on the side of the impaired BSG mobility. All the proposed methods are based on the creation of a single functioning fully anatomical formation - the palatopharyngeal ring, which includes all its elements (NZ, BSG, SGI). Other methods of elimination will be presented by us in subsequent publications.

Literature

1. A. A. Vodotyka Plasty of congenital clefts of the palate using a flap from the back of the pharynx... Dis. ... Cand. honey. sciences. - Dnepropetrovsk, 1970.
2. Gerasimova L.P. Comparative analysis the effectiveness of various methods of complex therapy for children with congenital cleft lip and palate: Author's abstract. dis. …. Cand. honey. sciences. - Perm, 1991 .-- 21 p.
3. Gutsan A.E. Uranoplasty with reciprocal flaps... - Chisinau: Shtintsa, 1982 .-- 94 p.
4. Dmitrieva V.S., Lando R.L. Surgical treatment of congenital and postoperative palate defects... - M., 1968.
5. V. I. Zausaev Plastic surgery of the soft palate with a mucous-muscular flap from the back of the pharynx... Dentistry, 1956; 3: 22-25.
6. Malevich E.S., Malevich O.E., Vodotyka A.A. Pharyngeal-palatine flap for plastics of congenital clefts of the palate// Proceedings of the V All-Union Congress of Dentists. - M., 1970 .-- S. 188-191.
7. Mamedov A.A., Vasiliev A.G., Volkhina N.N., Ionova Zh.V. Endoscopic method for assessing the function of the palatopharyngeal ring: a methodological letter for doctors... - Yekaterinburg, 1996 .-- S. 48.
8. A. A. Mamedov Palatopharyngeal insufficiency and ways to eliminate it... / Sat. scientific. tr., volume XXXII, Tbilisi State medical University... - Tbilisi, 1996 .-- S. 449-450.
9. A. A. Mamedov Pharyngoplasty in case of insufficiency of the palatopharyngeal ring// New technologies in dentistry and maxillofacial surgery. Abstracts of the V International Symposium, Khabarovsk, July 8-12. - Publishing house of the Khabarovsk State Medical Institute, 1996. - P. 51.

A complete list of references is in the editorial office

Palatine-pharyngeal insufficiency means a violation of the normal physiological interaction of the structures of the palatine-pharyngeal ring. In children with congenital clefts palate after palate plasty, palatine-pharyngeal insufficiency is a consequence of insufficiently complete closure of the soft palate with the posterior pharyngeal wall and manifests itself in the form of a speech disorder - rhinolalia. Indistinct speech, nasal sounds, nasal emissions (audible leakage of air from the mouth into the nasal cavity) and compensatory mechanisms of articulation (including compensatory grimaces on the face) are typical signs of pharyngeal insufficiency.

The main cause of palatal-pharyngeal insufficiency is insufficiently full participation of the soft palate in the mechanism of palatine-pharyngeal closure: in some cases, the soft palate is too short, in others it is not sufficiently mobile.

The main reasons for the formation of palatine-pharyngeal insufficiency:

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

performing primary plastic surgery of the palate after the first year of life;

violation of normal healing processes in the postoperative period.

Methods for diagnosing opharyngeal insufficiency

The simplest and most affordable method for diagnosing palatine-pharyngeal insufficiency is speech therapy examination and testing. It is carried out by a highly qualified speech therapist and is based on the detection of nasal and nasal emission when pronouncing special words that require the complete closure of the palatine-pharyngeal ring (read).

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

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

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

Treatment methods

The program for the treatment of children with palatal-pharyngeal insufficiency developed at the center includes the following stages:

1. Courses of speech therapy training in a hospital or in a center polyclinic.

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 the use of pharyngeal tissue to achieve palatal-pharyngeal closure).

Note!
Rhinolalia is a speech pathology that is observed in almost 100% of cases in children with congenital clefts of the palate after late plastic surgery of the palate.

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

Diagnosis palatine-pharyngeal - means that after repeated courses of speech therapy training, clinical signs of rhinolalia persist, and with nasopharynoscopy, there is a significant area of ​​non-closure of the soft palate with the posterior pharyngeal wall. This usually implies the need for surgical treatment.

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The opharyngeal complex includes structures that separate the nasopharynx from the oropharynx. Velum (lat.) - an anatomical term for soft tissue structures - the palatine curtain or soft palate and uvula. Together with the adjacent structures of the pharynx, they form a valve that opens during nasal breathing and closes when speaking and swallowing. Normally, palatopharyngeal functions differ depending on the type of activity or speech produced. It has been established that the palatopharyngeal valve behaves differently during speech, breathing, whistling, swallowing and vomiting. In comparison with breathing and pronunciation of sounds, swallowing, apparently, is accompanied by more active palatopharyngeal movements.

Physiologically, the palatopharyngeal movements during swallowing, apparently, differ from the movements during breath and speech. Physiological differences in movement between speech and non-speech activity are supported by the following clinical observation: patients who can achieve complete opharyngeal closure on swallowing (i.e., do not have nasal regurgitation of food) may have insufficient or inconsistent closure during speech.

In speech production, the pharyngeal complex acts as an articulator, as does the jaw, tongue, mouth, lips, pharynx, and larynx, which work together to form various speech sounds. Normally, the palatopharyngeal functions differ in accordance with the characteristics of the speech produced. The opening and closing of the pharyngeal valve is influenced by factors such as the pitch of the vowel sound, the type of consonant sound, the proximity of the nasal sounds to the mouth 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 palatine curtain is greater than when pronouncing low vowel sounds. For example, the height of the palatine curtain is usually higher when pronouncing high vowels and / and / than when pronouncing low vowels / ah /. However, there were no persistent differences in the pronunciation of the front / back and tense / non-tense vowel sounds. It was found that the magnitude of the raising of the palatine curtain is usually greater when pronouncing the sound / in / than when pronouncing low vowel sounds.

When pronouncing oral consonants and vowels, the palatopharyngeal 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 be observed, especially if the production of a vowel sound is close to a nasal consonant sound. V English language there are three nasal sounds: / n /, / t / and / ng /. When pronouncing these nasal sounds, there is a low activity of the palatine valve, as a rule, something in between a relaxed and fully closed position. Therefore, the palatopharyngeal foramen changes its relatively open and closed states depending on the ratio of oral and nasal consonants arising under the influence of speech stimuli (Fig. 1).

Rice. 1. When pronouncing "tense" speech sounds, the air flow should be directed to the structures of the mouth. It does this by lifting the palate and separating the nose from the mouth. A opharyngeal leak occurs when the opharyngeal opening is not hermetically closed and air flows into the nasal cavity, as shown in Figure A. Figure B shows the closure of the opharyngeal valve.

Normally, the speed of movement and the displacement of the palatine curtain vary significantly depending on the specific speech situation. The displacement of the palatine curtain decreases with increasing speech speed. However, the loudness of the speech does not significantly affect the degree of the curtain of the palate. Have different people the closure of the palatopharyngeal opening is not the same, due to different types interactions of the muscles of the soft palate and pharynx. The muscles involved in the functioning of the palatine-pharyngeal sphincter include the five muscles of the soft palate: the muscle that strains the palatine curtain, lifts the palatine curtain, the uvula muscle, the palatopharyngeal and palatopharyngeal muscle. The sixth muscle, the superior constrictor of the pharynx, is also involved in the closure of the pharyngeal valve.

During speech, the palatopharyngeal opening is closed when the palatine curtain moves in the posterior-superior direction towards the posterior pharyngeal wall, and the lateral pharyngeal walls are displaced medially. In some people, the back of the throat may move anteriorly. Normally, a variety of movements can occur when the palatopharyngeal valve is closed.

The movement of the palatine curtain posteriorly and upward occurs due to the action of the muscle that lifts the palatine curtain (PNZ), which constitutes the bulk of the soft palate and is the main muscle involved in lifting the palatine curtain. There are individual differences in the magnitude of the angle of attachment of the PNZ to the palatine curtain relative to the base of the skull. Contraction of the palatine and palatopharyngeal muscles possibly serves to displace the palatine curtain downward, thereby counteracting the upward tension that creates the PNZ. The palatopharyngeal muscle also helps to stretch the palatine curtain in the lateral direction, which increases the mobility of the velar region and the contacting surface. Small changes in the height of the palatine curtain, when it is in the raised position, occur due to contractions of the palatopharyngeal muscle. The thickening on the dorsal side of the palatine curtain corresponds to the muscle of the uvula.

Although in different people the participation of the lateral pharyngeal wall in the closure of the palatopharyngeal valve is expressed in varying degrees, it was found that it usually manifests itself during a conversation and is due to the peculiarities of speech. According to the literature, the maximum movements of the pharynx occur at the level of the full length of the palatine curtain and the hard palate, well below the protrusion of the muscle that lifts the palatine curtain. It has been suggested that lateral movement is the result of selective contraction of the uppermost fibers of the superior constrictor muscle. Laterally, the superior constrictor connects to the fibers of the palatopharyngeal muscle, so that this muscle is also actively involved in the movement of the lateral pharyngeal wall.

The Passavanti ridge is a transverse elevation of the posterior pharyngeal wall found in some people during conversation and when swallowing, which is associated with active movement of the lateral pharyngeal wall. Apparently, its presence is due to the contraction of the uppermost fibers of the upper constrictor, with the connecting fibers of the palatopharyngeal muscle. In some people, this is the main pharyngeal structure, located at the back of the pharynx at the level of the palatine curtain. However, the position of the Passavanti ridge relative to the palatine curtain is different. The data obtained suggest that in about one third of the examined patients, the Passavanti ridge is one of the main pharyngeal structures at the level of the otopharyngeal closure. The presence of a Passavanti ridge in some people may or may not contribute to otopharyngeal closure.

Thus, six muscles of the soft palate and pharynx are involved in the otopharyngeal closure. Normally, closure occurs differently in different people, which is expressed in different participation of the palatine curtain and the lateral and posterior pharyngeal walls. The types of pharyngeal closure differ from person to person. The opening and closing of the palatopharyngeal foramen correspond to the needs of speech.

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

Opharyngeal insufficiency

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

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

oral cavity and nasal cavity.

This is due to the formation of lamellar protrusions of the palatine processes on the inner surfaces of the maxillary processes. At the beginning eighth week the edges of the palatine processes are directed obliquely downward and lie along the bottom of the oral cavity, on the sides of the tongue. The lower jaw is enlarged. The tongue descends into this space, making it possible to move the palatine processes from a vertical position to a horizontal one.

At the end second month 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 mouth bay is the rudiment of a hard and soft palate. It separates the final oral cavity from the nasal cavity. At the same time, the growth of the nasal septum occurs, which grows together with the palate and divides the nasal cavity into the right and left nasal chambers.

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

and by the end of the 12th week, fragments of the soft palate grow together with each other. The condition of the lip and palate in the embryo at certain stages of development is the same as in nonunions observed in the clinic: from a through bilateral fissure defect of the lip, alveolar ridge and palate to nonunion of only the soft palate and even only the uvula or latent 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 is obviously the pressure of the tongue, the size of which, as a result of the discorrelation of growth, turned out to be larger than usual. Such a discrepancy can arise on the basis of hormonal metabolic disorders in the mother's body.

Topic 3. Causes and mechanisms of disorders in rhinolalia

.Rhinolalia reasons.

Types and forms of congenital clefts.

Classification of rhinolalia.

Mechanism of occurrence speech disorders with rhinolalia.

Mechanisms of impairment of speech breathing, voice formation and sound pronunciation.

Etiology

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

TO exogenous factors relate:

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

2) chemical (hypoxia, maternal malnutrition during critical periods of 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 discorrelations. cause fetal hypoxia and deformities in it, the influence of chemical compounds that mimic the effect of ionizing radiation, such as mustard gas;

H) biological (measles viruses, mumps, shingles, bacteria and their toxins);

4) mental (cause hyperadrenalinemia).

TO endogenous factors belong to:

1) predisposition to pathological heredity (there is no gene carrying a hereditary predisposition to non-union)

2) biological inferiority of cells;

H) the influence of age and gender.

In the history of patients and their parents, it is often possible to establish the following factors with which the appearance of birth defects has to be associated: infectious diseases transferred by the mother during pregnancy; toxicosis, spontaneous and induced abortion; heavy physical injury at 8-12 weeks of pregnancy; diseases of the genital area; severe mental trauma to the mother; late childbirth; malnutrition of the mother.

Types and forms of congenital clefts

Congenital maldevelopments of the palate include:

1) congenital cleft palate and lip

2) submucosal clefts;

3) congenital underdevelopment of the palate;

4) congenital asymmetry of the face with deformation of the palate.

Most often in practice, there are clefts of the lip and palate. The forms of palatine clefts are extremely diverse, but they all lead to speech impairment.

Cleft lips. Distinguish between partial and complete cleft lip. The anatomical structure and size of the lips in children and adults vary considerably.

A normally developed upper lip has the following anatomical components:

1) filter 2) two columns; H) red border; 4) the median tubercle; 5) the 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 its listed elements.

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

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

2.on partial(when the non-union has spread only to the red border or simultaneously with the red border there is a non-union of the lower part of the skin part 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 palate is normally a mass that separates the mouth, nose and throat. It consists of a hard and soft palate. Solid has a bone base. In front and on the sides, it is framed by the alveolar process of the upper jaw with teeth, and behind it is the soft palate. The hard palate is covered with a mucous membrane, the surface of which behind the alveoli has an increased tactile sensitivity. The height and configuration of the hard palate affects resonance.

The soft palate is the posterior part of the septum between the cavities of the nose and mouth. The soft palate represents muscle formation. The front third of it is practically motionless, the middle one is most actively involved in speech, and the back one is in tension and swallowing. Ascending, the soft palate lengthens. At the same time, there is a thinning of its anterior third and a thickening of the posterior one.

The soft palate is anatomically and functionally connected with the pharynx, the palatopharyngeal 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 back 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 lateral walls of the pharynx, its upper constrictor.

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

Rhinolalia - violation of the timbre of the voice and sound pronunciation, due to 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 due to 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 for the nasal ones, the nasopharyngeal and nasal cavity is separated from the pharyngeal and oral cavity.

Rhinolalia forms

Depending on the nature of the dysfunction of the palatine-pharyngeal closure, various forms of rhinolalia are distinguished.

Closed rhinolalia characterized by a reduced physiological nasal resonance during the pronunciation of speech sounds.

Typically:

Violation of pronunciation Nosoval consonants (m, m ", n, n" sound like mouth 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 palatine-pharyngeal closure. Organic changes are caused by painful phenomena, as a result of which the patency of the nose decreases and nasal breathing becomes difficult.

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

Posterior closed rhinolalia in children, it is most often the result of large adenoid growths, rarely nasopharyngeal polyps, fibromas or other nasopharyngeal tumors.

Functional closed rhinolalia occurs in children often, but 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 a functional closed rhinolalia, the timbre of nasal and vowel sounds can be more disturbed than with an organic one. The reason is that the soft palate, during phonation and pronunciation of nasal sounds, rises above normal and closes the sound waves access to the nasopharynx. Similar phenomena are more often observed in neurotic disorders in children.

Open rhinolalia .

Typically:

Violation of the timbre of vowel sounds;

Violation of the timbre of some consonants. When pronouncing hissing sounds and fricatives f, b, x, a hoarse sound arising in the nasal cavity is added. The explosive sounds n, b, d, t, k and d, as well as the sonorous l and p, sound unclear, since the air pressure necessary for their accurate pronunciation cannot form in the oral cavity.

Open rhinolalia can be organic and functional.

Organic Open Rhinolalia can be congenital or acquired.

Most frequentthe cause of the congenital form is the splitting of the soft and hard palate.

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

The causes of functional open rhinolalia may be different. For example, it happens 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 - the habitual open rhinolalia, observed, for example, after the removal of large adenoid growths, arises as a result of prolonged limitation of the mobility of the soft palate.

Functional examination with open rhinolalia does not reveal organic changes in the hard or soft palate. A sign of a functional open rhinolalia is also the fact that the pronunciation of only vowel sounds is usually disturbed, while when the consonants are pronounced, the palatal-pharyngeal closure is good and nasalization does not occur.

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

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

There are the followingtypes of crevices :

1) cleft of the upper lip and alveolar process

2) clefts of the hard and soft palate;

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

4) submucosal (submucous) cleft palate. With clefts of the lip and palate, all sounds acquire a nasal or nasal tone, which grossly violates the intelligibility of speech.

Influence on the physical development of the child

As a result of this defect, children develop serious functional disorders in the process of their physical development.

In children with congenital non-union 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. V most children with clefts are predisposed to catarrh of the upper respiratory tract, bronchitis, pneumonia, rickets, anemia.

Often, such children have pathological changes in the lororgan: curvature of the nasal septum, deformation of the wings of the nose, adenoids, hypertrophy (enlargement) of the tonsils. Often they have inflammation in the nasal region. The inflammatory process can move from the mucous membrane of the nose and throat 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 hearing loss of varying degrees (more often 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 the underdevelopment of the upper jaw and malocclusion with defective teeth positioning.

Numerous functional disorders caused by a defect 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 of various specialties observe children and jointly agree on a comprehensive treatment plan.

During the first years of a child's life, the leading role belongs to the pediatrician, who supervises the feeding and daily regimen 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; often it is produced in maternity hospitals in the first days after birth.

In cases of a cleft palate, the orthodontist uses various devices, including an obturator, which facilitate nutrition and create conditions for the development of speech 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.

With deviations in mental development and the presence of pronounced neurotic reactions of the child is consulted by a neuropathologist.

The operation to restore the palate (uranoplasty) is performed in most cases at preschool age.

According to the state of 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 oligophrenia (varying degrees). On neurological examination, signs of pronounced focal brain damage are usually not observed. Some children have separate neurological micro-signs. Functional disorders are much more common in children. nervous system, sometimes significantly pronounced psychogenic reactions, increased excitability.

Congenital clefts of the palate have a negative effect on the development of a child's speech.

Cleft lip and palate play a different role in the formation of speech underdevelopment. It depends on the size and shape of the anatomical defect.

Typical is the imposition of additional noises on nasalized sounds, such as aspiration, snoring, larynx, etc. There is a specific violation of the timbre of the voice and sound production.

To prevent the passage of food through the nose, children from a very young age acquire the habit of raising the back of the tongue to block the passage into the nasal cavity. This position of the tongue becomes familiar and also changes the articulation of sounds.

During speech, children usually open their mouths a little and raise the back of the tongue higher than required. The tip of the tongue therefore does not move fully. This habit worsens the quality of speech, since with a high position of the jaw and tongue, the oral cavity takes on a shape that contributes to the ingress of air into the nose, which increases nasality.

When trying to pronounce the sounds n, b, f, c, a child with rhinolalia uses "his" methods. The sounds are replaced by a pharyngeal click, which characterizes the speech of a child with severe rhinolalia in a very peculiar way. A specific click, reminiscent of the sound of a valve, is formed when the epiglottis comes into contact with 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 due to large individual differences in the configuration of the nasal and oral cavities in children, the ratio of resonating cavities and compensatory techniques that each child uses to increase the intelligibility of his speech. In addition, the intelligibility of speech depends on the age and individual psychological characteristics of children.

Speech therapy classes with a child must be started in the preoperative period in order to prevent the occurrence of serious changes in the functioning of the speech organs. On 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 a directed oral exhalation is developed. All this, taken together, creates favorable conditions for increasing the efficiency of the operation and subsequent correction. 15-20 days after the operation, the 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 the defective anatomical and physiological conditions of speech formation, the limited motor component of speech lead not only to the abnormal development of its sound side, but in some cases to a deeper systemic impairment of all its components.

With the age of the child, the indicators of speech development deteriorate (in comparison with the indicators of normally speaking children), the structure of the defect is complicated due to a violation different forms written speech.

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