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Mit einer Prävalenz von ca 1:1250 – 1:600 sind die submuköse Gaumenspalte (SMGS) und das kongenital kurze Velum (KKV) seltene Missbildungen im Bereich des weichen Gaumens. Die klassische Trias beinhaltet dabei die Uvula bifida, die Zona pellucida und die fehlende Spina nasalis posterior mit tastbarer negativer Kerbe am Ende des harten Gaumens. Typische Begleiterscheinungen beider Störungsbilder sind das offene Näseln, nasale Penetrationen und Tubenbelüftungsstörungen, wodurch ein suffizienter velopharyngealer Abschluss und eine Normakusis oftmals verhindert werden. Für diese Arbeit wurden die Daten von 180 Patienten (161 mit SMGS und 19 mit KKV) ausgewertet, die zwischen 2006 und 2016 am Universitätsklinikum Ulm vorstellig waren. 23,3% davon wiesen eine zusätzliche syndromale Erkrankung auf. Alle Patienten mit symptomatischer Spalte wurden mit der medialisierenden Umschlingungsnaht nach Prof. Dr. Dr. Stephan Haase operiert, durch die das Velum plastisch-chirurgisch gestrafft und um bis zu 0,5 cm verlängert werden kann. Es konnten dabei erstmalig die langfristige Hörbilanz generell und die Auswirkungen der jeweiligen Diagnose, des OP-Alters oder zusätzlicher syndromaler Erkrankungen auf das postoperative Hörvermögen analysiert werden. Der Vergleich der prä- und postoperativen Werte zeigt, dass die Operation zu einem signifikant verbesserten velopharyngealen Abschluss und einem signifikant verbesserten Hörvermögen (auch langfristig über 2,8 Jahre im Median) führt. Die Patienten mit KKV wiesen dabei mit durchschnittlich 5,7 Jahren ein signifikant höheres Diagnosealter als diejenigen mit SMGS auf (4,2 Jahre) und hatten ein signifikant schlechteres Ergebnis in Bezug auf die postoperative velopharyngeale Insuffizienz. Ein niedrigeres Diagnosealter brachte einen signifikant verbesserten velopharyngealen Abschluss mit sich. Bei Vorliegen einer zusätzlichen syndromalen Erkrankung konnte ein signifikant niedrigeres Diagnosealter (3,8 Jahre) erreicht werden, das Outcome war jedoch vor allem in Bezug auf das postoperative Hörvermögen signifikant schlechter. Insgesamt profitierten beide Gruppen vom Spaltverschluss, während die Kinder mit SMGS ein besseres Outcome vorweisen können. Eine frühzeitige Diagnosestellung ist dabei grundsätzlich von Vorteil. Die Suche nach der kompletten Trias ist nicht erfolgsversprechend. Bei einer bekannten syndromalen Erkrankung muss aufgrund der Häufigkeit von zusätzlichen Weichgaumendefekten der Gaumen immer sorgfältig untersucht und palpiert werden. Eine langfristige HNO-ärztliche Nachsorge und eine langjährige sprachtherapeutische Begleitung sind in den meisten Fällen obligat.

A submucous cleft palate and a congenitally short velum are diagnosed rather late, because symptoms are often mild.The pre- and postoperative clinical symptoms for both conditions are presented.The data of 180 patients with a submucous cleft palate (161) or congenitally short velum (19) were retrospective analyzed. In 23.3%, a syndromic association was found.Clinical findings for both conditions included middle ear problems, hypernasal speech, nasal penetration, the absence of the posterior nasal spine of the hard palate and/or a bifid uvula with a zona pellucida. The average age at diagnosis was 4.2 years in submucous clefts and 5.7 years in children with a congenitally short velum. Surgical palatoplasty with fusion of soft palate muscles and/or elongation of the soft palate was performed in 83.9% of the children, aiming to achieve sufficient velopharyngeal closure (VPC) with a significant decrease of symptoms and, hence, better conditions for speech therapy interventions. The overall success rate of the VPC was 63.7% with improvement in up to 2 of the 3 clinical symptoms (hypernasal speech, nasal penetration, middle ear problems). Hypernasal speech was more common (in 89.5%) in children with a congenitally short velum before surgery and in 81.3% 8 weeks after surgery; however, prior to surgery they had a short soft palate.Surgical intervention was particularly effective in children younger than 5 years. Syndromic diseases are disproportionately associated with soft palate defects.

Oropharyngeal cancer of the soft palate is a therapeutic challenge. This is due to crucial importance of velopharyngeal competence for articulation and swallowing. Patient counseling must present the whole therapeutic spectrum in order to receive informed consent. Basically, in primary therapy of oropharyngeal cancer multimodal concepts have to be considered including surgical resection and radiochemotherapy. With regard to the occasional difficulties predicting the functional outcome after primary therapy the ladder of reconstructive options has to be discussed a priori. Among numerous pedicled flaps the radial forearm free flap nowadays belongs definitely in the surgical armoury, which offers almost ideal reconstructive possibilities after extensive resections. This implies some additional aspects in pre- and postoperative workup that are reviewed in this article.

Submucous cleft palate (SMCP) is often diagnosed very late and can cause velopharyngeal insufficiency with open nasal speech and Eustachian tube dysfunction.A retrospective analysis of 106 patients (100 children, 6 adults) who had been surgically treated for SMCP was made. Age of diagnosis, physician who initially diagnosed the SMCP, typical symptoms for cleft palate, clinical examination of the palate, therapy options and accompanying diseases were evaluated.SMCP was diagnosed in 79 cases by a specialist for Phoniatrics/ENT surgery of the University and in 21 cases by a physician, who does not work at hospital at the age of 4.9 years. Main symptoms were Eustachian tube dysfunctions (61.3%) and hypernasal speech (48.1%). Typical findings of the palate were: reduced contraction (69.8%), lack of posterior nasal spine (55.7%) and bifid uvula (51.9%). In 18 patients a dysmorphic syndrome was observed and in 83% a conductive hearing loss which resolved after palatoplasty (often in combination with adenotomy and insertion of ventilation tubes). Following surgery 18 patients required speech therapy and of these 6 needed velopharyngoplasty due to continuing open nasal speech.SMCP is often diagnosed very late, though symptoms of velopharyngeal insufficiency such as open nasal speech, Eustachian tube dysfunction and reduced contraction of the palate with bifid uvula are present. It is also often found in children with craniofacial dysmorphic syndromes. We therefore recommend that all patients with such findings are examined by an appropriate specialist such as Phoniatrics, ENT-Surgeon and Oral-Maxillofacial Surgeon so that early diagnosis and palatoplasty can be performed.

Hintergund Lippen-, Kiefer- und Gaumenspalten haben eine Prävalenz von bis zu 0,40%; dabei macht die submuköse Spalte des weichen Gaumens (SMGS) bis zu 10% aller Gaumenspalten aus. Sie kann klinisch unauffällig sein, so bei 55% der Patienten mit isolierter submuköser[for full text, please go to the a.m. URL], 26. Wissenschaftliche Jahrestagung der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie (DGPP)

Adenoidectomy and tonsillectomy are the most frequently recommended childhood ENT operations. Although current standards of practice are high, note still needs to be taken of indications, especially in patients with palatal anomalies. These are not always easily estimated or recognised. The origin and therapy of velopharyngeal insufficiency are of particular importance.

Velopharyngeal dysfunction (VPD) is generally known to be difficult to influence. Dysfunctional velopharyngeal motor patterns during speech were analyzed with the aim of optimizing the therapeutic strategies.Velopharyngeal dysfunctions were videotaped and contextually analyzed during 89 speech sequences in 25 patients. Distinctive features of the motor patterns formed the basis of categorization by three therapists experienced in nasopharyngoscopy. There was a high inter-rater reliability of 94%.A total of four different function profiles were found: 1. VPD with retracted articulatory placement (compensatory articulation) (38%), 2. VPD with motor coordination problems characterized by mistiming of VP movements and voice onset/offset (15%), 3. VPD with verbal dyspraxia characterized by a silent positioning of VP closure before phonation started and a malregulation of muscle tonus (10%) and 4. phoneme-specific VPD (37%).Specific knowledge regarding the characteristics of dysfunctional speech motor patterns enables specifically tailored therapy.

Besides operation the mandibular advancement splint (MAS) is one of the main options for treatment of snoring. Especially the MAS by Hinz, which exclusively blocks mandibular retrusion, has been established as an effective alternative. The aim of this study is to examine the effectiveness of this MAS and to evaluate the role of obstruction at the level of the tongue base as a successful pretherapeutic predictor by using the sleep nasal endoscopy.From August 2001 until August 2006 we have examined over 450 patients with sleep disorders at our hospital. All patients have had an ENT examination, a standardized polysomnography and a sleep nasal endoscopy with therapy simulation. The application of a MAS is indicated if an obstruction at the level of the tongue base is detected and the RDI (respiratory disturbance index) is below 10/h. 10 patients are examined by PSG and partly by sleep nasal endoscopy before and after adjustment of the MAS. The patient group is classified in three velum- (n = 3), isolated tongue base-snorers, five combined tongue base-/velum- and two tongue base-/epiglottis-snorers.The subjective sleep recovery and the snoring-intensity can be improved by the MAS in eight of ten patients. In addition the long-term acceptance of this therapy is very high.According to our experiences the MAS by Hinz is an effective treatment option for patients with an obstruction level at the tongue base confirmed by sleep nasal endoscopy.

Tonsillectomy is one of the most commonly performed surgical procedures in the field of otorhinolaryngology. The first tonsillectomy was done about 600 B.C. [3]. This operation is indicated for patients with recurrent tonsillitis, peritonsillar abscess, hypertrophy or asymmetry of the tonsils. Even though a routine procedure, it has a relatively high risk of complications such as post operative hemorrhage, infection or impaired wound healing. The reported case involves a 20 year old female patient who developed velopharyngeal insufficiency as a result of impaired wound healing after tonsillectomy. The patient was treated conservatively and is free of discomfort after 2 months.

Nasal continuous positive airway pressure (nCPAP) ventilation is the gold standard in the treatment of obstructive sleep apnea (OSA). For patients with CPAP-intolerance and for those tolerating the CPAP-mask but without success, surgical strategies are of growing interest. There are several surgical concepts which combine different surgical procedures on both the velopharyngeal and the retro-lingual section of the upper airway. The case presented here describes the failed CPAP-therapy in an OSAS-patient who tolerates the CPAP-mask. The apneas and hypopnoes could not be reduced by using the CPAP-mask, even more they increased under CPAP-ventilation. Performing a video-documented sleep-endoscopy of the upper airway (under physiological sleep patterns) the location of the obstruction could be identified. After performing a hyoid suspension in combination with a radiofrequency therapy of the base of tongue the apneas and hypopneas decreased. Only by using the sleep endoscopy the reason for the failed CPAP-therapy could be identified and therefore the surgical protocol succeed. To what extend the sleep video endoscopy becomes a standardized procedure in sleep labs warrants further investigations.

Infants with Pierre-Robin sequence (PRS) may suffer severe upper airway obstruction resulting in hypoxemia that is difficult to treat. We are currently evaluating a new therapeutic approach involving an oral appliance that widens the pharynx by pulling the base of the tongue forward using a preepiglottic baton. Here we present a patient treated with this device who showed a decrease in his desaturation index from 50 to1.

Children with cleft palate frequently demonstrate speech and resonance disorders following primary cleft repair. In some patients no improvement can be achieved with conservative therapy and a velopharyngoplasty (VPP) may be indicated. This study was performed to evaluate the long-term results after VPP.Twenty-six patients were followed up on an average 9 years after VPP (mean age: 16+/-5 years). Apart from the phoniatric-pedaudiologic findings, the speech intelligibility and nasality were judged by speech pathologists and by laymen. The extent of the speech handicaps was evaluated with a questionnaire. The nasalance was measured with NasalView. The vowels, two test sentences, and three reading texts (LT(1-3)) were used as test materials.The phoniatric-pedaudiologic examination revealed a clear improvement of hearing, language, and speech function. Compared to the previous results, decreased nasality and improved ability in articulation were detected. The judgment of laymen was also positive. The speech intelligibility was mostly evaluated as favorable. A speech handicap was present in only a few patients. The evaluation using NasalView showed significantly increased nasalance values for the LT(2) ( p=0.030). Moreover there were lower nasalance values for all the reading texts compared to the control group (LT(1) p=0.257, LT(2) p=0.408, LT(3) p=0.187).A clear improvement can be achieved with VPP in patients with a high degree of therapy-resistant nasality. In many cases even normal colloquial language is possible. The evaluation of nasalance has proved to be successful for rating surgical outcome.

For the implementation of an uvulopalatopharyngoplasty (UPPP) it is nowadays common practice to operate in a manner which is gentle on the tissue and which retains as much muscle as possible. However, even when the greatest possible care is taken during the operation, serious complications such as persistent velopharyngeal insufficiency can arise.Based on a case report of a 55 year old man with a persistent severe velopharyngeal insufficiency after UPPP performed at another institution and serious OSA, we suggest a so-called push back technique, adapted from the cleft-palate surgery, for the extension of the soft-palate. With regard to the operative technique, it is thus possible to produce an effective extension of the soft-palate by means of a dorsocaudal displacement of a wide and on the palatal vascular fascicle pedicled mucoperiosteum flap of the mucous membrane of the hard palate, as well as similar mobilisation of the soft-palate from the os-palatinum.Only 3 weeks after the operation, our patient showed a clinically sufficient velopharyngeal functioning. After 3 months, a complete restoration of the nasal CPAP-acceptance was evident. As a result, a complete social rehabilitation was possible for our patient.The modified push back technique of the palate retrodisplacement which is described above offers an efficient possibility of anatomically and functionally correcting the persistent and serious velopharyngeal insufficiency after UPPP.

Rhinophonia is often present in patients with cleft lip and palate (CLP) many years after palatoplasty. It may be caused either by organic deficits, functional disorders, or both. NasalView is known as an instrument for the objective assessment of nasalance in cases of velopharyngeal insufficiency or incompetence.However,normative values for the German language are not yet available. In order to overcome this problem, this study evaluated such norms using NasalView.A total of 50 individuals with normal speech development were examined with NasalView. The median age was 14 years (range 11-20 years). The tone material used comprised the vowels /a:/, /e:/, /i:/, /o:/, /u:/, the sentences S(1): "Die Schokolade ist sehr lecker."("This chocolate is very tasty.") and S(2): "Nenne meine Mamma Mimmi."("Call my mummy Mimmi."), and the text passages of LT(1): "Nordwind und Sonne"("Northwind and sun"), LT(2): "Kindergeburtstag"("A child's birthday party") and LT(3): "Der grosse Gesang"("A famous song").The mean nasalance for the vowels was 35.9% (+/-8.4), for S(1) (containing no nasal consonants) 24.9% (+/-5.3), and for S(2) 69.6% (+/-5.5) (with many nasal sounds). The results for the text passages were 42.1% (+/-4.2) for LT(1), 36.9% (+/-4.3) for LT(2) and 38.2% (+/-4.4) for LT(3).The norms of nasalance for the German language presented here may be useful in measuring the long-term outcome of cleft lip and palate.

After introducing the Furlow's double opposing palatoplasty [4] in our clinic in 1991 114 patients were operated on and registered prospectively. Using this procedure for closure of small clefts and/or with moderate velopharyngeal incompetence only at the beginning it became the method of choice not only for primary palatoplasty at the age of 18-24 months but also for corrective measures now. An increase of length of the soft palate of 10 +/- 3 mm at the average was gained immediately after surgery. There were no specific side effects of the method, especially no fistulas occurred. Good speech results were obtained in 61% at the age of 8 years using profound phoniatric tests. Mixed velopharyngeal closure investigated by means of nasal videoscopy was the dominating form in 55%. The results underwent a positive change comparing results in patients after longitudinal investigation at the age of 5 and 8 years bzw. They corresponded with or exceeded the results found in a control group operated on with other methods of palatoplasty at another centre.

A two-armed, prospective, randomized study was performed to evaluate the influence of primary velopharyngoplasty on speech and facial growth in patients with cleft lip and palate.Forty-two patients born between 1978 and 1982 were included. All patients were treated with an intravelar veloplasty, and 21 patients simultaneously with a velopharyngoplasty according to Sanvenero-Rosselli. The patients were examined at the age of 5, 10, 15, and 18 years according to the recommendations of the research group of the German Association of Craniomaxillofacial Surgery for minimal documentation.Patients treated with primary velopharyngoplasty showed a higher deficit in transversal growth of the maxilla of 0.6 mm in the molar region in adolescence in comparison to the control group. The sagittal growth of the maxilla was reduced at 2.6 degrees in the SNA angle. A statistically significant decrease in growth of the maxilla caused by primary velopharyngoplasty was not detectable (p0.05). The incidence of rhinophonia and dyslalia did not differ significantly. Primary velopharyngoplasty did not lead to speech improvement either in childhood or in adolescence.With regard to a potential decrease in growth of the maxilla and the disadvantages of a hindered nasal respiration, a primary velopharyngoplasty therefore does not seem to be indicated.

The problem with primary soft palate repair is shortness of the soft palate and a soft tissue deficit in this region. The authors introduce a modification of the intravelar veloplasty allowing lengthening of the soft palate at the time of primary closure.The "soft palate wavy incision procedure" combines a wavy or undulating type of incision at the velar cleft margins with intravelar veloplasty. In 12 patients with complete clefts of the palate, postoperative breathing and speech was analyzed 3 years later. The investigator did not know whether a modification of the common procedure had been performed in these patients or not.It was found that the soft palate wavy line procedure is easy to perform and closure in three layers is possible even in wide clefts of the soft palate. No postoperative fistula was observed. An average lengthening of the soft palate of about 56% (24-83%) was achieved, measured immediately at the end of surgery. Three years later the patients have good speech results following this technique.Experience has shown that the soft palate wavy incision procedure is straightforward, safe, and easy. It seems that this technique leads to better results than classic intravelar veloplasty. This paper is only a first report, and further investigations are necessary.

Velopharyngeal incompetence is a well described complication of uvulopalatopharyngoplasty (UPPP) for snoring or obstructive sleep apnea. A new uvulopalatal flap technique (UPF), first presented by Powell in 1996 was now modified by our team. The new technique intends to lateralize the posterior faucial pillars as the UPPP, entirely sparing uvulopalatal muscles.No statistical difference existed in change of AHI before and after surgery in all patients even though 14 patients had a statistically significant decrease in AHI (pre 19.2 +/- 19.6; after 8.2 +/- 9.8; p0.05). Snoring decreased clearly (p0.05) from 49.4% to 25.9%.

The localization of an upper airway collapse in snorers and patients suffering from obstructive sleep apnea was a subject frequently discussed in the last few years. Pharyngolaryngoscopy during sleep or drug-induced sleep allows evaluation of upper airway conditions.A total of 324 patients suffering from snoring or obstructive sleep apnea underwent flexible pharyngolaryngoscopy while awake and under propofol-induced sedation in the course of routine diagnostic procedures in the sleeping lab. In this study, the results of pharyngolaryngoscopy are compared to results of the Müller maneuver and polysomnographic recordings. The therapeutic consequences of this additional investigation are discussed.In 95% of cases snoring was observed during drug-induced sleep. A significant discrepancy was seen between results of the endoscopy while being awake (Müller maneuver) and during drug-induced sleep. The degree of collapse differed significantly in the area of the base of the tongue. Severe collapse was seen much more often with pharyngoscopy during drug-induced sleep compared to the results during the Müller maneuver.The collapsibility in the area of the base of the tongue correlated with higher results in the RDI (respiratory disturbance index) registered with standard polysomnography. Snoring and upper airway collapse were easily surveyed, and the pharyngolaryngoscopy during propofol-induced sleep proved to be a simple, safe, readily controllable and effective supplementary diagnostic device for the diagnosis and treatment of obstructive sleep apnea and snoring.

Despite successful closure of the hard and soft palate and intensive speech therapy a velopharyngeal insufficiency is not completely avoidable in each case of cleft palate. An improvement by velopharyngoplasty should be possible.Two hundred and ninety patients suffering from cleft palate were examined before and one year after velopharyngoplasty according to Sanvenero-Rosselli. Four main symptoms of the affected speech were assessed: changes of the resonance, inappropriate nasal air emission, articulary disorders (deviations from articulation areas), and non-physiological facial expression during speaking, each divided into three grades. Afterwards, the complete speech quality was classified.Assessing the symptoms separately and summarised the therapy including velopharyngoplasty was suitable to improve the speech quality in 83.1% of the cases, resulting in a widely unaffected speech. The improvement was greater in younger patients undergoing operation (Gamma-test, p0.001). But the final results were independent from age due to poorer initial situation in younger patients (Gamma-test, p0.001).The velopharyngoplasty is an important method for repair of velopharyngeal insufficiency in patients with cleft palate. In each individual case it is necessary to consider carefully if and when this operation should be performed. An intensive interdisciplinary co-operation of all specialists involved in the treatment is indispensable.

Snoring, excessive daytime sleepiness and nocturnal apnoea are among the leading symptoms of the obstructive sleep apnoea syndrome (OSAS). Primary snoring without upper airway obstruction is a more common and normal phenomenon in sleep and has to be distinguished from OSAS. Patients with primary snoring are often suffering and complain of great distress and social embarrassment and therefore request professional help. Therefore, the otorhinolaryngologist has to be aware of the different treatment options that are possible and sensible. Apart from behavioral changes and general measures (weight loss, reduction of alcohol consumption, sleep position training), there are different conservative and surgical treatment options. In this article, the pathophysiology, diagnosis and treatment of primary snoring will be discussed.

Infolge eines primären Defizits der velopharyngealen Funktion liegen bei vielen Patienten mit Lippen-Kiefer-Gaumenspalten sekundäre kompensatorische Lautbildungen vor. Mit zwei neuen Computerprogrammen werden die Auswirkungen der kompensatorischen Artikulation auf die durchschnittliche Sprechgeschwindigkeit von 146 Patienten mit Lippen-Kiefer-Gaumen-spalten untersucht. Die Patienten wurden dabei nach dem Schweregrad der artikulatorischen Auffälligkeit gruppiert. Bei der schnellen Silbenwiederholung zeigte sich, dass die durchschnittliche Silbenrate pro Sekunde bei Patienten mit deutlich auffälliger Artikulation signifikant reduziert war. Beim Nachsprechen von Sätzen war die zum Nachsprechen benötigte Gesamtzeit bei dieser Patientengruppe signifikant erhöht, und das Zielwort des Satzes wurde signifikant später begonnen. Die Ergebnisse zeigen, dass die mittlere Sprechgeschwindigkeit von Patienten mit Lippen-Kiefer-Gaumenspalten mit kompensatorischer palatolalischer Artikulation niedriger ist.

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

Comprehensive evaluation of voice function is the precondition for indication and quality control of every phonosurgical procedure. In 53 patients presenting with glottic insufficiencies of different etiologies an external vocal fold medialisation was performed. Functional voice results obtained with this operation are presented and discussed.The following voice parameters were measured preoperatively and postoperatively, and statistical comparison was performed: mean fundamental frequency and sound pressure level, frequency and intensity range (voice range profile), perceptual evaluation of hoarseness, and maximum phonation time. The impairment of vocal communication skills was rated on a newly developed 7-point scale. A combined parameter called "Voice Dysfunction Index" was introduced for global assessment of vocal abilities in particular for long term observations.Statistically significant improvement of all voice parameters was demonstrated. Interestingly, in nearly all measurements male patients yielded significantly better results than females. Glottic insufficiencies due to scarring produced poorer functional results but without statistical significance. A statistically significant correlation between the preoperative and postoperative Voice Dysfunction Index could be observed. This score was also significantly correlated with the degree of glottal gap. No significant correlation between voice results and preoperative delay or follow-up period were observed. Voice therapy was performed in 81% of the patients. Correlation of duration of voice therapy and voice results was statistically significant and negative. Analysis of this surprising result showed that it was caused by some patients with vocal fold scarring in whom outcome was poor despite a long period of voice therapy.Significant improvement of vocal function can be obtained by external vocal fold medialization in patients with glottic insufficiencies. Glottal gaps caused by vocal fold scarring and/or atrophy can be treated with this method, too. However, results are not as good as in paralysis and require additional long term voice therapy. Satisfying results can be expected in patients with a long history of disturbances, and in older patients. Due to the reversibility of the operation, external vocal fold medialization can be performed even in cases of palsy prior to the spontaneous recovery period. The degree of glottic gap determines the functional disturbance. The degree of the preoperative impairment correlates with the outcome. Results are stable with respect to the follow-up period (mean 66 weeks).

Despite a first report as early as 1915 by Payr, vocal fold medialization by an external approach did not gain general acceptance for many decades. Only when Isshiki took up these first attempts again in the 1970s, fundamentally revised them, and expanded the methods into the groups of Laryngeal Framework Surgery and Thyroplasty, did these techniques spread. Now they are increasingly performed. We have been using this technique since 1991. In a retrospective study we critically reviewed surgical experience with the original technique and several newly developed surgical modifications.An external vocal fold medialization was performed in 53 patients (22 male, 31 female). The underlying cause for the glottic insufficiency was in most of the cases unilateral laryngeal palsy, predominantly caused by thyroid surgery. Ten patients presented with an atrophy and/or scar of the vocal folds. In 7 out of these 10 cases the vocal folds were mobile. Most of the patients were operated on (n = 32) using the Isshiki technique. In the remaining 21 patients surgical modifications were used. In 7 cases new developed implants made out of glass ionomer cement were used, in 5 patients vocal fold medialization was performed using a 0.25 mm titanium sheet.No intraoperative or postoperative complications could be observed. The surgical procedure was very well tolerated by all patients. The degree of glottic insufficiency was significantly reduced. There was also a statistically significant correlation between the preoperative and the postoperative degrees of glottic insufficiency. It was not always possible to close large glottic gaps completely in every case. Despite good overall results we experienced some limitations of the implant and the surgical technique as well. We therefore began to modify the implant and the surgical technique on the basis of anatomic and experimental studies.External vocal fold medialisation proved to be a safe and well tolerated surgical procedure. It is reversible and revisable, suitable for nearly all kinds of glottic insufficiencies, and can be combined with other phonosurgical procedures. Significant reduction of glottic insufficiency can usually be achieved, although large glottic gaps cannot be closed completely in every case. It should be possible to overcome certain limitations of the currently performed technique by developing new implants and modified surgical procedures. External vocal fold medialisation could then become established as a standard procedure providing even better and more stable functional results, at minimal risk to the patient.

In this study we developed another method for the detection of nasopharyngeal closing patterns. This investigation of dynamic closure patterns was based on flexible video-nasopharyngoscopy and was undertaken in both healthy subjects and patients with dysarthria. Quantitative assessments of pharyngeal wall excursions allowed evaluation of closure patterns which were then matched with a predefined, mathematically-based algorithm. The results showed that a greater velopharyngeal constriction was maintained in the following order: resonants, open vowels, forced expiration, closed vowels, consonants, and swallowing. Variations in phonetic expressions of phonemes mainly interfered with velum excursion, whereas the lateral pharyngeal mucosal wall was minimally involved and the posterior wall portions were unaffected. Velopharyngeal closure patterns varied with different tasks: the velum was mainly moved for phonetic parameters, while lateral and posterior pharyngeal wall motion was observed on a large scale for swallowing. Comparison of subject groups revealed that patients with dysarthrias had reduced velar motility, leading to a more frequent hypernasal sound. Here, lateral pharyngeal walls showed a variable motility that in some cases was even more than in healthy subjects. Both groups exhibited qualitatively comparable velopharyngeal closure patterns, but significant differences were proved in their distributions.

To answer the question if a cranially based pharyngeal flap in patients with cleft palate could affect nasal breathing, 49 children were examined by active anterior rhinomanometry with and without decongestion of the nasal mucosa. All patients were between 10 and 12 years old. In 18 of them palatoplasty with a cranially based pharyngeal flap was performed at the average age of 3.5 years. The control group consisted of 21 children who had been treated with an intravelar veloplasty without any flap at the age of 11-13 months. None of the patients had any appreciable narrowing of the nasal airways. Using the U test we found no significant difference between the inspiratory breathing volume of both groups. The difference between in- and expiratory volume in each group showed no significance either while the volumes we examined before and after decongestion differed significantly. Thus, we cannot conclude that the cranially based flap affects nasal breathing in cleft palate patients compared to those without any flap.

Dysphagia is a common symptom in clinical practice. Due to the broad spectrum of underlying diseases many disciplines are involved in the therapy and diagnosis of dysphagia, where radiology plays a central role. The radiologist is confronted with different diagnostic problems and has to choose the most appropriate type of investigation. In many cases no organic disorder can be demonstrated by clinical examination, endoscopy or conventional radiological techniques. In this setting cineradiography is an outstanding tool for finding functional or structural changes in the swallowing chain. This study underlines the efficiency of cineradiography in the diagnosis of dysphagia.

Videocinematography is a valuable tool in the diagnostic workup and planning of functional surgery in cleft patients. The high resolution and depiction of the finest mucosal structures in motion allow objective and dynamic assessment of the individual velopharyngeal function. A total of 170 cleft patients were examined by videocinematography, and the results were compared to nasoendoscopy and to the clinical examination. The marked superiority of this radiological technique with regard to clearness of depiction and ease of use is shown. It can therefore be recommended without reservation for the pre- and postoperative assessment of cleft patients.

An objective examination of velopharyngeal sphincter function (VP) is possible using a variety of signal and pictorial methods to differing degrees. Video endoscopy and videofluoroscopy are the currently accepted clinical standard. With the help of a new concept described here it is possible both to analyze VP function in the midsagittal plane using electromagnetic articulography (EMA) and also to examine simultaneously the horizontal plane video endoscopically. This multidimensional analysis of VP function is presented in a case study of a healthy test person and the timing aspects of VP closure and transverse-sagittal ratio of VP port-diameters ist reported.

We examined two groups of teenagers (between 13 and 21 years of age) who had been surgically treated as small children for congenital cheilognathouranoschisis or cleft palate. A group of 62 teenagers had been treated by the Dept. of Orthodontics at the University of Erlangen-Nuremberg, the other group of 61 by the Dept. of Orthodontics at the University of Rostock. There were differences between the two departments in sequence and time of the surgical closure as well as in the frequence of velopharyngoplasties. The velopharyngeal closure was examined in all patients by means of a flexible fibre endoscope which was pushed forward endonasally up to the choanae. Simultaneously we judged the audibility of the nasal perflation while pronouncing /k/. A residual gap during articulation of /k/ with clearly audible or alternately clearly and discreetly audible nasal perflation was noted in 8 subjects in Erlangen and 14 subjects in Rostock. In subjects whose velum moved only anterior-posteriorly, closure was likely to be less good than in those with a circular closing mechanism of velum and lateral and/or posterior parts of the pharyngeal musculature. In rare cases we found a good velopharyngeal closure in spite of a large gap between the velum and the posterior pharyngeal wall at rest. This was the case when the velum moved more against the upper than the posterior wall of the nasopharynx. Velopharynxplasty did not reduce nasal airflow in case of insufficient function of the velar muscles. Differences in the mode of velopharyngeal closure might be due to statistically significant regional differences in skull structure.(ABSTRACT TRUNCATED AT 250 WORDS)

Children with cleft palates often suffer from chronic conductive hearing losses, delayed language acquisition and speech disorders. This study presents results of speech and language outcomes in relation to hearing function and types of palatal malformations found. 417 children with cleft palates were examined during followup evaluations that extended over several years. Disorders were studied as they affected the ears, nose and throat, audiometry and speech and language pathology. Children with isolated cleft lips were excluded. Among the total group, 8% had normal speech and language development while 92% had speech or language disorders. 80% of these latter children had hearing problems that predominantly consisted of fluctuating conductive hearing losses caused by otitis media with effusion. 5% had sensorineural hearing losses. Fifty-eight children (14%) with rhinolalia aperta were not improved by speech therapy and required velopharyngoplasties, using a cranial-based pharyngeal flap. Language skills did not depend on the type of cleft palate presents but on the frequency and amount of hearing loss found. Otomicroscopy and audiometric follow-ups with insertions of ventilation tubes were considered to be most important for language development in those children with repeated middle ear infections. Speech or language therapy was necessary in 49% of the children.

The use of high-frequency video cineradiography makes possible an objective and dynamic rendering of the individual velopharyngeal closer pattern. The high resolution and the depiction of the finest mucosal structures while in motion achieved by this technique opens up the possibility of exact and objective 3-dimensional evaluation of the velopharyngeal gap. Following secondary velopharyngoplasty on 80 cleft palate patients, the velopharyngeal closure was studied by means of high-frequency video cineradiography and this rendering was then compared to results obtained by nasoendoscopy and to the clinical findings. It became definitely apparent that the radiological technique is markedly superior in relation to clearness of depiction and ease of use, especially in young children. This imaging technique can be recommended without reservation for pre- and postoperative control of speech-improving procedures.

The velopharyngeal function while swallowing water was studied on a healthy volunteer patient with velopharyngeal closure and on a patient with velopharyngeal insufficiency. This patient suffers from open hypernasality as a result of shortened velum. Both subjects underwent nasoendoscopy with a flexible fiber glass optical device while swallowing water and while articulating the plosive consonant /k/. Velopharyngeal function was documented by means of videotaping and then the single video images were placed together along a time scale to form a new temporal image. This image makes possible a quick and comprehensive differentiation between physiological and disturbed motion patterns as demonstrated in this study using velopharyngeal function as the example. The videotaping in lapse time of such disordered movements can provide indicators of the therapeutical steps to be taken.

Velopharyngoplasty performed to correct velopharyngeal insufficiency in cleft palate patients may cause obstructive sleep apnea in individual cases. The aim of this study was to answer the question, following velopharyngoplasty to what extent and with what frequency can signs of breathing disturbances during sleep be observed. Following the recommendations of the German Sleep Society, a step-by-step procedure was adopted. In 25 patients, in some cases before the operation and in all cases following surgery, nightly oxygen saturation, heart rate, and snoring were recorded. When observable pathological signs surfaced, a cardiorespiratory polygraph was taken. Up to this point only quickly passing signs of sleep related breathing disturbances have been observed. In not a single case could lasting sleep related breathing disturbances as a result of velopharyngoplasty be proven. Nevertheless, the call for pulse oximetric monitoring in the immediate postoperative phase together with corresponding pre-operative observation is legitimate. Even if at this point the danger of sleep related breathing disturbances following velopharyngoplasty appears to be minimal, these preliminary results should be polysomnographically studied within the framework of a much larger test study in order to reach still more reliable conclusions and in order to intercede if necessary with counter measures in the rare individual case of breathing disturbance during sleep following velopharyngoplasty.

Psychological interviews with cleft palate patients have revealed why a number of these patients do not profit, or do so only on a limited basis, from conventional speech therapy. They don't control articulation by means of the auditory canal. To treat these patients the video feedback therapy with the nasopharyngoscopy (Witzel et al.) was employed as the initial step. The next step was to expand on this method by establishing indication criteria, necessary diagnostic techniques, and an efficient therapy plan. In this paper a single case study is employed to discuss this method and show the results attained by its use.

Forty three out of 148 patients who had undergone velopharyngeal flap graft between 1980 and 1992 to treat velopharyngeal insufficiency, and for whom pre- and postoperative data were available, were studied for the purpose of determining the long term morphological functional results of the treatment. Almost all of the 43 patients (93.5%) had received a velopharyngeal flap graft according to Sanvenero-Rosselli. The remaining 4.7% had received a velopharyngeal adhesion according to Stellmach. Four physicians from the fields of oral surgery, orthodontics, phoniatrics, and logopedics evaluated the pre- and postoperative data as well as the results of the follow-up examination according to subjective criteria from their respective disciplines. All four physicians judged that following velopharyngeal flap graft a gradual improvement in the ability to speak had been achieved in 86% of the patients in the follow-up study. At the time of the follow-up examination 70% of these cases were judged to have achieved a "good" qualitative level of articulation and 21% were judged to have achieved a "usefull" level. The best results were obtained in patients who had been operated on before the age of six. The reason is that in these young patients muscular malfunction and pathological movement patterns can be more easily modified than in older patients. In many cases additional speech improvement was achieved through logopedic therapy following the velopharyngeal flap graft. In the most difficult cases intensive therapy while the patients were still hospitalized proved to be especially effective.(ABSTRACT TRUNCATED AT 250 WORDS)

We examined two groups of teenagers who had been surgically treated as small children for cleft palate. Most patients were between 13 and 21 years of age. One group had been looked after by the Dept. of Orthodontics at the University of Erlangen-Nürnberg, the other by the Dept. of Orthodontics at the University of Rostock. There were differences in sequence and time of the surgical closure between the two departments. Additionally, 60% of the people treated in Rostock had a velopharyngoplastic, which was rarely the case in Erlangen. In both groups only a few patients had been seen by an ENT-doctor regularly. Only some patients had been previously treated with tubes. There was one patient in each group with a bilateral, most likely genetically determined, sensorineural hearing loss. In Erlangen we examined 66 teenagers (132 ears). Six ears had been previously treated with one or more tympanoplasties. 10 ears needed further treatment due to a seromucotympanon, adhesions, perforations of the ear drum, suspicion of cholesteatoma or insufficient improvement of hearing after previous tympanoplasty. Another 18 ears showed signs of former inflammations. The control group in Rostock included 63 patients (i.e. 126 ears). 14 of the ears examined had undergone one or more tympanoplasties previously. 13 other ears needed further treatment for seromucotympanon, adhesions, perforations of the ear drum, insufficient improvement of hearing after tympanoplasty or cholesteatoma. Residuals due to prior inflammations were found in another 26 ears. Possible reasons for the different occurrence of middle ear problems in both groups are discussed.

Employing nasal endoscopy a follow-up study of 59 adult CLP-patients was conducted for the purpose of investigating velopharyngeal functions both during swallowing and during phonation of the letter "K". The results were subsequently compared with cephalometric values. In relation to phonation, the velopharyngeal activity could be subdivided into two groups, one demonstrating predominantly circular muscular activity and the other velar muscular activity. Both groups exhibited differing but, overall, a high quality of velopharyngeal closure. When swallowing all patients experienced complete velopharyngeal closure. It was striking to note, however, the slight muscular activity of the Passavant ridge during both swallowing and phonation. Significant relations were found to be present between facial morphology and velopharyngeal functions in terms of inclination of both the basis of maxilla and the mid-basicranium.