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Alternative for better speech

Prosthesis proved effective in correcting labial malformations

The rehabilitation of persons with fissures and malformations in the lips and the roof of the mouth can now be carried out with special prostheses. The solution is a novelty in Brazil, and was developed by a multidisciplinary team in the HRAC, the Hospital for the Rehabilitation of Craniofacial Anomalies, of the University of São Paulo (USP), better known as the Bauru Center. The new technique replaces surgery in the treatment of such cases, which are one of the most common congenital problems in the world. In Brazil, where it is commonly known as harelip, this anomaly affects one in every 750 children born, adding 16 new babies a day to the population of 240,000 persons who have lip-palatine fissures.

Harelip would be bad enough if it were just an aesthetic problem. But it is not. Lip-palatine fissures are the main cause of velopharyngeal malfunction, a situation that is capable of jeopardizing speech in such a way that the person affected cannot communicate normally.  “It can lead an individual to a psychological maladjustment, and even to avoidance of social contact”, explains speech therapist Maria Inês Pegoraro-Krook, the coordinator of the research project ‘Treatment of Patients with Fissured Palate (Congenital or Acquired) by Means of a Speech Prosthesis’, which received funding from FAPESP in the amount of R$ 12,400.

Normally, this problem is treated with a surgical operation.  However, specialists realized a long time ago that a large number of patients with fissures, including as a result of accidents, could not be treated by surgery, and they were therefore indicated for a palatine prosthesis. To identify these situations, the Center’s team carried out a study that involved 71 patients.

High level
The use of a prosthesis helps people to overcome a serious problem of being excluded from society. “The anguish of being misunderstood and of being unable to express oneself represses creativity and the capability for learning”, observes Maria Inês.   A contribution to the success of the study was the fact that the Center brings together attending to people from all over the country and high level academic research, with the objective of perfecting the techniques for the treatment, not only of lip-palatine fissures, but also of problems of craniofacial malformations, as the abnormalities of the head are called, which also show auditive, visual, and linguistic deficiencies in general.

One of the prostheses developed by the Center corrects velopharyngeal malfunction, which affects a muscular valve situated between the nose and the mouth. Its function is to control the passage of air.  In people who have lip-palatine fissures, the valve does not carry out automatically the opening and closing movement, either through the lack of tissue, or incapacity for making the appropriate movements. If the valve is not working perfectly, the person, even if he has good diction, cannot produce the sounds of speech in a natural way.  There is a loss of air through the nose during speech, which characterizes hypernasality, or a nasal voice.

Acoustic analysis
The researchers of Bauru started the project by identifying some situations where, according to current indications, the use of a prosthesis would be preferable to the traditional surgical operation. The chosen situations were: when the fissures are so big that there is not enough tissue for a surgical repair; when there is not enough tissue to close the hard palate, the bony part of the roof of the mouth, with tissue from the same region; or when there are neuromuscular deficiencies in the palate or in the pharynx.

71 patients with a cleft palate, congenital or acquired after birth, were selected. The main instrument used in research was an apparatus for acoustic analysis called a nasometer.  The apparatus captures separately, by means of two directional microphones, separated by a horizontal bar placed above the lips, the sounds issued by the nose and the mouth. The signals, filtered and digitalized by electronic modules and processed on a computer, indicate the degree of nasality, or the intensity of the patient’s hypernasality.

In the end, the research used the data of 59 patients. The others were eliminated, either because they had a cold, or because the recordings had technical problems. All the patients read a standard text, made up of 73 words in eight sentences, called ‘The Story of the Black Bear’. Afterwards, the patient was asked to talk about some fact, to register what is called “spontaneous speech”.

The project did not stop there. Some of the patients with a prosthesis underwent intensive programs of speech therapy in the hospital itself, or in their own cities.  In the end, they made new recordings, and the results were compared.  This led to some important conclusions, not only regarding the prosthesis, but also as to the speech therapy treatment and to the alterations that had taken place in the pharyngeal bulb. Also as part of the project, some patients were filmed, with and without the prosthesis.

Significant improvement
The researchers reached the conclusion that there really are situations that indicate a prosthesis as the most suitable treatment for the fissure. Of the 59 patients, 41, or 69.49%, showed significant improvements regarding speech understating with the use of a prosthesis.  Of the rest, three, or 5.08% showed no difference, and 15, or 25.42%, showed a slight deterioration.

As to assessment with the nasometer, carried out on 62 patients, there was an improvement in 43 patients, or 69.36%, deterioration in 18, or 29.03%, and identical results with one, or 1.61%. The assessment of the speech resonance, done for 55 patients, showed a reduction in hypernasality with the use of the prosthesis in 38, or 69.09%, no difference in six, of 10.9%, and a slight increase in hypernasality in 11, or 20%.

Agreement with Florida
The results of the project have expanded the knowledge acquired by the Hospital of Rehabilitation, which, in its 32 years of existence, has already attended almost 50,000 persons, and is regarded as a national center of excellence by the Ministry of Health, and a world center of reference by the WHO, the World Health Organization.  Maria Inês, besides being Professor of the Speech Therapy Department of the Bauru School of Odontology, of the University of São Paulo (USP), is responsible for the Acoustic Phonetics Laboratory and for the Center’s Palatine Prosthesis Service.  She also manages an agreement between USP and the University of Florida, in the United States.

This project was signed in 1992, and has the objective of comparing the results obtained in speech and in the velopharyngeal function in patients with a unilateral fissure of the lip and the palate, who have been submitted to palatine plastic surgery, or the surgical closing of the palatine fissure by means of two surgical techniques, Von Langenbeck and Furlow. The project, which started in 1996, includes the participation of 352 patients.

To carry out the research, the University of Florida received a budget of US$ 1 million from the National Institute of Health of the United States.  This is quite something.  “We are the first Brazilian university to have a project approved by this respected and  highly required organ of the American government”, comments Maria Inês.

• Maria Inês Pegoraro-Krook is 38 years old and graduated in Phonoaudiology from the Pontifical Catholic University of Campinas in 1982.  She took her master’s and doctor’s degrees at Unifesp, the Federal University of São Paulo, and is concluding the post-doctorate program at the Craniofacial Center of the University of Florida, in the United States.  She has completed specialized courses at the University of Copenhagen, in Denmark, and in the General Hospital of Malmö, of Lund University, in Sweden.
Project: Treatment of Patients with Fissured Palate (Congenital or Acquired) by Means of Speech Prosthesis
Investment: R$ 12,430.70