Bulbar syndrome: symptoms and treatment. Progressive bulbar palsy What is soft palate paresis

Laryngeal paresis (paralysis) is a decrease in muscle strength in the area of ​​the respiratory system that connects the pharynx to the trachea, containing the vocal apparatus. Characterized by damage to the motor pathway of the nervous system.

The vocal apparatus is an expansion and contraction of the gap located in the larynx between the vocal cords, through which air passes to produce sounds, and the level of tension of the vocal cords depends on the activity of the muscles of the larynx due to nerve impulses. If part of this system is damaged, laryngeal paresis occurs.

This disease is characterized by a decrease in the ability to perform actions related to the activity of the larynx, such as breathing and producing sounds.

Considering that paralysis of the larynx is caused by quite common causes, it occupies one of the leading places among ENT diseases (ear, nose, throat).

Paralysis is provoked by a fairly diverse number of causes and affects people regardless of age and gender. Often formed as a result of other diseases.

Causes of the disease:

• thyroid diseases;
• tumors of the larynx, trachea, cervical spine and their metastases;
• previous strokes;
• various inflammations of the serous membrane of the lungs;
• peripheral nerve disease as a consequence of previous intoxications, infectious diseases (tuberculosis, botulism, ARVI, etc.), poisoning;
• hematoma formation due to mechanical damage to the neck;
• accumulation in the tissues of the body of elements mixed with blood and lymph during infectious inflammation of the larynx;
• protrusion of the wall of an artery or vein caused by its stretching;
• immobility of the arytenoid cartilage;
• diseases of the brain and spinal cord, as well as the spine;
• postoperative injuries to the cervical region, head, chest (paralysis of the vocal cords, as a consequence of the operation, is characteristic in most cases of incorrect surgical intervention);
• harmful effects of chemotherapy drugs.

Paresis of the larynx often occurs in people whose work involves a high load on the vocal apparatus.

Paresis of the vocal cords is also observed in people, the causes of which were severe stress, smoking, harmful production conditions associated with the exhalation of harmful and toxic substances, as well as cold, smoky air and mental illness.

Types, symptoms, consequences

Interestingly, paralysis of the larynx and paresis of the palate (part of the soft palate that separates the oral cavity from the pharynx) have the same clinical picture.

Symptoms depend on the duration of the disease and the nature of the inflammation of the larynx.

Paralysis occurs: unilateral, bilateral. If there is a second one, sick leave is provided. Unilateral paresis is characterized by inflammation of half of the larynx, the left or right fold. With unilateral paresis, the signs of the disease are less pronounced and may develop disruption of the lungs and bronchi.

Considering that bilateral paralysis, like paresis of the soft palate, have symptoms associated with impaired breathing, they can cause asphyxia and, as a consequence, death, as well as severe changes in the voice, including its complete loss.

The following symptoms most characterize laryngeal paresis:

• hoarseness, change in voice;
• conversation in a whisper;
• rapid fatigue of the vocal cord;
• difficulty swallowing;
• pain in the neck;
• disturbances in the motor activity of the tongue and soft palate;
• shortness of breath, slow pulse;
• sensation of a lump or foreign object in the throat;
• cough;
• headache, irregular sleep, weakness, increased anxiety (with paralysis provoked by stressful situations, mental disorders);
• blueness above the upper lip;
• choking;
• respiratory failure (typical of bilateral paralysis and requires urgent treatment).

The main external signs of inflammation of the vocal cords are disturbances in the functions of speech and breathing.

In addition to the nature of the disease (unilateral, bilateral), laryngeal paresis is divided into types, also often depending on its nature: myopic, neuropathic, functional.

Myopic, characteristic of bilateral paresis with impaired speech and breathing functions, up to asphyxia.

Neuropathic, in most cases, occurs unilaterally, associated with the formation of weakening muscles that widen the gap, gradually turning into the muscles of the larynx. Restoration of phonation occurs after a long time. With bilateral neuropathic paresis of the larynx, asphyxia may occur.

Functional is typical for people who have experienced stressful situations or viral diseases. The uniqueness of this type lies in the fact that it is characterized by the sonority of the voice when crying, laughing or coughing. There is a sore throat, pain, and pain in the head, irritability, weakness, sleep disturbance, and mood swings.

Diagnosis and treatment

Taking into account that this is a rather dangerous disease, its timely diagnosis and subsequent treatment are an important factor for the further normal functioning of a person.

Before treating the disease, it is necessary to correctly diagnose it. To establish it, you need to see a doctor and undergo the prescribed examination. It is not recommended to diagnose yourself!

The attending physician, after analyzing the complaints and external examination of the neck and oral cavity, will prescribe one of the following examinations: laryngoscopy, which includes studying the location of the vocal cords, the presence of inflammation, the condition of the laryngeal mucosa and its integrity, tomography, radiography and electromyography, which allows for an assessment of the condition of the muscles. To determine the level of impairment of vocal functions, phonography, stroboscopy, and electroglottography can be used.

The therapy provided directly depends on the causes of the disease, as well as its nature. Its task is to restore the basic functions of the larynx: breathing and sound production.

If vocal functions are impaired due to overexertion, treatment is not required, but rest is necessary to restore them.
Drug therapy, surgical intervention, and physiotherapeutic procedures are used, among which phoniatric exercises are common for paresis of the vocal cords.

Most often, for diseases of the larynx, medications are prescribed (taking into account the cause of the disease): decongestants, antibacterial, antiviral, vascular, improving brain function, activating muscle activity, antidepressants, vitamin complex.

Surgical intervention is required in the presence of tumors, thyroid diseases, muscle laxity, and the onset of suffocation.

Physiotherapy includes electrophoresis, magnetic therapy, acupuncture, hydrotherapy, massage, psychotherapy, phonopedia, and gymnastics.
Breathing exercises, including slowly blowing and drawing in air, using a harmonica, puffing out the cheeks and releasing air slowly, taking an extended breath, as well as training the neck muscles, have become of great importance in the rehabilitation and treatment of paralysis of the larynx and soft palate.

Prevention and prognosis

Paresis of the palate and larynx can be avoided. To do this, it is necessary to exclude a possible part of the causes of their occurrence. This is to avoid stressful situations, reboots of the vocal cords, viral diseases, avoid smoking and inhaling stale air if possible. And also to prevent complications of diseases that can cause paresis.

For any disease, maintaining a healthy lifestyle and maintaining immunity have beneficial effects on the body and increase the body's resistance to various inflammatory processes.

Paresis of the larynx is completely treatable, especially if it is unilateral, and subsequently does not have any consequences after the therapy.

The danger of bilateral paralysis is primarily characterized by suffocation, which can lead to death and complete loss of voice. Therefore, in order to avoid such consequences, it is necessary to consult a doctor in a timely manner for the purpose of treatment.
In any case, the sooner you start treatment, which must be prescribed by a specialist (only in this case can you hope for its effectiveness), the more positive the prognosis for a complete cure.

This disease has similar symptoms to other diseases, for example, palate paresis, and therefore you need to be able to correctly diagnose the disease in time in order to prescribe the correct treatment.

Since this disease has a fairly wide range of causes, it poses a danger to life and for the normal functioning of the body it must be taken quite seriously, and not delay or neglect the treatment prescribed by a specialist.

Gradually developing dysfunction of the bulbar group of the caudal cranial nerves, caused by damage to their nuclei and/or roots. A triad of symptoms is characteristic: dysphagia, dysarthria, dysphonia. The diagnosis is made based on examination of the patient. Additional examinations (cerebrospinal fluid analysis, CT, MRI) are carried out to determine the underlying pathology that caused the bulbar palsy. Treatment is prescribed in accordance with the causative disease and existing symptoms. Urgent measures may be required: resuscitation, mechanical ventilation, combating heart failure and vascular disorders.

General information

Bulbar palsy occurs when the nuclei and/or roots of the bulbar group of cranial nerves located in the medulla oblongata are damaged. The bulbar nerves include the glossopharyngeal (IX pair), vagus (X pair) and hypoglossal (XII pair) nerves. The glossopharyngeal nerve innervates the muscles of the pharynx and provides its sensitivity, is responsible for the taste sensations of the posterior 1/3 of the tongue, and provides parasympathetic innervation to the parotid gland. The vagus nerve innervates the muscles of the pharynx, soft palate, larynx, upper digestive tract and respiratory tract; gives parasympathetic innervation of internal organs (bronchi, heart, gastrointestinal tract). The hypoglossal nerve provides innervation to the muscles of the tongue.

The cause of bulbar palsy may be chronic cerebral ischemia, which develops as a result of atherosclerosis or chronic vascular spasm in hypertension. Rare factors causing damage to the bulbar group of cranial nerves include craniovertebral anomalies (primarily Chiari malformation) and severe polyneuropathies (Guillain-Barré syndrome).

Symptoms of progressive bulbar palsy

The clinical manifestations of bulbar palsy are based on peripheral paresis of the muscles of the pharynx, larynx and tongue, which results in disturbances in swallowing and speech. The basic clinical symptom complex is a triad of signs: swallowing disorder (dysphagia), impaired articulation (dysarthria) and speech sonority (dysphonia). Difficulty swallowing food begins with difficulty taking liquids. Due to paresis of the soft palate, fluid from the oral cavity enters the nose. Then, with a decrease in the pharyngeal reflex, swallowing disorders of solid foods develop. Limitation of tongue mobility leads to difficulty chewing food and moving the food bolus in the mouth. Bulbar dysarthria is characterized by slurred speech and a lack of clarity in the pronunciation of sounds, which is why the patient’s speech becomes incomprehensible to others. Dysphonia manifests itself as hoarseness of voice. Nasolalia (nasality) is noted.

The patient's appearance is characteristic: the face is hypomimic, the mouth is open, there is drooling, difficulty chewing and swallowing food, and food falling out of the mouth. Due to damage to the vagus nerve and disruption of the parasympathetic innervation of somatic organs, disorders of respiratory function, heart rate and vascular tone occur. These are the most dangerous manifestations of bulbar palsy, since often progressive respiratory or heart failure causes the death of patients.

When examining the oral cavity, atrophic changes in the tongue, its folding and unevenness are noted, and fascicular contractions of the tongue muscles may be observed. The pharyngeal and palatal reflexes are sharply reduced or not evoked. Unilateral progressive bulbar palsy is accompanied by drooping of half of the soft palate and deviation of its uvula to the healthy side, atrophic changes in 1/2 of the tongue, deviation of the tongue towards the affected side when it protrudes. With bilateral bulbar palsy, glossoplegia is observed - complete immobility of the tongue.

Diagnostics

A neurologist can diagnose bulbar palsy by carefully studying the patient’s neurological status. The study of the function of the bulbar nerves includes assessment of the speed and intelligibility of speech, timbre of voice, volume of salivation; examination of the tongue for the presence of atrophies and fasciculations, assessment of its mobility; examination of the soft palate and checking the pharyngeal reflex. It is important to determine the frequency of breathing and heart contractions, and study the pulse to detect arrhythmia. Laryngoscopy allows you to determine the lack of complete closure of the vocal cords.

During diagnosis, progressive bulbar palsy must be distinguished from pseudobulbar palsy. The latter occurs with supranuclear damage to the corticobulbar tracts connecting the nuclei of the medulla oblongata with the cerebral cortex. Pseudobulbar palsy is manifested by central paresis of the muscles of the larynx, pharynx and tongue with hyperreflexia (increased pharyngeal and palatal reflexes) and increased muscle tone characteristic of all central paresis. Clinically it differs from bulbar palsy in the absence of atrophic changes in the tongue and the presence of oral automatism reflexes. Often accompanied by violent laughter resulting from spastic contraction of the facial muscles.

In addition to pseudobulbar palsy, progressive bulbar palsy requires differentiation from psychogenic dysphagia and dysphonia, various diseases with primary muscular damage causing myopathic paresis of the larynx and pharynx (myasthenia gravis, Rossolimo-Steinert-Kurshman myotonia, paroxysmal myoplegia, oculopharyngeal myopathy). It is also necessary to diagnose the underlying disease that led to the development of bulbar syndrome. For this purpose, a study of cerebrospinal fluid, CT and MRI of the brain is carried out. Tomographic studies make it possible to visualize brain tumors, demyelination zones, cerebral cysts, intracerebral hematomas, cerebral edema, displacement of cerebral structures during dislocation syndrome. CT or radiography of the craniovertebral junction can reveal abnormalities or post-traumatic changes in this area.

Treatment of progressive bulbar palsy

Treatment tactics for bulbar palsy are based on the underlying disease and leading symptoms. In case of infectious pathology, etiotropic therapy is carried out; in case of cerebral edema, decongestant diuretics are prescribed; in case of tumor processes, the issue of removing the tumor or performing shunt surgery to prevent dislocation syndrome is decided together with a neurosurgeon.

Unfortunately, many diseases in which bulbar syndrome occurs are a progressive degenerative process occurring in cerebral tissues and do not have effective specific treatment. In such cases, symptomatic therapy is carried out to support the vital functions of the body. Thus, in case of severe respiratory disorders, tracheal intubation is performed and the patient is connected to a ventilator; in case of severe dysphagia, tube feeding is provided; vascular disorders are corrected with the help of vasoactive drugs and infusion therapy. To reduce dysphagia, neostigmine, ATP, and vitamins are prescribed. B, glutamic acid; for hypersalivation - atropine.

Forecast

Progressive bulbar palsy has a highly variable prognosis. On the one hand, patients may die from cardiac or respiratory failure. On the other hand, with successful treatment of the underlying disease (for example, encephalitis), in most cases, patients recover with complete restoration of swallowing and speech function. Due to the lack of effective pathogenetic therapy, bulbar palsy associated with progressive degenerative damage to the central nervous system (with multiple sclerosis, ALS, etc.) has an unfavorable prognosis.

Diphtheria croup

Diphtheria tonsils

Parotitis.

Orchiepididymitis

Herpes zoster.

Streptococcal impetigo.

Dühring's dermatosis herpeptiformis.

Pemphigus.

Simple herpes.

19. A 10-year-old patient suffered from mumps the day before, after which pain appeared in the right half of the scrotum radiating to the groin area, enlargement of the right half of the scrotum, hyperemia of the scrotum, and an increase in body temperature to 38°C. The testicle on the right is large in size, densely elastic in consistency, and sharply painful. The scrotum is hyperemic and edematous. The left testicle is at the bottom of the scrotum, painless. What is the most likely diagnosis?

Testicular torsion.

Testicular tumor.

Acute hydrocele of the testicle.

Torsion of Morgagni's hydatid.

20. A 4-year-old child was examined by a local pediatrician. Complaints of pain when chewing, opening the mouth, headache, increased body temperature up to 38.9°C. In the areas of the parotid salivary glands, a swelling is contoured, moderately painful on palpation, the skin over the swelling is not changed. When examining the oropharynx, the opening of the Stenon's duct is hyperemic. What is the most likely diagnosis in this case?

Cervical lymphadenitis.

Sialadenitis.

Diphtheria of the tonsils.

Infectious mononucleosis.

21. A 12-year-old patient fell ill acutely with a rise in T to 37.8°C, a slight sore throat, and malaise. On examination, there is cyanotic hyperemia in the pharynx, islands of white-gray plaque on the tonsils, difficult to remove with a staple, with bleeding of the underlying tissue of the tonsils when trying to remove them. The submandibular lymph nodes are slightly painful. To diagnose:

Infectious mononucleosis

Follicular tonsillitis

Simanovsky-Rauchfuss' sore throat

Fungal tonsillitis

22. A 1.5-year-old patient fell ill with a rise in T to 37.5°C and a rough cough. By the end of the day, the voice became hoarse, the cough intensified, and acquired a “barking” character. By the 3rd day of illness, the condition worsened: noisy, rapid breathing appeared with stretching of the pliable parts of the chest. The voice became aphonic, the cough was silent, the pulse was paradoxical. The skin is cold, sticky, moist, and acrocyanosis is pronounced. Make a clinical diagnosis.

Retropharyngeal abscess

False croup

Foreign body of the larynx

Laryngeal papillomatosis

23. A 9-year-old patient with diphtheria of the tonsils developed a nasal voice on the 11th day of illness, liquid food poured out of the nose, the soft palate had limited mobility, there was cyanotic hyperemia in the pharynx, and there were no plaques on the tonsils.

What causes the nasopharynx lesion in the patient?

Retropharyngeal abscess

Peritonsillar abscess

Diphtheria croup

Adenoids

24. A 4-year-old patient was admitted to the infectious diseases department with a diagnosis of “membranous tonsillitis.” By the 3rd day of hospital stay, the condition improved, positive dynamics of changes in the pharynx were noted. Diphtheria bacillus was isolated in the culture of mucus from the pharynx. What laboratory test is necessary for the final diagnosis?

Rhinolalia

For the most part, fathers and mothers believe that rhinolalia This applies only to those cases where the child has the so-called “cleft palate” (congenital cleft of the hard and soft palate) or “cleft lip” (cleft lip and upper jaw). But the concept of “rhinolalia” (in common parlance – “nasality”) is much broader. We will try to cover this phenomenon in as much detail as possible.

1. What is rhinolalia?

From a scientific point of view rhinolalia- this is a change in voice timbre, which is accompanied by distortion of sound pronunciation due to a violation of the resonator function of the nasal cavity. As a result of these violations, the air stream goes the “wrong way”, and the sounds acquire a “nasal” tint:

The air stream can be directed into the nose for almost all speech sounds. In this case they talk about open rhinolalia (these are the same “cleft palate”, “cleft lip”, or cleft palate and lip as a result of craniofacial injuries);

• During phonation, air flows only through the oral cavity, even when pronouncing nasal sounds. Then we are dealing with closed rhinolalia (it occurs as a result of obstruction of the nasal cavity or nasopharynx: adenoid growths, deviated nasal septum, craniofacial injuries, etc.). This defect in speech therapy also has a name rhinophony (palatophony).
• Is there some more mixed This is when, with nasal obstruction, there is also an insufficient velopharyngeal seal. In this case, the nasal resonance decreases (for nasal phonemes [n], [n"], [m], [m"]), while simultaneously distorting the remaining phonemes of the language (not nasal!), the timbre of which becomes like open rhinolalia.

2. Congenital open rhinolalia

Common sign of open rhinolalia : the passage into the nasal cavity is open for one reason or another (the oral and nasal cavities are, as it were, a single whole), as a result of which most sounds are pronounced with a nasal connotation. Most often this occurs with congenital cleft of the upper lip, hard and soft palate.

Congenital defects of the upper lip:

No skin deformation

Hidden cleft lip section of the nasal cavity;

Incomplete cleft of the upper lip without skin deformationbut-cartilaginous part of the nasal cavity;

Incomplete cleft lipwith deformation of the skin-cartilaginoussection of the nasal cavity;

Full cleft upper lip with deformation of the skin-cartilaginoussection of the nasal cavity.

Congenital defects of the hard palate:

Incomplete cleft of the hard palate;

Complete cleft of the hard palate;

Sumbucous (hidden) cleft of the hard palate.

Congenital defects of the soft palate:

Bifurcation of the small tongue-uvula (uvula);

Absence of a small uvula;

Sumbucous (hidden) cleft of the soft palate

Complete unilateral clefts:

- complete unilateral alveolar cleft

- complete unilateral cleft of the upper lip, alveolar ridgetissue and anterior part of the hard palate;

Complete unilateral alveolar cleft

Complete unilateral cleft of the upper lip, alveolar ridge

Complete bilateral clefts:

Complete bilateral cleft of the upper lip, alveolar process and anterior hard palate;

- tissue and anterior part of the hard palate;

- complete bilateral alveolar clefttissue, hard and soft palate;

Complete bilateral cleft of the upper lip, alveolar ridgetissue, hard and soft palate.

All of the above defects in the structure of a child’s speech apparatus are difficult to miss. The only difficult thing to diagnose is sumbucose (submucosa) cleft : it is when The oral and nasal cavities are separated from each other only by a thin mucous membrane (film). To identify this cleft, it is necessary to do a test in which special attention is paid toblows on the back surface of the soft palate. Pwhen pronouncing the sound [a] in an exaggerated manner (with a wide openwith your mouth!), the mucous membrane of the palate is pulled upward in the form of a triangleNick, it is thinned and has a paler (whitish) color.

3. Congenital open rhinolalia and accompanying disorders

A rhinolalic child has a very peculiar position of the tongue in the oral cavity. You can observe how the entire tongue is pulled back (it seems to “sink” into the throat), while the root and back of the tongue are “turned up” high, which is due to increased muscle tone in these parts of the tongue. At the same time, the tip of the tongue is usually poorly developed, it is flaccid (paretic). The reason for such dramatic changes in language is that children experience feeding difficulties from the very first days of life. And this position of the tongue is a kind of adaptation to the pathological condition of the nasopharynx. A rhinolalic baby sucks with the root of his tongue, strongly straining his facial muscles. In the future, these difficulties persist: the baby instinctively holds the root of the tongue up, covering the cleft with it when feeding and breathing. The root of the tongue becomes increasingly hypertrophied (enlarged), the tip of the tongue becomes even weaker and passively retracts deeper into the oral cavity. Only elementary, undifferentiated movements of the tongue become available to the child. Therefore, his first words appear very late (around three years), but they are difficult to understand due to the strong distortion of sounds and the nasal tone of his voice.

Significant disturbances are also observed in the soft palate. His movements are defective not only during speech phonation, but also during the acts of chewing and swallowing. The soft palate does not fulfill its main function: it does not separate the nasal and oral cavities (its closure with the back wall of the pharynx is impossible!).

It should be noted that inhalation through a cleft causes frequent colds in such children. Their lung ventilation is significantly impaired, hence the general physical weakness. Quite often, hearing loss is detected in people with rhinolitis (due to chronic otitis media, inflammation of the Eustachian tube, cochlear neuritis).

Due to hearing loss and defective articulation, children with open rhinolalia experience underdevelopment of phonemic hearing (hearing for individual sounds of a language), which in turn leads to difficulties in mastering the sound structure of words. This entails underdevelopment of the lexical and grammatical structure of speech and ends with the final chord - general speech underdevelopment (ONR), in other words, a significant delay in speech development. Hence: fear of speech, speech negativity, neuroses and other “bouquet” of concomitant diseases at an early age.

With congenital organic rhinolalia, the interaction of the muscles of the entire peripheral part of the speech-motor apparatus is not coordinated. There are disturbances in the articulatory and facial muscles: violent, exaggerated movements. Synkinesis is observed both in the speech apparatus and in the muscles of the hands. In some cases, tic-like movements (twitching) of the facial muscles can be observed. The synchronicity in the interaction of the articulatory and respiratory apparatus is also disturbed.

Speech breathing with rhinolalia is most often superficial and rapid. Speech exhalation is uneven, it is abrupt and can be made in the middle of a word or phrase, which is why speech takes on a “chopped” character.

We have already said that with organic open rhinolalia, all sounds are pronounced with a nasal connotation. Vowel sounds are most affected because they require the strongest velopharyngeal seal. The articulation of consonant sounds moves to the root of the tongue, the sounds are distorted and acquire a hoarse (guttural) tone. Rhinolalic speech is characterized by a large number of sound substitutions, and the substitute sounds are also distorted. The most often impaired pronunciation of consonant sounds that require high oral pressure: plosives [p], [b], [t], [d]; labial-dental [v], [f], all whistling and hissing, sonors [l], [r]. It takes more than one year for a child with rhinolalic to produce sounds.

4. Surgical treatment of children with open rhinolalia.

Open congenital rhinolalia requires comprehensive medical, pedagogical and orthodontic approaches. At the earliest stages it is required orthodontic closing the defect of the hard and soft palate with a temporary obturator. A soft rubber obturator is especially necessary when feeding a baby. The rigid obturator is made individually and is worn by the child until surgical closure of the defect in the bottom of the nasal cavity and the velum palatine. It is removed approximately 14 days before the planned operation. Surgical treatment of rhinolalia is carried out in several stages.

Cheiloplasty (surgery to reconstruct the upper lip) and uranoplasty (operations to restore the integrity of the bottom of the nasal cavity) are indicated even for newborns. But! There are a number of contraindications for performing them at such an early age ( anemia, pneumonia, acute respiratory viral infection, intrauterine malnutrition, birth trauma, asphyxia, prematurity, congenital heart defects, spina bifida, fistulas in the digestive tract, hypoplasia, pulmonary aplasia, the presence of other severe malformations).

Uranoplasty methods are different. Gentle uranoplasty It is carried out for children from one and a half years old, provided there are no contraindications (see above).

The most successful way to restore the anatomical structure of the nasopharynx is radical uranoplasty . It is quite traumatic and technically complex. For children from 3 to 5 years old, non-through clefts are corrected with its help, and at the age of 5-6 years, through clefts (unilateral and bilateral) are corrected. It is not recommended to perform radical uranoplasty in early childhood (up to 3 years), since this surgical intervention often provokes slow growth of the lower jaw.

Uranoplasty using the method of A. A. Limberg most effective for correcting the cleft palate defect. According to this technique, the formation of the integrity of the palate occurs due to mucoperiosteal flaps and tissues of the soft palate. Some elements of this technique are used when performing less traumatic methods of uranoplasty. In its classical form, the Limberg method is not used in young children.

5. Acquired open rhinolalia (rhinophonia).

Acquired open rhinolalia (rhinophonia) , - a consequence of complications after removal of the tonsils (tonsillectomy), operations on the throat, larynx and nasopharynx (tumors, polyps, etc.); residual effects after burns and injuries of the throat, larynx and nasopharynx. The results of all this could be:

Scars of the soft palate;

Paresis, paralysis of the soft palate;

Shortening of the soft palate;

Fistulas and clefts of the soft and hard palate

As a result, the soft palate, when pronouncing sounds, lags far behind the back wall of the pharynx, leaving a significant gap; it is not able to perform the function of a valve and is not able to block the air path, as a result of which a significant part of it enters the nasal cavity. In a word, everything is very similar to congenital organic rhinolalia.

6. Functional open rhinolalia (rhinophonia)

This form of rhinolalia can occur during hysteria. In this case, a temporary stressful nasal tone occurs due to incoming hysterical paralysis.

Functional open rhinolalia (rhinophonia) can occur after organic open rhinolalia has been overcome. Uranoplasty was performed, the mobility of the soft palate was restored, but the voice is still “nasal”! In this case, the soft palate is lowered “out of habit.” And this habit must be eliminated with the help of comprehensive speech therapy sessions.

Functional open rhinolalia is much less common than organic rhinolalia.

7.

Closed rhinolalia (rhinophonia) - a consequence of obstruction of the nasal passages (polyps, deviated nasal septum, chronic rhinitis). In this case, only the tone of the voice suffers, but the pronunciation and phonetic aspects of speech remain intact. Closed rhinolalia (rhinophonia) is formed with reduced physiological nasal resonance during the pronunciation of phonemes. In this case, the sounds [m], [m"], [n], [n’] sound, respectively, like [b], [b"], [d], [d’]. One of the external signs of closed rhinolalia (rhinophonia) is a child’s constantly open mouth.

In other words, the causes of closed rhinolalia (rhinophonia) are organic changes in the nasal or nasopharyngeal region or functional disorders of the nasopharyngeal seal. In this regard, the following are highlighted:

- organic closed rhinolalia (rhinophonia);

- functional closed rhinolalia (rhinophonia).

Closed organic rhinolalia is divided into

• back;
• front

(back) may be a consequence of adenoid growths that cover:

Upper edge of the choanae;

Half of the choanae or one of them;

Both choanae with filling of the entire nasopharynx with adenoid tissue.

Closed Organic Rhinolalia (back) can develop as a result of fusion of the soft palate with the posterior wall of the pharynx after inflammation, sometimes due to nasopharyngeal polyps, fibroids or other nasopharyngeal tumors. Very rare congenital choanal atresia , which completely separates the nasopharyngeal cavity from the nasal cavity.

Closed Organic Rhinolalia (front) is observed:

With significant curvature of the nasal septum;

If you have nasal polyps;

With a severe runny nose.

She may be transient(with inflammatory swelling of the nasal mucosa during a runny nose, allergic rhinitis) and long-term(for chronic hypertrophy of the nasal mucosa, for polyps, for deviated nasal septum, for tumors of the nasal cavity). Anterior closed rhinolalia, in other words, is obstruction of the nasal cavities.

Closed functional rhinolalia (rhinophonia) very common in children. She is also called habitual closed rhinophony. The child has narrow nasal passages, he is susceptible to frequent colds and allergies, and his nasal mucosa periodically becomes inflamed. But even when all of the above symptoms are eliminated and the nasal passages seem to be free, the child continues to “nasally”: he is accustomed to the fact that his nose is “clogged.” With functional rhinophony, the timbre of nasal (nasal) and vowel sounds can be disrupted even more than with organic forms of rhinolalia (rhinophonia).

8. What kind of rhinolalia (rhinophonia) does the child have?

You can determine whether a child has rhinolalia (rhinophonia): closed or open:

• by ear (it is quite difficult not to hear the “nasal” tone of the voice, and even more so not to notice an obvious cleft lip or palate!);
• using a mirror.

Let's look at the last method in more detail. If, when pronouncing vowel sounds (a, u, o, i), a mirror brought to the nose fogs up, it means that the child has - open twang. If, when pronouncing words with nasal sounds (mama, mine, car, etc.), a mirror brought to the nose does not fog up - closed.

9. How to distinguish paresis (paralysis) of the soft palate from functional nasality?

It is important to distinguish paresis (paralysis) of the soft palate from functional (habitual) nasality. You can do this in the following ways:

The child opens his mouth wide. The speech therapist (parent) presses with a spatula (the handle of a spoon) on the root of the tongue. If the soft palate reflexively rises to the back wall of the pharynx, we can talk about functional nasality, but if the palate remains motionless, there is no doubt that the nasality is of organic origin (paresis or paralysis of the soft palate).

The child lies on his back and says some phrase in this position. If the nasal sound disappears, then we can assume paresis (paralysis) of the soft palate (the nasal sound disappears due to the fact that when lying on the back, the soft palate passively falls to the back wall of the pharynx).

10. Eliminating nasal tone of voice with massage and exercises

First of all, you will need to activate the soft palate and make it move. For this you will need special massage . If the child is too small, adults do the massage:

1) with a clean, alcohol-treated index finger (pad) of the right hand, in the transverse direction, stroking and rubbing the mucous membrane at the border of the hard and soft palate (in this case, a reflex contraction of the muscles of the pharynx and soft palate occurs);

2) the same movements are made when the child pronounces the sound “a”;

3) make zigzag movements along the border of the hard and soft palate from left to right and in the opposite direction (several times);

4) with your index finger, perform acupressure and jerk-like massage of the soft palate near the border with the hard palate.

If the child is already big enough, then he can do all these massage techniques himself: the tip of the tongue will cope with this task perfectly. It is important to correctly show how all this is done. Therefore, you will need a mirror and the interested participation of an adult. First, the child performs massage with the tongue with his mouth wide open, and then, when there are no more problems with self-massage, he will be able to perform it with his mouth closed, and completely unnoticed by others. This is very important, because the more often the massage is performed, the sooner the result will appear.

When performing a massage, you must remember that you can cause a gag reflex in a child, so do not massage immediately after eating: there should be at least an hour break between meals and massage. Be extremely careful and avoid rough touches. Do not massage if you have long nails: they can damage the delicate mucous membrane of the palate.

In addition to massage, the soft palate will also need special gymnastics. Here are some exercises:

1) the child is given a glass of warm boiled water and asked to drink it in small sips;

2) the child gargles with warm boiled water in small portions;

3) exaggerated coughing with the mouth wide open: at least 2-3 coughs on one exhalation;

4) yawning and imitation of yawning with the mouth wide open;

5) pronouncing vowel sounds: “a”, “u”, “o”, “e”, “i”, “s” energetically and somewhat exaggerated, on the so-called “hard attack”.

11. Restoring breathing

First of all, it is necessary to eliminate the causes: carry out appropriate operations, get rid of adenoids, polyps, fibroids, deviated nasal septum, inflammatory swelling of the nasal mucosa with a runny nose and allergic rhinitis, and only then restore proper physiological and speech breathing.

It can be difficult, and sometimes even uninteresting, for a small child to perform exercises just for demonstration. Therefore, use gaming techniques, come up with fairy-tale stories, for example these:

“Ventilating the cave”

The tongue lives in a cave. Like any room, it must be ventilated often, because the air to breathe must be clean! There are several ways to ventilate:

Inhale air through your nose and exhale slowly through your wide open mouth (and so on at least 5 times);

Inhale through the mouth and exhale slowly through an open mouth (at least 5 times);

Inhale and exhale through your nose (at least 5 times);

Inhale through your nose, exhale through your mouth (at least 5 times).

"Snowstorm"

An adult ties pieces of cotton wool onto strings and fastens the free ends of the threads onto his fingers, thus making five strings with cotton balls at the ends. The hand is held at the level of the child’s face at a distance of 20–30 centimeters. The baby blows on the balls, they spin and deviate. The more these impromptu snowflakes spin, the better.

"Wind"

This is done in the same way as the previous exercise, but instead of threads with cotton wool, a sheet of paper is used, cut with a fringe at the bottom (remember, such paper was once attached to the windows to repel flies?). The child blows on the fringe, it deviates. The more horizontal the strips of paper take, the better.

"Ball"

Tongue's favorite toy is a ball. It's so big and round! He's so much fun to play with! (The child puffs out his cheeks as much as possible. Make sure that both cheeks puff out evenly!)

“The ball deflated!”

After prolonged games, the tongue's ball loses its roundness: air comes out of it. (The child first strongly inflates his cheeks, and then slowly exhales air through his rounded and elongated lips.)

"Pump"

The ball has to be inflated using a pump. (The child’s hands perform the appropriate movements. At the same time, he himself pronounces the sound “s-s-s-..." often and abruptly: the lips are stretched in a smile, the teeth are almost clenched, and the tip of the tongue rests against the base of the lower front teeth. The air comes out of the mouth strongly pushes).

"The tongue plays football."

Tongue loves to play football. He especially likes scoring goals from the penalty spot. (Place two cubes on the side of the table opposite from the child. This is an improvised goal. Place a piece of cotton wool on the table in front of the child. The baby “scores goals” by blowing from a wide tongue inserted between his lips onto a cotton swab, trying to “bring” it to the goal and get into them. Make sure that your cheeks do not swell and the air flows down the middle of your tongue.)

When performing this exercise, you need to make sure that the child does not accidentally inhale the cotton wool and choke.

"The tongue plays the pipe"

Tongue also knows how to play the pipe. The melody is almost inaudible, but you can feel a strong stream of air escaping from the hole in the pipe. (The child rolls a tube from his tongue and blows into it. The child checks the presence of a stream of air on his palm).

"Block and Key"

Does your child know the fairy tale “Three Fat Men”? If so, then he probably remembers how the girl gymnast Suok played a wonderful melody on the key. The child tries to repeat this. (An adult shows how to whistle into a hollow key).

If you don’t have a key at hand, you can use a clean, empty bottle (pharmacy or perfume) with a narrow neck. When working with glass vials, you must be extremely careful: the edges of the bubble should not be chipped or sharp. And one more thing: watch carefully so that the child does not accidentally break the bottle and get hurt.

As breathing exercises, you can also use playing children's musical wind instruments: pipe, harmonica, bugle, trumpet. And also inflating balloons, rubber toys, balls.

All of the above breathing exercises should only be performed in the presence of adults! Remember that when doing exercises, your child may become dizzy, so carefully monitor his condition, and stop the activity at the slightest sign of fatigue.

12. Articulation exercises for rhinolalia

For open and closed rhinolalia, it can be very useful to perform articulation exercises for the tongue, lips and cheeks. You can find some of these exercises on the pages of our website in the sections “Classical articulation gymnastics”, “Fairy tales from the life of Tongue”.

Here are a few more. They are designed to activate the tip of the tongue:

1) “Liana”: hang your long, narrow tongue down toward your chin and hold in this position for at least 5 seconds (repeat the exercise several times).

2) “Boa constrictor”: slowly stick your long and narrow tongue out of your mouth (do the exercise several times).

3) “Boa Tongue”: With a long and narrow tongue, sticking out as much as possible from the mouth, make several quick oscillatory movements from side to side (from one corner of the mouth to the other).

4) “Watch”: the mouth is wide open, the narrow tongue makes circular movements, like the hand of a clock, touching the lips (first in one direction and then in the other direction).

5) "Pendulum": the mouth is open, a narrow long tongue is protruding from the mouth, and moves from side to side (from one corner of the mouth to the other) counting “one - two”.

6) “Swing”: the mouth is open, the long narrow tongue either rises up to the nose, then falls down to the chin, counting “one or two.”

7) "Injection": a narrow long tongue from the inside presses on one or the other cheek.

13. Conclusion.

The production and automation of sounds in a child with rhinoplasty must be carried out in close collaboration with a speech therapist. In general, the rehabilitation course for rhinolalia is quite long, so you can’t expect immediate results.

Soft sky(lat. - palatum molle) is a muscular aponeurotic formation that can change its position, separating the nasopharynx from the oropharynx when the muscles that form it contract.

In humans, five pairs of muscles control the shape and position of the soft palate: the tensor veli palatini muscle, the levator veli palatini muscle, the uvula muscle, the palatoglossus muscle (m. palatoglossus) and palatopharyngeal muscles (m. palatopharyngeus).

The soft palate is innervated by three nerves: the vagus - innervates the muscles of the soft palate, trigeminal and, partially, glossopharyngeal - innervates the mucous membrane of the soft palate. Only the muscle that tenses the soft palate receives double innervation - from the vagus nerve and the third branch of the trigeminal nerve.

Paresis of the soft palate clinically characterized by disturbances in the processes of swallowing, breathing, speech formation, and ventilation of the auditory tube. Paralysis of the muscles of the soft palate leads to the flow of liquid food into the cavity of the nasopharynx and nose, dysphagia. Speech acquires a nasal nasal tone, as sounds resonate in the nasopharynx, and excessive use of the nasal cavity as a resonator occurs (hypernasality), manifested in excessive nasalization of vowel sounds.

With a unilateral lesion, the soft palate hangs down on the affected side, is immobile or lags behind on the same side when pronouncing the sound “a”. The tongue deviates to the healthy side. The pharyngeal and palatal reflexes are reduced on the affected side, anesthesia of the mucous membrane of the soft palate and pharynx develops.

Mild bilateral symmetrical paresis is manifested by the periodic appearance of slight difficulty when swallowing dry food, and a slight nasal tone of the voice is also noted.

note: impaired phonation with paresis of the soft palate usually occurs earlier and is more pronounced than impaired swallowing.

To diagnose the initial stage of paresis of the soft palate, a number of simple tests are proposed:

1 - with paresis of the soft palate, inflation of the cheeks is not possible;
2 - the patient is asked to pronounce the vowels “a - y” with a strong emphasis on them, first with open nostrils, and then with closed; the slightest difference in sound indicates insufficient shutdown of the oral cavity and nose by the palatal curtain.

The nature of paresis of the soft palate can be inflammatory-infectious in nature (damage to the nuclei and fibers of the cranial nerves in polio, diphtheria, etc.); congenital, caused by a developmental defect; ischemic- in case of cerebral circulation disorders in the vertebrobasilar system; traumatic, resulting from domestic trauma, trauma during intubation, mucus suction, probing and endoscopy, and trauma during adenectomy and tonsillectomy; Idiopathic paresis of the soft palate is also distinguished as an isolated clinical syndrome that occurs acutely after acute respiratory viral infection, often unilateral.