International SYMPOSIUM on OROFACIAL MYOFUNCTIONAL Therapy roma 6,7,8 giugno 2014

1. RELATION BETWEEN TONSILLAR HYPERTROPHY,
DISFUNCTIONAL SWALLOWING
AND DENTAL MALOCCLUSION
Ventosa Y. (SLP), Grandi D. (MS-SLP) & Albertí A. (ENT) - SPAIN.
Introduction
The main objective of this poster is to increase awareness of the importance of early detection
and interdisciplinary approach for orofacial dysfunctions and to promote the correct detection
and evaluation of tonsillar hypertrophy and so to avoid or minimize stomatognatic system
dysfunction and alteration.
At present there is controversy regarding the type of approach necessitated by the
presence of tonsillar hypertrophy. Different disciplines do not always share the same
criteria for the indication of tonsillectomy or techniques for tonsillar reduction. ENTs and
paediatricians give more importance to infectious and obstructive aspects and they generally
do not have in mind the muscular and functional consequences that the tonsils can produce in
the stomatognatic system.
However, SLPs specializing in Orofacial Motricity, and odontopaediatricians and orthodontists
with a more functional orientation consider the possibility of conducting a surgical intervention
in cases where they detect orofacial myofunctional imbalances and/or malocclusion. This
criterion results when the degree of tonsillar hypertrophy alters correct at rest lingual position
and also impedes the correct functioning of the stomatognatic system, in which case the
favourable evolution of orthodontic and speech language therapy treatment would be
compromised.
Material
and
methods
In this poster, we see the relationship between tonsillar hypertrophy, dysfunctional swallowing
and dental malocclusion, according to data collected through the application of the
Interdisciplinary Orofacial Examination Protocol for Children and Adolescents (Bottini
E., Carrasco A., Coromina J., Donato G., Echarri P., Grandi D., Lapytz L. y Vila E.;
Barcelona, 2008) from a group of 115 children aged 4 to 16 years who solicited the aid of an
SLP in Catalonia.
!
CHILDREN’s
QUANTITY
in
rela7on
to
AGE
-­‐
Xy=X
years
(n=115)
The principle variable studied was the presence of hypertrophic
tonsils (following the classification method of Duran Von Arx, J.)
Malocclusion (Angle)
Class I (Normal) Class II/1 Class II/2 Class III
Lips
Lip contact in rest
Tonsils
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Inferior lingual frenum (Ask patient to lift his/her tongue with the completely open mouth, and to try to touch his/her palate)
Previous
tonsillectomy
Very small
tonsils (< 25%)
No visible tonsils Tonsils occupy 1/3
of pharyngeal space
(25% - 50%)
Tonsils occupy 2/3
of pharyngeal space
(50% - 75%)
Tonsils occupy 3/3
of pharyngeal space
(>75%)
6
7
8
Dry or chapped lipsNo lip contact in rest
Bite Occlusion
Anterior deep bite
Alignment
Normal Spacing Crowding
Swallowing
Tongue thrust or lip thrust while swallowing
Posture alterations
Normal position Lordosis Cyphosis
Lumbar curvature
increased
Curved back, reduced
lumbar curvature
shoulders dropped,
flat thorax and
prominent abdomen
9
10
11
12
Recommended assessment by:
ENT Orthodontist Speech therapist Odontopediatrician
14
Open bite Crossbite (uni./bilat.)Normal bite
Normal Makes faces while swallowing
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Frenectomy Tongue tip
touches the palate
Almost touches
the palate
The distance between
the upper and lower
incisors is the same
Reaches
lower incisors
Doesn’t reach
lower incisors
5
13 Adenoids:
Phonetical test
(morning)
Positive (different)
Negative (same)
Endoscopy (only ENT)
No obstruction
Partial obstruction
Profile X-ray (only orthodontists) Severe obstruction
Thereafter, this variable was related to the presence of dental malocclusion, (Angel’s Class II
and Class III, Open Bite, Cross Bite, Deep Bite), and manifestations of altered Swallowing
(presence of grimace when swallowing and/or lip/tongue interposition); aspects evaluated
following the Protocol mentioned.
Malocclusion (Angle)
Class I (Normal) Class II/1 Class II/2 Class III
Lips
Lip contact in rest
Tonsils
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Inferior lingual frenum (Ask patient to lift his/her tongue with the completely open mouth, and to try to touch his/her palate)
Previous
tonsillectomy
Very small
tonsils (< 25%)
No visible tonsils Tonsils occupy 1/3
of pharyngeal space
(25% - 50%)
Tonsils occupy 2/3
of pharyngeal space
(50% - 75%)
Tonsils occupy 3/3
of pharyngeal space
(>75%)
6
7
8
Dry or chapped lipsNo lip contact in rest
Bite Occlusion
Anterior deep bite
Alignment
Normal Spacing Crowding
Swallowing
Tongue thrust or lip thrust while swallowing
Posture alterations
Normal position Lordosis Cyphosis
Lumbar curvature
increased
Curved back, reduced
lumbar curvature
shoulders dropped,
flat thorax and
prominent abdomen
9
10
11
12
Recommended assessment by:
ENT Orthodontist Speech therapist Odontopediatrician
14
Open bite Crossbite (uni./bilat.)Normal bite
Normal Makes faces while swallowing
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Frenectomy Tongue tip
touches the palate
Almost touches
the palate
The distance between
the upper and lower
incisors is the same
Reaches
lower incisors
Doesn’t reach
lower incisors
5
13 Adenoids:
Phonetical test
(morning)
Positive (different)
Negative (same)
Endoscopy (only ENT)
No obstruction
Partial obstruction
Profile X-ray (only orthodontists) Severe obstruction
Malocclusion (Angle)
Class I (Normal) Class II/1 Class II/2 Class III
Lips
Lip contact in rest
Tonsils
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Inferior lingual frenum (Ask patient to lift his/her tongue with the completely open mouth, and to try to touch his/her palate)
Previous
tonsillectomy
Very small
tonsils (< 25%)
No visible tonsils Tonsils occupy 1/3
of pharyngeal space
(25% - 50%)
Tonsils occupy 2/3
of pharyngeal space
(50% - 75%)
Tonsils occupy 3/3
of pharyngeal space
(>75%)
6
7
8
Dry or chapped lipsNo lip contact in rest
Bite Occlusion
Anterior deep bite
Alignment
Normal Spacing Crowding
Swallowing
Tongue thrust or lip thrust while swallowing
Posture alterations
Normal position Lordosis Cyphosis
Lumbar curvature
increased
Curved back, reduced
lumbar curvature
shoulders dropped,
flat thorax and
prominent abdomen
9
10
11
12
Recommended assessment by:
ENT Orthodontist Speech therapist Odontopediatrician
14
Open bite Crossbite (uni./bilat.)Normal bite
Normal Makes faces while swallowing
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
Frenectomy Tongue tip
touches the palate
Almost touches
the palate
The distance between
the upper and lower
incisors is the same
Reaches
lower incisors
Doesn’t reach
lower incisors
5
13 Adenoids:
Phonetical test
(morning)
Positive (different)
Negative (same)
Endoscopy (only ENT)
No obstruction
Partial obstruction
Profile X-ray (only orthodontists) Severe obstruction
The current criteria for indication of tonsillectomy (according to the 2006 document of
consensus between the Spanish Society of Otorhinolaryngology and the Spanish
Society of Paediatrics) consider aspects that are infectious, obstructive and/or suspect
of malignancy. Until January 2011, the American Academy of Otolaryngology – Head
and Neck Surgery (AAO-HNS) also considered craneo-facial alterations or presence
of malocclusions to be within the criteria of tonsillectomy, as long as they have been
documented by an orthodontist.
In children, significant tonsillar hypertrophy (Grade III to V) associated with adenoidal
hypertrophy or not, is frequently correlated with Obstructive Sleep Apnea Syndrome
(OSA), this being the principle indication of tonsil surgery during childhood. In grades
IV and V, if the clinical history is compatible with OSA, the surgical indication is clearer
and so the myofunctional orofacial imbalances caused or worsened by hypertrophic
tonsils can be minimized with surgery.
With Grade III hypertrophic tonsils, initially and according to the current criteria, OSA is
often not defined as evident or severe enough to indicate the need for conducting a
tonsillectomy. In these cases there must be an interdisciplinary evaluation of the
presence of orofacial myofunctional imbalances, putting special emphasis on the
anatomical aspects of the tonsils, specifically in the inferior poles, as it is these which
are in closest relation with the lingual base and the mobility.
The new contributions to the indications of tonsillary surgery proposed by an
interdisciplinary team working in a public Spanish hospital are very interesting. They
conducted an exhaustive review of the subject and suggested new criteria for surgery.
(Ventosa, Y., Albertí, A., Guirao, M., Larrosa, F. Visió interdisciplinar de les indicacions
de cirurgia amigdalar. Revista COEC. (157): 33-36, 2011.)
Results:
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In the following chart, we see the relationship between
the presence or absence of malocclusion and /or
dysfunctional swallowing for each tonsil grade, as well
as the number of children in whom no such alterations
are detected:
In
the
popula7on
studied,
78%
of
children
present
some
type
of
malocclusion,
those
of
greatest
prevalence
being:
Class
II/1
(27
children,
30%)
and
Open
Bite
(23
children,
26%).
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&&&%
(*+%
./01%2340%
,5+%
600/%2340%
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:+%
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The percentage of children presenting dysfunctional swallowing is also some 78%,
therefore the study concludes that the orofacial alterations observed
(malocclusion and dysfunctional swallowing) have a similar prevalence in the
population studied.
Of the results obtained, it can be deduced that most subjects (52
children: 45% of the total) present Grade II tonsils.
The following represents the grade of tonsils observed in relation to
the number of children:
The percentage of children presenting dysfunctional swallowing is also some 78%,
therefore the study concludes that the orofacial alterations observed
(malocclusion and dysfunctional swallowing) have a similar prevalence in the
population studied.
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Children’s
quan7ty
with
Tonsillar
Hypertrophy
Grade,
Malocclusion
&
Dysfunc7onal
Swallowing
(n=115)
Conclusions:
• Keeping in mind that our descriptive study observes that hypertrophic tonsils exhibit a high
degree of association with the presence of malocclusion and/or dysfunctional swallowing, it
would be interesting to conduct further investigative studies which evaluate the incidence of
hypertrophic tonsils in the presence of dental malocclusion and dysfunctional swallowing in
the different age ranges
• We would consider it to be of interest to review and evaluate the surgical indication of
tonsillectomy as well cases of maxillofacial alterations or the presence of dental
malocclusions, when it is considered that hypertrophic tonsils can be a etiological or
aggravating cause of these alterations.
Disclosure:
Y. Ventosa, D. Grandi & A. Albertí have no relevant financial or non financial relationships to disclose.
yve_evc@terra.com
digran@telefonica.net
aalber7casas@gmail.com
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