Diana grandi relation between tonsillar hypertrophy,

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 CyphosisLumbar curvatureincreased

Curved back, reduced lumbar curvature shoulders dropped, flat thorax and prominent abdomen

9

10

11

12

Recommended assessment by:

ENT Orthodontist Speech therapist Odontopediatrician14

Open bite Crossbite (uni./bilat.)Normal bite

Normal Makes faces while swallowing

Level 0 Level 1 Level 2 Level 3 Level 4 Level 5Frenectomy Tongue tip

touches the palateAlmost touchesthe palate

The distance between the upper and lower incisors is the same

Reacheslower incisors

Doesn’t reach lower incisors

5

13 Adenoids:

Phonetical test(morning)

Positive (different)

Negative (same)

Endoscopy (only ENT)No obstruction

Partial obstructionProfile 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.



Lips

Lip contact in rest

Tonsils








6

7

8


Bite Occlusion

Anterior deep bite

Alignment


Swallowing


Posture alterations



9

10

11

12










5

13 Adenoids:



Negative (same)





Lips

Lip contact in rest

Tonsils








6

7

8


Bite Occlusion

Anterior deep bite

Alignment


Swallowing


Posture alterations



9

10

11

12










5

13 Adenoids:



Negative (same)



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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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. [email protected] [email protected] [email protected]

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Española de Pediatría. Acta Otorrinolaringol Esp., 57, 59-‐65. •  Darrow, D.H. i Siemens, C. (2002). Indica7ons for Tonsillectomy and Adenoidectomy. The Laryngoscope 112, 6-‐10. •  Durán, J. (2003). Mul7func7on System “MFS”. Las 8 claves de la matriz funcional. Ortodoncia clínica, 6, 10-‐13. •  Durán, J. (2003). Técnica MFS: Diagnós7co de la matriz funcional: codificación. Ortodoncia clínica, 6, 138-‐40. •  Echarri, P., Carrasco, A., Vila, E. i Boqni E. (2009): Protocolo de exploración Interdisciplinar orofacial para niños y adolescentes. Revista Ortod. Esp.; 49 (2); 107-‐115. •  Grandi, D. (2012) The Interdisciplinary Orofacial Examina7on for children and adolescents: a resource for the interdisciplinary assesment of the Stomatogna7c System. Inter. Journal Orofacial

Myology, IAOM. Vol. 38, 15-‐26. •  Peltomäki, T. (2007). The effect of mode of breathing on craniofacial growth – revisited. European Journal of Orthodon7cs, 29, 426-‐429. •  Riera, A. y Piñedo, J. (2008). Patología inflamatoria de las vías aerodiges7vas en el niño. Tratado de Otorrinolaringología y Cirugía de Cabeza y Cuello. Madrid: Ed. Panamericana. •  Rosenfeld, R. et al. (1990). Tonsillectomy and adenoidectomy:changing trends. Ann Otol Rhinol Laryngol, 99, 187-‐191. •  Yalcin, H. i Thukkahrman, H. (2009). Effects of Airway Problems on Maxillary Growth: A Review. European Journal of Den7stry, 3, 250-‐254.

Health & Medicine

Diana grandi relation between tonsillar hypertrophy,