Corrective work with rhinolalia. Violations of the function of sensory and motor innervation of the pharynx and larynx ENT diseases paresis of the soft palate

Rhinolalia

For the most part, moms and dads think that rhinolalia include only those cases where the child has the so-called "wolf mouth" ( congenital splitting hard and soft palate) or "cleft lip" (cleft lip and upper jaw). But the concept of "rhinolalia" (in the common people - "nasal") is much broader. We will try to cover this phenomenon in as much detail as possible.

1. What is rhinolalia?

Scientifically rhinolalia- this is a change in the timbre of the voice, which is accompanied by a 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 "in the wrong direction", and the sounds acquire a "nasal" tone:

The air jet can be directed into the nose at almost all speech sounds. In this case, one speaks of open rhinolalia (these are the same "cleft palate", "cleft lip", or cleft palate and lips 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 a violation of the patency of the nasal cavity or nasopharynx: adenoid growths, curvature of the 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 palatopharyngeal closure. In this case, nasal resonance decreases (for nasal phonemes [n], [n "], [m], [m"]), while the remaining phonemes of the language (not nasal!), The timbre of which becomes like with open rhinolalia, is simultaneously distorted.

2. congenital open rhinolalia

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

Birth defects of the upper lip:

No skin deformation

Hidden cleft lip department of the nasal cavity;

Incomplete cleft lip without skin deformitybut-cartilaginous department of the nasal cavity;

Incomplete cleft lipwith deformation of the skin and cartilagedepartment of the nasal cavity;

complete cleft upper lip with deformation of the skin and cartilagesection of the nasal cavity.

Birth defects of the hard palate:

Incomplete cleft of the hard palate;

Complete cleft of the hard palate;

Sumbucous (hidden) cleft palate.

Birth defects of the soft palate:

Bifurcation of a small uvula (uvula);

Absence of a small uvula (uvula);

Sumbucous (hidden) cleft palate

Complete unilateral clefts:

- complete unilateral cleft of the alveolus

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

Complete unilateral cleft of the alveolus

Complete unilateral cleft of the upper lip, alveolar process

Complete bilateral clefts:

Complete bilateral cleft lip alveolar process and anterior hard palate

- tissue and anterior hard palate;

- complete bilateral cleft of the alveolar processtissue, hard and soft palate;

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

It is difficult not to notice all of the above defects in the structure of the child's speech apparatus. The only difficult one to diagnose is sumbucous (submucosal) 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 isblows to the back surface of the soft palate. Pwith an exaggerated pronunciation of the sound [a] (with a wide openwith your mouth!), the palate mucosa is drawn upwards in the form of a trianglenickname, it is thinned and has a paler (whitish) color.

3. Congenital open rhinolalia and related disorders

A child with rhinolalia has a very peculiar position of the tongue in 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 highly “upturned”, due to the increased muscle tone in these parts of the tongue. At the same time, the tip of the tongue is usually poorly developed, it is sluggish (paretic). The reason for such dramatic changes in the language is that children from the very first days of life experience difficulties in feeding. And this position of the tongue is a kind of adaptation to pathological condition nasopharynx. A rhinololic infant sucks with the root of the tongue, strongly straining the facial muscles. In the future, these difficulties persist: the baby instinctively holds the root of the tongue at the top, covering the cleft with it when eating and breathing. The root of the tongue is increasingly hypertrophied (increased), the tip of the tongue becomes even weaker and passively retracts deep into the oral cavity. Only elementary, undifferentiated movements of the tongue become available to the child. Therefore, the first words appear to him very late (around three years old), but it is difficult to understand them because of the strong distortion of sounds and the nasal tone of the voice.

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

It should be noted that the implementation of inspiration through the cleft causes frequent colds in such children. They have significantly impaired lung ventilation, hence the general physical weakness. Quite often, hearing loss is detected in rhinolalics (due to chronic otitis media, inflammation of the Eustachian tube, cochlear neuritis).

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

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

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

We have already said that with organic open rhinolalia, all sounds are pronounced with a nasal tone. Vowel sounds suffer the most, as they require the strongest palatopharyngeal closure. The articulation of consonant sounds is relegated to the root of the tongue, the sounds are distorted, acquiring a hoarse (guttural) hue. Rhinolalic speech is characterized by a large number of sound substitutions, and the substitute sounds are also distorted. The pronunciation of consonant sounds that require high oral pressure is most often violated: explosive [p], [b], [t], [d]; labio-dental [v], [f], all whistling and hissing, sonors [l], [p]. It takes more than one year for a child with rhinolalia to set up sounds.

4. Surgical treatment of children with open rhinolalia.

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

Cheiloplasty (upper lip repair surgery) and uranoplasty (operations to restore the integrity of the bottom of the nasal cavity), are shown even to newborns. But! There are a number of contraindications for their implementation at such an early age ( anemia, pneumonia, acute respiratory infections, intrauterine malnutrition, birth trauma, asphyxia, prematurity, congenital heart defects, spinal hernia, fistulas in the digestive tract, hypoplasia, aplasia of the lungs, the presence of other severe malformations).

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

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

Uranoplasty according to 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 the mucoperiosteal flaps, and tissues of the soft palate. Part of the elements of this technique is 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 (rhinophony).

Acquired open rhinolalia (rhinophony) , - a consequence of complications after the removal of the palatine 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 can 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, when pronouncing sounds, the soft palate lags far behind the back wall of the pharynx, leaving a significant gap, it is not able to function as 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 (rhinophony)

This form of rhinolalia can be with hysteria. In this case, a temporary stressful nasality occurs, due to incoming hysterical paralysis.

Functional open rhinolalia (rhinophonia) may 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 already “out of habit”. And this habit must be removed with the help of complex speech therapy classes.

Functional open rhinolalia is much less common than organic.

7.

Closed rhinolalia (rhinophony) - a consequence of impaired patency of the nasal passages (polyps, curvature of the 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 (rhinophony) is formed with reduced physiological nasal resonance during the pronunciation of phonemes. At the same time, the sounds [m], [m "], [n], [n '] sound, respectively, like [b], [b "], [d], [d ']. One of the external signs of closed rhinolalia (rhinophonia) is the child's constantly open mouth.

In other words, the causes of closed rhinolalia (rhinophony) are organic changes in the nasal or nasopharyngeal region or functional disorders of the nasopharyngeal closure. In this regard, there are:

- organic closed rhinolalia (rhinophony);

- functional closed rhinolalia (rhinophony).

Closed organic rhinolalia is subdivided into

• back;
• anterior

(rear) may be the result of adenoid expansions that cover:

The upper edge of the choan;

Half of the choanas or one of them;

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

Closed organic rhinolalia (rear) can develop as a result of fusion of the soft palate with the posterior pharyngeal wall after inflammation, sometimes due to nasopharyngeal polyps, fibromas or other nasopharyngeal tumors. Very rare congenital choanal atresia , which completely separates the nasopharyngeal cavity from the nasal cavity.

Closed organic rhinolalia (anterior) is observed:

With a significant curvature of the nasal septum;

In the presence of polyps in the nose;

With severe cold.

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

Closed functional rhinolalia (rhinophony) very common in children. She is also called habitual closed rhinophony. The child has narrow nasal passages, he is prone to frequent colds, allergic diseases, 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 “nasal”: he is used to the fact that his nose is “clogged”. With functional rhinophony, the timbre of nasal (nasal) and vowel sounds can be disturbed even more than with organic forms of rhinolalia (rhinophony).

8. What is rhinolalia (rhinophonia) in a child?

To determine which rhinolalia (rhinophonia) a child has: closed or open, you can:

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

Let's take a closer look at the last method. If, when pronouncing vowel sounds (a, y, o, and), the mirror brought to the nose fogs up, then the child has - open nasality. If, when pronouncing words with nasal sounds (mother, mine, car, etc.), the 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 (spoon handle) on the root of the tongue. If the soft palate reflexively rises to the back 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 nasality disappears, it means that paresis (paralysis) of the soft palate can be assumed (the nasality disappears due to the fact that when positioned on the back, the soft palate passively falls to the back of the pharynx).

10. Eliminate nasal tone of voice with massage and exercises

First of all, it will be necessary to activate the soft palate, make it move. This will require special massage . If the child is too small, massage is done by adults:

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

2) the same movements are done 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 the index finger, make a point and jerky 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 do an excellent job with this task. 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 does massage with the help of 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 already 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 a child can cause a gag reflex, so do not massage immediately after eating: there should be at least an hour break between eating and massage. Be extremely careful, avoid rough touches. Do not massage if you have long nails: they can injure 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 is invited to drink it in small sips;

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

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

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

5) pronunciation of vowels: “a”, “y”, “o”, “e”, “i”, “s” energetically and somewhat exaggerated, on the so-called “hard attack”.

11. Restoration of breathing

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

It can be difficult for a small child, and sometimes even uninteresting, to perform exercises just for show. Therefore, use game techniques, come up with fabulous stories, for example:

"Ventilate the cave"

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

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

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

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

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

"Snowstorm"

An adult ties pieces of cotton wool to threads, fastens the free ends of the threads on his fingers, thus, five threads with cotton balls at the ends are obtained. The hand is held at the level of the child's face at a distance of 20 - 30 centimeters. The kid blows on the balls, they spin and deviate. The more these impromptu snowflakes spin, the better.

"Wind"

It is done similarly to the previous exercise, but instead of threads with cotton wool, a sheet of paper cut from the bottom with a fringe is used (remember, once such paper was attached to the windows to scare away flies?). The child blows on the fringe, it deviates. The more horizontal position will accept strips of paper, the better.

"Ball"

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

"The ball is deflated!"

After long games, the ball at the Tongue loses its roundness: air comes out of it. (The child first puffs out his cheeks strongly, and then slowly exhales the air through rounded and protruding lips.)

"Pump"

The ball has to be inflated with a pump. (The child’s hands perform the corresponding movements. At the same time, he himself utters 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 on the base of the lower front teeth. The air comes out of the mouth strong jerks).

"Tongue plays football."

The tongue loves to play football. He especially enjoys scoring goals from the penalty spot. (Put two cubes on the opposite side of the table from the child. These are improvised gates. Put a piece of fleece on the table in front of the child. The kid "scores goals" by blowing from a wide tongue stuck between his lips on a cotton swab, trying to "bring" it to the gate and get in. Make sure that the cheeks do not swell, and the air flows in a trickle in the middle of the tongue.)

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

"The tongue plays the flute"

And the Tongue can also play the flute. At the same time, the melody is almost inaudible, but a strong stream of air is felt, which escapes from the hole of the flute. (The child rolls a tube from his tongue and blows into it. The baby checks for a trickle of air on his palm).

"Suok and Key"

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

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

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

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

12. Articulation exercises for rhinolalia

With 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", "Fairytale stories from the life of the Tongue".

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

1) "Liana": hang a long narrow tongue down to the chin, hold in this position for at least 5 seconds (repeat the exercise several times).

2) "Boa constrictor": slowly stick out a long and narrow tongue from your mouth (do the exercise several times).

3) "Language of the boa constrictor": with a long and narrow tongue, protruding 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, while touching the lips (first in one direction and then in the other direction).

5) "Pendulum": the mouth is open, a narrow long tongue is stuck out of 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, a long narrow tongue either rises up to the nose, then falls down to the chin, counting "one - two".

7) "Prick": a narrow long tongue from the inside presses first on one, then on the other cheek.

13. Conclusion.

The staging and automation of sounds in a rhinolalic child must be carried out in close collaboration with a speech therapist. In general, the rehabilitation course for rhinolalia is quite long, so there is no need to wait for immediate results.

Nervous diseases can manifest themselves in disorders of the sensory or motor innervation of the pharynx, larynx and oral cavity. They occur when the peripheral endings of sensory and motor nerves, their conductors or central sections are damaged.

There are disorders in the form decreased sensitivity (hypostesia), lack of sensitivity (anestesia), increased sensitivity (hyperestesia) and perversion of sensitivity (paraestesia).

Decrease and loss of sensitivity of the oral mucosa occur with peripheral lesions of the second and third branches trigeminal nerve, with functional diseases - hysteria.

An increase in the sensitivity of the mucous membrane of this area is observed with trigeminal neuralgia, especially during attacks of pain accompanied by difficulty in chewing. The tongue on the side deprived of sensitivity is often bitten, the food is not completely swallowed and remains lying in the deepening of the cheek, especially in the presence of a motor disorder - paralysis of the facial nerve.

A decrease or loss of sensitivity of the mucous membrane of the pharynx and larynx can be observed when the nerve is compressed by a tumor, with pronounced atrophic processes in the mucous membrane of the pharynx, with severe exhaustion of the body, with neuroses - hysteria, as a result of toxic neuritis with influenza, diphtheria, syphilis, etc.

Tziemsen, studying the electrical reaction of the muscles of the soft palate, showed that the violation of sensitivity and motor innervation of the soft palate in diphtheria is associated with damage to the peripheral nerves.

Hypersensitivity of the mucosa of the pharynx and larynx is observed in local inflammatory processes, in smokers, alcoholics, neuroses, dorsal tabes, sometimes occurs in pregnant women. Hyperesthesia is detected not only during examination, i.e., touching the mucous membrane, but can also occur independently in the form of a sensation of irritation in the throat, and a cough appears. With increased sensitivity of the pharyngeal mucosa, sometimes even protruding the tongue causes nausea and vomiting. They were repeatedly observed in a patient who, at the sight of objects that could get into his mouth (toothbrush, food), had vomiting, but as soon as the patient began to eat, these sensations disappeared.

Sensitivity disorders of the upper mucosa respiratory tract have a wide variety of manifestations, as evidenced by the following case history.

Patient G., 32 years old, was admitted to the Institute of Neurosurgery 17/V with complaints of a constant barking cough that interfered with her sleep and work. She was already at the same institute, where she underwent an operation to expose the vagus nerves in her neck using novocaine blockade, which gave a temporary positive effect. Before entering the Neurosurgical Institute, she was examined and treated for a long time in various medical institutions.

The patient coughs continuously. Changes in the nervous system, internal and ENT organs were not found.

Diagnosis: reflex-cough syndrome of a functional nature.

Novocaine blockade of the lumbar sympathetic nerves and oxygen were used for treatment. Under the influence of this treatment, improvement occurred, and on 12/VI the patient was discharged..

As already mentioned, disorders of the sensitive innervation of the pharynx and larynx can also be expressed in a perversion of sensations, namely: there is a feeling of pressure, tickling, scratching, burning, cold, sore throat, the presence of a foreign body in the throat. This may cause shortness of breath and swallowing disorders. It occurs mainly in persons suffering from neurosis and hysteria.

Violations of the motor innervation of the oral cavity, pharynx and larynx can be expressed in spasms, paresis and paralysis of the muscles.

Spasms - convulsive conditions of the muscles - often occur reflexively as a result of irritation of the nerve endings in the organ itself, for example, when a foreign body enters the larynx, sometimes when the larynx is lubricated or in the presence of a polyp. The most common cause of muscle cramps is irritation. vagus nerve in places more distant from the larynx, for example, when the nerve is compressed by an enlarged aorta, a tumor of the mediastinum.

Muscle cramps can be observed in patients with chorea, epileptics, hysterics. A patient repeatedly applied to the institute, in whom strong excitement, as a rule, caused stenotic breathing associated with a short-term spasm of the muscles of the larynx of a functional nature.

The most important is the convulsive contraction of the muscles of the larynx in infants - the child may even die during such an attack. It is assumed that the cause of seizures can be various factors: pressure of enlarged bronchial glands on the laryngeal nerves, worms, dropsy of the brain, anemia or hyperemia of the brain, adenoids, severe teething. Some believe that laryngeal convulsions in children are caused by pressure from an enlarged gland, thymus.

Convulsions of the tongue are expressed by its constant movement in the oral cavity, impaired speech and swallowing. Spasms of chewing muscles cause lockjaw, grinding and chattering of teeth.

With spasms of the muscles of the palatine curtain, the latter is pressed against the back wall of the pharynx. Due to the gaping of the Eustachian tube, the patient's own voice may seem louder; sometimes there is a crackling noise in the ear.

Convulsive states of the muscles of the pharynx and oral cavity are noted with rabies, tetanus, sometimes they occur in stutterers or hysterical subjects.

Paresis and paralysis of the muscles of the mouth, pharynx and larynx can occur with local pathological processes that compress the nerves in the oral cavity, pharynx, larynx (tumors of the larynx itself, foreign bodies, enlarged lymphatic glands).

Peripheral damage to the nervous apparatus of this area also occurs as a result of inflammatory processes, neck injuries, fractures and dislocations of the cervical vertebrae. According to E. A. Neifakh, traumatic injuries of the lower laryngeal nerve during the war were noted in 13.8% of all neck injuries.

Motor disorders of the pharynx and larynx can be observed with compression of the nerves at any segment of their anatomical path to the brain stem (scars after strumectomy, mediastinal tumors, lung tumors, aneurysm of the aortic arch, enlargement of the heart, cancer of the esophagus, enlarged bronchial lymph glands, pleuritic exudates and adhesions ).

Paresis and paralysis of the muscles are sometimes caused by neuritis of the recurrent nerve due to a general infection (diphtheria, scarlet fever, typhoid, influenza). More often, peripheral paralysis of the soft palate and pharyngeal muscles occurs as a result of diphtheria.

Central paralysis of the pharynx and larynx occurs during pathological processes more often in the region of the medulla oblongata, less often they are of cortical origin.

Various pathological processes in the region of the brainstem (tumors, syringomyelia, dorsal tabes, progressive bulbar palsy, hemorrhages) can cause damage to the nucleus of the vagus and other cranial nerves (IX, XI) and related dysfunctions of the body.

Violations of the motor ability of the muscles of the lips cause difficulty in speech, the patient cannot whistle and blow; in complete paralysis, the mouth does not close, and food and saliva flow out of the mouth.

Paralysis of the chewing muscles is expressed by the difficulty of grinding food and, in the end, chewing becomes impossible.

With unilateral paralysis of the tongue, its tip, when protruding, deviates to the paralyzed side, the act of swallowing and speech are upset.

Incomplete paralysis of the palatine curtain is accompanied by a slight disorder of speech function. The affected half of the palate lags behind during movement and the muscles of the healthy side pull the tongue to their side.

With bilateral paralysis, the palatine curtain is almost motionless, it hangs down, the tongue looks like an elongated one. Speech acquires a pronounced nasal tone, liquid food can enter the nose, especially with concomitant paralysis of the muscles of the tongue.

Paralysis of the pharyngeal muscles and soft palate is determined on the basis of speech disorders (nasal voice) and disorders of the act of swallowing (food enters the nose, since the palatine curtain does not isolate the nasopharynx during swallowing).

With paralysis of the muscles of the pharynx, swallowing can become completely impossible.

When the pathological process affects the trunk of the vagus nerve or its motor nuclei in the medulla oblongata, not only paralysis of the soft palate occurs (the act of swallowing is upset - liquid food enters the nose, the patient "chokes"), but also paralysis of the muscles of the larynx.

Paralysis of the laryngeal nerves is accompanied by a loss of sensitivity of the mucous membrane of the larynx, disorders of the voice and respiratory function(hoarse voice, sometimes complete aphonia, shortness of breath). Sometimes the act of swallowing is violated, since during swallowing the entrance to the larynx is not closed.

Combination of mucosal anesthesia with damage to the muscles of the larynx indicates damage to the upper and lower laryngeal nerves in the trunk n. vagi above the origin of the superior laryngeal nerve. Damage to one upper laryngeal nerve causes a violation of the sensitivity and reflexes of the mucous membrane of the larynx, as well as paralysis of m. cricothyreo-ideus anterior. Movement disorders are less pronounced. During laryngoscopy during phonation, the paralyzed ligament, due to insufficient tension, appears shorter and lower than the healthy one.

In the presence of bilateral damage n. laryngeus superior occurs bilateral paralysis m. cricothyreoideus - both ligaments cannot vibrate, there is a gap in the ligamentous part. Clinically, paralysis of the cricothyroid muscle is expressed by hoarseness, weakness of the voice and the inability to take high notes.

Damage to the recurrent nerve is accompanied by a violation of the muscles of the larynx. Depending on the involvement of laryngeal dilators or constrictors in the process, various degrees of voice dysfunction are determined (from mild hoarseness to complete aphonia).

Bilateral damage to the recurrent nerve causes not only a disorder of the voice function, but also difficulty in breathing.

When the recurrent nerve is damaged, the muscle that opens the larynx (m. posticus) is paralyzed first of all, and laryngoscopy shows that one ligament does not depart from the midline either during breathing or during phonation - the ligament is in the cadaveric position.

If there is bilateral paralysis of the recurrent nerve, both ligaments are in a cadaveric position and the larynx is closed, a tracheotomy is inevitable.

Paralysis of all muscles of a functional nature occurs in hysteria, when the patient's glottis is wide open during breathing and phonation.

In persons suffering from hysteria, bilateral paralysis of the internal muscles of the vocal cords (thyroid-arytenoid), combined with paralysis of m. transverse. In this case, an oval fissure and a triangular space in the posterior glottis are formed between the ligaments.

Functional disorders of the nervous apparatus of the pharynx and larynx most often based on neuropsychiatric disorders (hysteria, neurasthenia, traumatic neurosis). In these diseases, the voice function usually suffers due to a bilateral violation of the voluntary muscles of the larynx. Usually, patients have variability in voice function, the voice can be either loud or hoarse, and coughing and laughter often remain sonorous.

An important differential diagnostic value for paralysis of the larynx is stroboscopy, which allows you to determine the vibrations of the vocal cords. With the immobility of half of the larynx caused by fixation of the joint, the vibrations of the vocal cords during phonation are preserved, while the paralyzed ligament does not oscillate.

Central paralysis of the muscles of the larynx, caused by pathological processes in the medulla oblongata, correspond to the side of the brain lesion and clinical picture similar to peripheral paralysis.

Peripheral and bulbar paralysis are diagnosed on the basis of the reaction of degeneration in the muscles with the help of a faradic current. It has been established that in the 2nd week of such diseases, the electrical excitability of the affected muscle soon fades away.

Dysfunctions of the motor muscles of the pharynx and larynx of cortical origin are rare. Unilateral processes usually give mild muscle lesions, and severe lesions are observed only when both hemispheres are affected.

Cortical paralysis is characterized by the loss of voluntary motor impulses of voluntary movements of the vocal cords, and breathing remains free.

It is known that the motor nuclei of the vagus nerve in the medulla oblongata are connected to the cortical motor centers with the help of crossed and non-crossed fibers, receiving bilateral cortical innervation. Therefore, when the cortico-bulbar tract is turned off on only one side, there is usually no dysfunction of the muscles of the pharynx and larynx. Only with bilateral lesions of the cortico-bulbar tract, phonation and swallowing disorders occur.

Treatment of sensory and motor innervation the oral cavity, pharynx and larynx must be directed to eliminate the cause that caused the damage. If the cause of the disorders is a foreign body or tumor, then they must be removed. With syphilis, specific treatment is indicated. Violations of sensory and motor innervation caused by hysteria, neurasthenia, reactive neurosis, are under the influence of psychotherapy, hydrotherapy, the use of bromine drugs and other methods of treatment.

Disorders of the innervation of the pharynx and larynx, associated with a general weakening of the body, disappear under the influence of general strengthening treatment.

For the treatment of sensitive disorders of the larynx, local narcotic drugs, inhalations, and electrification are used. Anesthesia of the pharynx and larynx of infectious etiology (diphtheria) disappears after 2 months without any treatment.

With convulsive muscle contractions in children, fresh air is needed. Sometimes in these cases there is a need for urgent assistance (artificial respiration, intubation).

For the treatment of laryngospasm in children, general ultraviolet irradiation (suberythemal doses) is also used, which increases the amount of calcium in the blood.

Some use diathermo-iontophoresis to treat overstrain of the nervous apparatus of the larynx.

Recently, for the treatment of functional disorders of the voice, the method of muffling has been used (using the Barani ratchet or special devices). During muffling, the patient strains his voice, and when the muffler is suddenly turned off, his ability to speak loudly is revealed. This technique exercises the voice and has a mental effect on the patient.

In this article, it is necessary to touch upon the disorders of the voice and speech functions that occur when the central nervous system is damaged due to concussions (as a result of the action of a blast wave).

Speech and voice disorders can manifest as aphasias, dysarthria, and dysphonias and are often associated with auditory disorders. In these cases, measures of a general effect on the central nervous system and a direct effect on the vocal apparatus are required.

In case of increased excitability, pharmacological agents that cause sleep are used (chloral hydrate, sodium amytal, veronal, medinal, etc.). Sometimes speech is restored after the use of sleep therapy. In case of inhibition phenomena, disinhibitory agents are recommended (seismotherapy, faradization). In addition, hypnosis is used, which relieves speech convulsions during the session.

Restoration of the voice was sometimes achieved by developing conditioned reflexes in the labor process. All sorts of measures were used to influence the emotional sphere in order to evoke a defensive reaction. Sometimes noise stun was effective.

In order to influence the peripheral vocal apparatus, a vibrational massage of the larynx was used, they resorted to inducing a cough reflex by introducing lubricants into the larynx, pressing the thyroid cartilage with a hand to facilitate phonation, faradization of the thyroid cartilage region, and methods of educating the vocal apparatus by irradiating speech. In some cases, rhythmic breathing exercises and articulatory exercises.

Bulbar syndrome (or bulbar paralysis) is a complex lesion of the IX, X and XII cranial nerves (vagus, glossopharyngeal and hypoglossal nerves), whose nuclei are located in the medulla oblongata. They innervate the muscles of the lips, soft palate, tongue, pharynx, larynx, as well as the vocal cords and epiglottic cartilage.

Symptoms

Bulbar palsy is a triad of three leading symptoms: dysphagia(swallowing disorder) dysarthria(violation of the correct pronunciation of articulate speech sounds) and aphonia(violation of the sonority of speech). A patient suffering from this paralysis cannot swallow solid food, and liquid food will enter the nose due to the paresis of the soft palate. The patient's speech will be incomprehensible with a hint of nasality (nazolium), this violation is especially noticeable when the patient pronounces words containing such complex sounds as "l" and "r".

To make a diagnosis, the doctor must conduct a study of the functions of the IX, X and XII pairs of cranial nerves. Diagnosis begins with finding out if the patient has problems swallowing solid and liquid food, whether he chokes on it. During the answer, the patient's speech is carefully listened to, violations characteristic of paralysis, noted above, are noted. Then the doctor examines the oral cavity, performs laryngoscopy (a method for examining the larynx). With unilateral bulbar syndrome, the tip of the tongue will be directed towards the lesion, or completely motionless with bilateral. The mucous membrane of the tongue will be thinned and folded - atrophic.

Examination of the soft palate will reveal its lag in pronunciation, as well as the deviation of the palatine uvula to the healthy side. Using a special spatula, the doctor checks the palatine and pharyngeal reflexes, irritating the mucous membrane of the soft palate and the posterior pharyngeal wall. The absence of vomiting, coughing movements indicate damage to the vagus and glossopharyngeal nerves. The study ends with laryngoscopy, which will help confirm the paralysis of the true vocal cords.

The danger of bulbar syndrome is vagus nerve injury. Lack of function of this nerve will cause heart rate and respiratory distress, which can be immediately fatal.

Etiology

Depending on the disease caused by bulbar palsy, there are two types of it: acute and progressive. Acute most often occurs due to acute circulatory disorders in the medulla oblongata (heart attack) due to thrombosis, vascular embolism, and also when the brain is wedged into the foramen magnum. Severe damage to the medulla oblongata leads to a violation of the vital functions of the body and the subsequent death of the patient.

Progressive bulbar palsy develops with amyotrophic lateral sclerosis. This rare disease is a degenerative change in the central nervous system that causes damage to motor neurons, causing muscle atrophy and paralysis. ALS is characterized by all the symptoms of bulbar paralysis: dysphagia when taking liquid and solid foods, glossoplegia and atrophy of the tongue, sagging of the soft palate. Unfortunately, there is no cure for amyotrophic sclerosis. Paralysis of the respiratory muscles causes the death of the patient due to the development of suffocation.

Bulbar paralysis often accompanies a disease such as myasthenia gravis. No wonder the second name of the disease is asthenic bulbar palsy. The pathogenesis consists in an autoimmune lesion of the body, causing pathological muscle fatigue.

In addition to bulbar lesions, muscle fatigue joins the symptoms after physical activity disappearing after rest. The treatment of such patients consists in the appointment of anticholinesterase drugs by the doctor, most often Kalimin. The appointment of Prozerin is not advisable because of its short-term effect and a large number of side effects.

Differential Diagnosis

It is necessary to correctly differentiate bulbar syndrome from pseudobulbar palsy. Their manifestations are very similar, however, there is a significant difference. Pseudobulbar paralysis is characterized by reflexes of oral automatism (proboscis reflex, distance-oral and palmar-plantar reflex), the occurrence of which is associated with damage to the pyramidal tracts.

The proboscis reflex is detected when a neurological hammer is gently tapped on the upper and lower lip - the patient pulls them out. The same reaction can be traced when the hammer approaches the lips - a distance-oral reflex. Stroke irritation of the skin of the palm above the elevation of the thumb will be accompanied by a contraction of the mental muscle, causing the skin to pull up on the chin - palmo-chin reflex.

Treatment and prevention

First of all, the treatment of bulbar syndrome is aimed at eliminating the cause that caused it. Symptomatic therapy consists in the elimination of respiratory failure with a ventilator. To restore swallowing, a cholinesterase inhibitor is prescribed -. It blocks cholesterase, as a result of which the action of acetylcholine is enhanced, leading to the restoration of conduction along the neuromuscular fiber.

M-anticholinergic Atropine blocks M-cholinergic receptors, thereby eliminating increased salivation. Patients are fed through a tube. All other therapeutic measures will depend on the specific disease.

There is no specific prevention for this syndrome. To prevent the development of bulbar paralysis, it is necessary to treat diseases that can cause it in a timely manner.

Video on how exercise therapy is performed for bulbar syndrome:

Paresis of the larynx (paralysis) is a decrease in the strength of the muscles of the section of the respiratory system that connects the pharynx to the trachea, which contains the vocal apparatus. It is characterized by damage to the motor pathway of the nervous system.

The vocal apparatus is an expansion and narrowing of the gap located in the larynx between the vocal cords, through which the air, passing through, forms 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, paresis of the larynx is formed.

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

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

Paralysis is provoked by a fairly diverse number of causes, it affects people regardless of different age and gender. Often formed due to other diseases.

Causes of the disease:

• disease thyroid gland;
• tumors of the larynx, trachea, cervical regions and their metastases;
• previous strokes;
• various inflammations of the serous membrane of the lungs;
• disease of the peripheral nerve, as a consequence of intoxication, infectious diseases (tuberculosis, botulism, SARS, etc.), poisoning;
• hematoma formation due to mechanical damage to the neck;
• accumulation in the tissues of the body of elements with an admixture of blood, lymph in case of 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 of the neck, head, chest(paralysis of the vocal cords, as a consequence of the operation, is typical in most cases for incorrect surgical intervention);
• harmful effects of chemotherapy drugs.

Paresis of the larynx is often found in people whose work is associated with a high load on the vocal apparatus.

There is also paresis of the vocal cords 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.

Varieties, symptoms, consequences

Interestingly, paralysis of the larynx and paresis of the palate (the 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 inflammation of the larynx.

There is paralysis: unilateral, bilateral. If there is a second, a sick leave is provided. Unilateral paresis is characterized by inflammation of half of the larynx, left or right folds. With unilateral paresis, the signs of the disease are less pronounced, they can develop impaired functioning of the lungs and bronchi.

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

The most characteristic paresis of the larynx are the following symptoms:

• hoarseness, voice change;
• whispering;
• rapid fatigue of the vocal cord;
• difficulty with swallowing;
• pain in the neck;
• violations of the motor activity of the tongue, soft palate;
• shortness of breath, slowing of the 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);
• blue above the upper lip;
• choking;
• respiratory failure (typical with bilateral paralysis and requires urgent treatment).

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

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

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

Neuropathic, in most cases, occurs unilaterally, associated with the formation of a weakening of the muscles, increasing the gap, gradually passing into the muscles of the larynx. Occurs after a long time recovery of phonation. 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 during tears, laughter or coughing. The throat feels sore, pain, and there is also a pain syndrome in the head, irritability, weakness, sleep disturbance, mood changes.

Diagnosis and treatment

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

Before treating the disease, it is necessary to correctly establish the diagnosis. To establish it, you need to consult a doctor, undergo a prescribed examination. Self-diagnosis is not recommended!

The attending physician, after analyzing the complaints and external examination of the neck and oral cavity, will prescribe one of the following examinations: laryngoscopy, including the study of 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 to assess the condition of the muscles. To determine the level of violation of voice functions, phonography, stroboscopy, electroglottography can be used.

The therapy carried out directly depends on the causes of the disease, as well as on its nature. Its task is to restore the basic functions of the larynx: breathing and reproducing sounds.

If overexertion has become a violation of the voice functions, treatment is not required, but rest is needed to restore them.
Drug therapy, surgery, physiotherapy procedures are used, among which phoniatric gymnastics is common for paresis of the vocal cords.

Most often, in case of laryngeal disease, they are prescribed (be sure to take into account the cause of the disease) medicines: decongestant, antibacterial, antiviral, vascular, improving brain function, activating muscle activity, antidepressants, vitamin complex.

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

Physiotherapy includes electrophoresis, magnetotherapy, acupuncture, hydrotherapy, massage, psychotherapy, phonopedia, and gymnastics.
Great importance in the rehabilitation and treatment of paralysis of the larynx and soft palate has acquired breathing exercises, including slow blowing out and drawing in air, the use of a harmonica, puffing out the cheeks and releasing slowly air, an elongated breath, as well as training the muscles of the neck.

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 the avoidance of stressful situations, reboots of the vocal cords, viral diseases, to exclude smoking, inhalation of stale air if possible. And also to prevent complications of diseases that can cause paresis.

In any disease, maintaining a healthy lifestyle and maintaining immunity have beneficial effects on the body, 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 bear any consequences after the therapy.

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

This disease has similar symptoms to other diseases, such as paresis of the palate, and therefore it is necessary 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 the normal functioning of the body, it must be taken quite seriously, not to delay or neglect the treatment prescribed by a specialist.