106 THE INDIAN JOURNAL OF PEDIATRICS 1994; Vol. 61. No. 1

Hypertrophic Tonsils Causing Articulation Defect

Ishwar Singh, Geeta Gathwala*, Raini Pathania, Jagat Singh and S.P.S. Yadav

Departments of Otolaryngology and Pediatric Medicine* Medical College and Hospital, Rohtak

Tonsils and adenoids are known to un- dergo hypertrophy in prepubescent chil- drenY Because of their anatomic location they may affect, hearing, resonance, speech and airway. Hypertrophied tonsils and adenoids are known to cause-middle ear effusion and hearing loss due to eustachian tube obstruction, la Adenoids are known to affect the resonance of sound. Atrophy or surgical removal of adenoids may lead to rhinolalia aparta, 3-~ whereas hypertrophy leads to rhinolalia closa. The other prob- lems of hypertrophied tonsils and ade- noids are sleep apnoea, 9-H mouth breathing and a chronic open mouth posture and adenoid faces ~2,13 due to nasopharyngeal obstruction. This obstruction forces the child to adopt mandible and tongue down posture to further open the airway. 13 Long term effects include permanent den- toalveolar changes 12 and lisping. TM The other severe problem reported are corpul- monale l~ and obstructive dysph- agia. 1,~~ Recently we came across a young healthy child who had articulation defect due to tonsillar hypertrophy.

CASE REPORT

A five years old male child was brought to speech therapy clinic by parents for his inability to speak certain words like \K\ , \Kh\ , \ I \ , \ Ih \ . He substituted "t" for 'K', and 'Th' for "Kh'. The sound was high pitched and shrill. After the first speech as- sessment it was observed that there was

restricted mobility of the posterior part of the tongue. This probably was responsible for his inability to pronounce sounds like \K\ , \Kh\ , \ I \ and \ Ih \ .

He was an intelligent and co-operative child studying in first standard. His simulation was good. He was given 10 sittings of speech therapy without any improvement. His oral cavity examination revealed hypertrophied tonsils almost meeting in mid line. It was concluded that hypertrophic tonsils were restricting the movement of tongue. Parents were not prepared for tonsillectomy. Then with the help tongue depressor, anterior portion of tongue was pressed and he was asked to say\K\ . With much practice for one month, the child was able to produce these sounds correctly.

DISCUSSION

Hypertrophic adenoids are known to affect the resonance of speech sound but the role of enlarged tonsils is not yet well under- stood. Tonsils alter resonance if they inter- ude into the nasopharynx. It is said that large tonsils may interfere with the trans- mission of air into the oral cavity. 3 Re- cently hypernasal speech was thought to be caused by tonsillar hypertrophy. 13,16,n It was found that prolapsed tonsils were interposed between velum and posterior pharyngeal wall. 17 If large tonsils obstruct sound transmission in to the oral cavity sound will resonate in the pharynx causing

1994; Vol. 61. No. 1 THE INDIAN JOURNAL OF PEDIATRICS 107

cul-de-sac resonance. This type of reso- nance has been called potato ' in mou th speech. 13

The articulation defect seen in the pres- ent case due to hyper t rophied tonsils has not been described so far. The enlarged tonsils meeting in mid line restrict the free movement of base o f tongue due to me- chanical obstruction. The tonsils get sand- wiched between the soft palate and tongue leading to defective product ion of retro oral sounds l i k e \ K \ K h \ . Tonsil lectomy is known to help the po ta to in m o u t h speech. 17,1s In the present case however parents refused tonsil lectomy and speech therapy alone was able to help the child.

REFERENCES

1. Mawson SR, Adlington P, Evans M. A con- trolled study evaluation of adeno-tonsillec- tomy in children. J Otolaryngol 1967; 81 : 777-750.

2. Pruzansky S. Roentgencephalometric stud- ies of tonsils and adenoids in normal and pathologic states. Ann Oto Rhinolaryngol 1975; 84 : 55-62.

3. Subtelny JD, Koepp-Baker H. The signifi- cance of adenoid tissue in velopharyngeal function. PIast Reconstr Surg 1956; 17 : 235- 250.

4. Calnan JS. Permanent nasal escape in speech after adenoidectomy. Br J Plast Surg 1971; 24 : 197-204.

6. Croft CB, Shprintzen RJ, Ruben RJ. Hyper- nasal speech following adenoton- sillectomy. Otolaryngology Head Neck Surg 1981; 89 : 179-188.

7. Goode RL, Ross J. Velopharyngeal insuffi- ciency after adenoidectomy. Arch Otorhino- laryngol 1972; 96 : 223-226.

8. Lowson LI, Chierici G, Castro A et al. El-

fects of adenoidectomy on speech of chil- dren with potential velopharyngeal dysfunction. J Speech Hear Disord 1972; 37 : 390-402.

9. Witzel MA, Rich RH, Margar-Bacal F et al. Velopharyngeal insufficiency rafter adenoi- dectomy. An 8 year review. Int J Pediatr Otorhinolaryngol 1986; 11 : 15-20.

10. Grundfast KM, Wittich DJ Jr. Adenotonsil- lar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope 1982; 92 : 650-656.

11. Mahboubi S, Marsh RR, Potsic WP et al. The lateral neck radiograph in adenoton- sillar hyperplasia. Int J Pediatr Otorhinolar- yngol 1985; 10 : 67-73.

12. Richardson MA, Seid AB, Cotton RJ et al. Evaluation of tonsils and adenoids in sleep apnea syndrome. Laryngoscope 1980; 90 : 1106-1110.

13. Blum DJ, Neel HB III. Current thinking on tonsillectomy and adenoidectomy. Compr Ther 1983; 9 (12) : 48-56.

14. Shprintzen RJ, Sher AE, Croft CB. Hyper- nasal speech caused by tonsillar hypertrophy. Int J P.ediatr Otolaryngol 1986; 14 : 45-56.

15. Morris HL. The speech pathologist looks at the tonsils and the adenoids. Ann Otol Rhi- nol Laryngol 1975; 84 (19) : 63-66.

16. Cayter GG, Johnson EE, Lewis BE et al. Heart failure due to enlarged tonsil and adenoids. Am J Dis child 1969; 118 : 708- 717.

17. Mac Kenzie-Stephner K, Witzel MA, Stringer DA et al. Velopharyngeal insufficiency due to hypertrophic tonsils. A report of two cases. Int J Pediatr Otorhino Laryngol 1987; 14 : 57-63.

18. Kummer AW, Billmire DA, Myer CM. Hypertrophic tonsils : The effect on resonance and velopharyngeal. Plast Reconstr Surg 1993; 91 : 608-611.