Question
My son is 5 years old and has just been referred to an ENT by our school speech pathologist because he demonstrates velopharyngeal incompetencies in speech. He pronounces s,v,z,sh,ch nasally. My son has large tonsils and the ENT doctor scheduled a tonsile
Answer
Thank you for this question. A five year old child is expected to have large tonsils and adenoids. This part of your son's story is quite normal. The tonsils and adenoids can become large by age three, and remain large until around age 12 years until they begin to slowly involute away. It is possible for tonsils to be so large that they inhibit the soft palate from full elevation. While large tonsils are typical for a five year old, huge or "kissing" tonsils may pose a problem.
Large tonsils can lead to hypernasality on sibilant sounds (that you described) if the soft palate is unable to elevate fully and participate in closure of the velopharyngeal port in speech. If a tonsillectomy is done under these circumstances, the soft palate can be freed up to reach its full potential for elevation and make a contact with the posterior wall of the pharynx. Hypernasality could possibly be eliminated if the palate itself is normal. However, this sequence of events may not occur following tonsillectomy because of scar tissue that will develop as a natural result of the operation.
The recommendation for tonsillectomy based on one oral exam by the ENT specialist is reason to give you pause, and yes, I would recommend a second opinion. Your child could best be evaluated by a cleft palate team where several tools of evaluation are available such as nasendoscopy, airflow, and various radiographic techniques.
The problem with a one time oral examination is that the dimensions of the velopharyngeal area cannot be adequately evaluated. At the least, a standard cephalometric x-ray taken in the lateral view during the sustained production of /s/, or a vowel, would be needed to observe the relationships between the soft palate and the posterior wall of the pharynx. In some cleft centers, videofluoroscopy is the radiographic procedure of choice, providing multiple views of the pharynx and soft palate in function. Your son may have a short soft palate; the velum could buckle in the wrong place during elevation and thus prohibit a contact with the back wall of the throat; there could be tethering (connective tissue strands) on the nasal surface of the velum; or there may be a neuromotor deficit in his palate. I don't suspect that he has a submucous cleft, as I presume this would have been caught by the ENT specialist or by the speech pathologist. But a short soft palate in a five year old could be difficult to diagnose by intraoral inspection alone. My point is that the tonsils may not be the sole reason for the hypernasality, and perhaps other treatment options may turn out to be more appropriate than tonsillectomy.
The red flag in your question involves the inclusion of the adenoid mass for removal. Perhaps you mentioned the adenoid mass since it is common to talk of a "T & A" (tonsillectomy and adenoidectomy)? When hypernasality is present, removal of the adenoids is contraindicated. An adenoidectomy would only make the situation worse since the adenoids serve as a target for soft palate contacts in achieving velopharyngeal closure. Removal of adenoids moves the speech target farther from the soft palate. I would be very surprised if the ENT surgeon mentioned removing the adenoids along with the tonsils. This is a definite no-no, as every ENT specialist and speech pathologist should know.
Several questions remain about your child's history that may be germane to this situation. Have your child's tonsils been large for several years? Has the hypernasality been evident since he began to talk? Has he had several bouts with tonsillitis? Has he needed ear tubes? Does he ever regurgitate fluids through his nose during drinking? Does he move his lips actively when he speaks or does he mumble? Do you often have to ask him to repeat what he has said? The answers to these questions would be of interest in an evaluation by a cleft palate team.
In summary, I advise you to not proceed with a tonsillectomy on the basis of a one-time oral evaluation. It may be that your son will need a tonsillectomy, but because there may be other anatomical or physiological problems involved, I strongly recommend imaging of the velopharyngeal mechanism before you agree to surgery. Under no circumstance should you agree to a total adenoidectomy. As mentioned above, where hypernasality already exists, an adenoidectomy will only worsen the situation.
In recommending you to a cleft palate clinic for a thorough evaluation of your son, please know that this does not mean that I suspect an undetected cleft in your child. The members of a cleft palate team have the appropriate knowledge and resources to thoroughly evaluate your son. A team evaluation may be expensive, but their findings and recommendations should be definitive. The other option would be to find a single resource who is knowledgeable about velopharyngeal problems and can arrange for a radiographic evaluation. If you experience difficulty in identifying a cleft team or an individual in your area, please seek help by contacting the Cleft Palate Foundation of the American Cleft Palate-Craniofacial Association. Their number is 919-933-9044; ask for Lisa Gist. Good luck!
Robert M. Mason, DMD, Ph.D. is a speech-language pathologist (CCC-ASHA Fellow), a dentist, and orthodontist. He is a Past President of the American Cleft Palate-Craniofacial Association, a professional, interdisciplinary organization specializing in problems associated with facial and oral deformities. Dr. Mason has studied and written extensively about orofacial evaluations, developmental problems related to the tongue, and the anatomy and physiology of the speech and hearing mechanisms. His reports have appeared in speech, dental, medical, and plastic surgical journals and texts. He is considered to be an expert in tongue thrusting, tongue tie, and other problems related to tongue functions and speech.