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Inadequate closure the velopharyngeal sphincter, a MUSCLE at the back of the soft palate, that directs air flow to the NOSE or to the MOUTH. Velopharyngeal insufficiency often accompanies CLEFT PALATE/CLEFT PALATE AND LIP anomalies and interferes with both speech and swallowing. It also can occur as a complication of tonsillectomy and adenoidectomy, operations to remove the tonsils and ADENOIDS, respectively, and of neurologic damage, such as from STROKE, that restricts neuromuscular function of the pharynx. The hallmark symptoms of velopharyngeal insufficiency are nasal speech and regurgitation food into the back of the nose with swallowing. Sometimes the person has chronic or recurrent SINUSITIS resulting from food particles becoming trapped in the sinuses. The doctor may be able to feel a previously undiagnosed cleft in the hard palate beneath an intact soft palate. ULTRASOUND or COMPUTED TOMOGRAPHY (CT) SCAN can confirm the diagnosis.

Treatment for velopharyngeal insufficiency when the cause is a structural anomaly begins with surgery to restore sphincter function to the extent possible. Operations may include repair of a cleft palate or reconstructive surgery to extend the soft palate (pharyngoplasty) to make the velopharyngeal opening smaller. Most people subsequently need speech therapy to retrain oralfacial structures to form the sounds the velopharyngeal insufficiency kept them from properly making. These therapeutic interventions typically restore complete function, though may not be appropriate or successful when the cause of the velopharyngeal insufficiency is neurologic damage or a neuromuscular disorder.

Surgical reconstruction of the TYMPANIC MEMBRANE (eardrum). Damage to the tympanic membrane can occur as a result of scarring due to repeated OTITIS media (middle EAR INFECTION), traumatic injury, and acquired defects such as might remain following removal of a CHOLESTEATOMA (pocketlike growth). The otolaryngologist cuts out a small piece of FASCIA (thin connective tissue that covers muscle) from the temporal MUSCLE at the point of incision behind the ear when the OPERATION begins; this becomes the new tympanic membrane. Restoration of hearing varies and may depend on factors not related to the tympanoplasty. Infection, which may be present in the middle ear at the time of the surgery, can cause the new tympanic membrane to fail. About 80 percent of adults who undergo tympanoplasty experience improvement in hearing and reduced otitis.

A thin piece of tissue that stretches across the base of the auditory canal (EAR canal). The tympanic membrane, commonly called the eardrum, vibrates in response to sound waves that reach it by traveling from the outer ear through the auditory canal. The vibrations amplify the sound waves, which activate the auditory ossicles, tiny bones in the middle ear, to set in motion the cascade of events that results in NERVE signals traveling to the BRAIN.

The tympanic membrane is vulnerable to perforation, commonly called RUPTURED EARDRUM. Perforation may occur as a result of injury, such as penetration of an object or from a sharp blow to the outer ear, or spontaneously. Fluid accumulation in the middle ear behind the tympanic membrane, usually the consequence of INFECTION, is the most common cause of spontaneous perforation. Spontaneous perforation generally heals without intervention. Traumatic perforation may require surgical repair (TYMPANOPLASTY).

In addition to amplifying and transferring sound waves, the tympanic membrane protects the middle and inner ear from bacteria and debris. A perforated eardrum exposes the delicate structures behind it to possible infection and other damage. Repeated spontaneous perforation due to chronic OTITIS media (middle ear infection) can permanently scar the tympanic membrane, restricting its ability to vibrate. The otolaryngologist may insert a small tube through the tympanic membrane to allow collected fluid to drain (MYRINGOTOMY) as a preventive measure in children who have chronic ear infections.